Contraception Mythbusters: It is not safe to take COC continuously without a monthly break

Read our latest blog by Dr Savita Brito-Mutunayagam, Specialist Registrar in Sexual and Reproductive Health, Aberdeen Community Health Village.

Evidence

The early combined oral contraception (COC) regimens were intentionally designed to have a 28-day cycle in order to mimic naturally occurring menstrual cycles. These regimens comprise 21 days of active hormones followed by 7 days of non-pill taking (or placebo pills) during which there is a withdrawal bleed. However, the bleed experienced during the hormone-free interval (HFI) is due to the withdrawal of hormones rather than physiological menstruation.1 Women should be informed that withdrawal bleeding with COC is not medically necessary and there can be real advantages for some women in terms of avoiding it. (1)

Extended-cycle COC (greater than 28 days of active hormones, followed by a HFI) and continuous COC (no HFI) regimens are becoming increasingly common modes of administration. These regimens enable women to delay bleeds for personal or therapeutic reasons. Continuous pill taking also improves efficacy due to exceptionally low risk of breakthrough ovulation. While there is limited evidence on the long-term health effects of continuous administration, the physiology of COCs and their impact on the hypothalamic-pituitary-ovarian axis support the safety of this method. (2)

The most common extended regimen for monophasic COC pills is “tricyling,” taking 3 cycles of active pills (63 active pills) back-to-back followed by a 7 day break. This can be applied to other modes of delivery of combined hormonal contraception (CHC) such as the patch and ring, with the HFI occurring after the 3rd ring or 9th patch.1 Other regimens supported by the FSRH for monophasic pills include a shortened pill-free interval of 4 days (21/4, or 63/4) and ‘tailored’ use (method used continuously for ≥21 days until breakthrough bleeding occurs) with a shortened (4 days) or regular (7 days) pill-free interval.

A Cochrane review(2) of RCTs determined that continuous dosing or extended regimens have similar safety profiles, participant satisfaction, discontinuation rates and participant adherence as the traditional cyclical dosing regimen. Several menstruation-associated symptoms such as headaches, bloating and menstrual pain improved with extended dosing in the studies that looked at this outcome. While breakthrough bleeding may be an initial concern, overall, bleeding patterns appear to be improved with continuous administration, with most studies showing a decrease in overall bleeding days.

A variety of pill taking regimens and preparations have been studied and there is currently insufficient data to recommend one approach over another. Although continuous or extended regimes of CHC are off licence, health professionals should inform women of the advantages and reassure them of their safety. (1) Giving women more long term choice in their pill taking regimens may improve compliance and satisfaction with their method.

FACT: While continuous and extended regimes of COC are off licence, women should be informed that they are safe, effective and may have favourable bleeding patterns.

Update January 2019

A new updated Combined Hormonal Contraception guidance was released in January 2019 after this blog was published. You can view this guidance online here. 

References
1 Faculty of Sexual & Reproductive Healthcare.Combined Hormonal Contraception. October 2011 (Updated August 2012). Available at https://www.fsrh.org/standards-and-guidance/documents/combined-hormonal-contraception/ (Accessed 25/04/17)

2 Edelman A, Micks E, Gallo MF, et al. Continuous or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception. Cochrane Database Syst Rev 2014;:CD004695. doi:10.1002/14651858.CD004695.pub3