What combined oral contraceptives (COCs) are formulated for continuous use to suppress menstruation and reduce menstrual blood loss?

Combined Oral Contraceptives Formulated for Continuous Use

Extended and continuous combined oral contraceptive regimens (using active pills for more than 28 consecutive days) are specifically designed to suppress menstruation and reduce menstrual blood loss, with 24/4 regimens (24 active pills followed by 4 hormone-free days) providing superior ovulation suppression compared to traditional 21/7 cycles. 1

Specific Formulations and Regimens

24/4 Regimens (Preferred for Menstrual Suppression)

• 24/4 COC regimens provide greater suppression of ovulation compared to standard 21/7 regimens due to the shorter hormone-free interval (4 days vs 7 days), resulting in lower pregnancy rates and significantly greater ovulation suppression among women with irregular periods 1
• These formulations contain 24 consecutive days of active hormonal pills followed by only 4 days of placebo or hormone-free interval 1

Extended-Cycle Regimens (84/7 Pattern)

• Extended-cycle regimens involve taking active pills for 84 consecutive days followed by 7 hormone-free days, effectively reducing withdrawal bleeding to once every 3 months 2, 3
• Clinical trials demonstrate an initial increase in unscheduled bleeding during the first few months, but an absolute decrease in total bleeding days from the first cycle of use 2

Continuous Regimens (No Hormone-Free Interval)

• Continuous use eliminates the hormone-free interval altogether, with active pills taken daily without interruption 4, 3
• The contraceptive vaginal ring (NuvaRing) can be used continuously by replacing it every calendar month (up to 35 days) rather than the labeled 28-day cycle, making it an excellent option for extended use 5

Clinical Indications for Continuous/Extended Use

Medical Conditions Benefiting from Menstrual Suppression

• Anemia, heavy menstrual bleeding, and Von Willebrand disease or other bleeding diatheses are primary indications where continuous COC use reduces blood loss 5
• Severe dysmenorrhea and endometriosis respond well to extended or continuous regimens 5, 6
• Conditions that worsen cyclically benefit from continuous use: migraine without aura, epilepsy, irritable bowel syndrome, inflammatory bowel disease, and psychiatric/behavioral symptoms 5

Managing Breakthrough Bleeding

Expected Pattern and Counseling

• Unscheduled spotting or bleeding is the most common adverse effect during the first 3-6 months of extended or continuous use, but this bleeding is not harmful and decreases with continued use 7
• Patients must understand that breakthrough bleeding does not indicate contraceptive failure 7

Treatment Algorithm for Persistent Bleeding

• First-line management: Continue the regimen without interruption during the first 3-6 months unless bleeding is clinically concerning 7
• If bleeding persists and treatment is desired:
  • NSAIDs for 5-7 days during bleeding episodes 1, 7
  • If NSAIDs fail, consider a hormone-free interval of 3-4 consecutive days (not during the first 21 days of use and not more than once per month to maintain contraceptive effectiveness) 1, 7
  • Changing to a COC with higher estrogen content may be considered 7
• Rule out underlying pathology: Cigarette smoking, sexually transmitted infections, pregnancy, and new uterine conditions (fibroids, polyps) can contribute to breakthrough bleeding 7

Contraceptive Effectiveness Considerations

Initiation and Backup Contraception

• If COCs are started within the first 5 days of menstrual bleeding, no additional contraceptive protection is needed 5
• If started >5 days since menstrual bleeding began, use backup contraception (condoms or abstinence) for 7 consecutive days 5, 1

Missed Pill Instructions

• One pill late (<24 hours): Take as soon as possible and continue regular schedule 1
• One pill missed (24-48 hours): Take missed pill immediately and use backup contraception for 7 days 1
• Two or more consecutive pills missed (≥48 hours): Take most recent missed pill immediately and use backup contraception for 7 days 1
• Emergency contraception is indicated if 2 or more pills are missed in the first week of the cycle 5

Important Caveats

Contraindications

• COCs should not be prescribed for patients with severe uncontrolled hypertension, ongoing hepatic dysfunction, complicated valvular heart disease, migraines with aura, thromboembolism, or thrombophilia 1
• For women with risk factors for thromboembolism, consider progestin-only methods as alternatives 1

Follow-Up Requirements

• Schedule follow-up visits 1-3 months after initiating continuous COC use to address adverse effects or adherence issues 1
• Measure blood pressure at follow-up visits for women using combined hormonal contraceptives 1
• If irregular bleeding persists beyond 3-6 months and is unacceptable to the patient, counsel on alternative contraceptive methods (IUD, implant, or injectable) that are less dependent on user adherence 1, 7