What oral contraceptive pill (OCP) is recommended for continuous use?

Oral Contraceptive Pills for Continuous Use

For continuous use oral contraceptive pills, monophasic combined hormonal contraceptives containing 20-30 mcg ethinyl estradiol with levonorgestrel, drospirenone, or dienogest are recommended, taken continuously without the hormone-free interval. 1, 2

Preferred Options for Continuous Use

• Monophasic combined oral contraceptives (COCs) are the best choice for continuous use regimens, as they provide consistent hormone levels throughout the cycle 2
• Pills containing 20-30 mcg ethinyl estradiol with levonorgestrel offer effective contraception with acceptable cycle control and good tolerability for continuous use 3, 2
• Drospirenone-containing pills (3 mg drospirenone/20-30 mcg ethinyl estradiol) are also suitable for continuous use, with the added benefit of treating PMDD symptoms if present 4
• 17β-estradiol-based pills with dienogest or nomegestrol acetate can be used continuously and may offer improved side effect profiles compared to ethinyl estradiol formulations 1, 5

Administration Protocol for Continuous Use

• Take one active hormonal pill daily without interruption (skip the placebo/inactive pills) 1, 2
• When starting a new pack, begin with the active pills immediately after finishing the active pills from the previous pack 1
• Consistent daily administration at approximately the same time each day is essential for maximum contraceptive effectiveness 4
• For optimal results, pills should be taken preferably after the evening meal or at bedtime with some liquid 4

Managing Breakthrough Bleeding

Breakthrough bleeding is the most common side effect of continuous OCP use and a primary reason for discontinuation:

• If breakthrough bleeding occurs, continue taking pills daily without interruption 1
• For persistent breakthrough bleeding that is bothersome to the patient, a 3-4 day hormone-free interval can be implemented (not during the first 21 days of continuous use and not more than once per month) 1
• After the brief hormone-free interval, resume continuous active pill use 1
• NSAIDs taken for 5-7 days may help reduce breakthrough bleeding 1
• Breakthrough bleeding typically improves over time with continued use 1, 2

Special Considerations

• If pills are missed, follow standard missed pill protocols - take the missed pill as soon as remembered and use backup contraception if 2 or more consecutive pills are missed 1
• In case of vomiting or diarrhea lasting >48 hours, use backup contraception until 7 consecutive days of pill-taking after symptoms resolve 1
• Continuous use OCPs are appropriate for women who want to reduce or eliminate monthly bleeding, treat menstrual-related symptoms, or improve contraceptive effectiveness 2
• Women with conditions exacerbated by menstruation (such as endometriosis, dysmenorrhea, menorrhagia, or menstrual migraines) may particularly benefit from continuous regimens 2

Common Pitfalls and Caveats

• Breakthrough bleeding is more common with continuous regimens, especially during the first 3-6 months, but typically improves with time 1, 2
• Patient counseling about expected bleeding patterns is essential to improve adherence 1
• Switching between therapeutically equivalent and brand-name low-dose OCPs may affect hormone bioavailability and increase breakthrough bleeding 6
• Continuous use does not increase overall side effects compared to cyclic use but may require more management of breakthrough bleeding 2
• If breakthrough bleeding persists despite management strategies, consider switching to a different formulation or returning to cyclic use 1, 2