What methods can be used to delay menstruation?

Delaying Menstruation: Evidence-Based Methods

The most effective method to delay menstruation is to use combined hormonal contraceptives (pills, patch, or ring) in an extended or continuous regimen by skipping the hormone-free interval and immediately starting the next cycle of active hormones. 1, 2

Primary Method: Extended/Continuous Combined Hormonal Contraceptives

For Women Already Using Combined Oral Contraceptives

• Skip the 7-day hormone-free interval (placebo pills) and immediately start a new pack of active pills to delay menstruation for as long as desired 1, 3
• This can be done for single-cycle postponement or extended periods of 6-12 weeks or longer 3, 4
• No additional contraceptive protection is needed when continuing active pills 1

For Women Not Currently Using Hormonal Contraception

• Start combined hormonal contraceptives approximately 7 days after ovulation (mid-cycle) if attempting to delay a single expected period 3
• Alternatively, start combined hormonal contraceptives and plan for extended use from the beginning 5
• If started >5 days after menstrual bleeding began, use backup contraception for 7 days 1

Available Formulations

Combined hormonal contraceptives include: 1

• Oral contraceptive pills (various formulations)
• Transdermal patch (releases 150 μg norelgestromin and 20 μg ethinyl estradiol daily)
• Vaginal ring (releases 120 μg etonogestrel and 15 μg ethinyl estradiol daily)

Expected Bleeding Patterns and Management

Initial Adjustment Period

• Unscheduled spotting or bleeding is common during the first 3-6 months of extended or continuous use and generally decreases with continued use 1, 2
• This breakthrough bleeding is not harmful and does not indicate method failure 1
• Enhanced counseling about expected bleeding patterns significantly reduces discontinuation rates 2

Managing Persistent Breakthrough Bleeding

If breakthrough bleeding persists beyond 3-6 months and is bothersome: 1

• First rule out: pregnancy, medication interactions (especially with other drugs), cigarette smoking, STDs, or new uterine pathology (polyps, fibroids) 1
• If no underlying problem is found, consider a 3-4 day hormone-free interval (but NOT during the first 21 days of continuous use, and NOT more than once per month to maintain contraceptive effectiveness) 1
• If bleeding remains unacceptable despite management, counsel on alternative contraceptive methods 1

Clinical Efficacy and Safety

Effectiveness Data

• Extended regimens (84 days active pills + 7 days placebo) show pregnancy rates <1% for compliant users and 1.5% for all participants 3
• Extended use successfully suppresses endometrial activity and prevents menstruation for several months 5
• 80-100% of women achieve amenorrhea by 10-12 months of continuous use 6

Mechanism of Action

Combined hormonal contraceptives delay menstruation by: 2

• Creating a thinner endometrial lining through estrogen and progestin effects
• Inhibiting ovulation and the hormonal cascade that triggers menstruation
• Reducing prostaglandin production, which decreases uterine motility and cramping

Safety Considerations

Absolute contraindications to combined hormonal contraceptives include: 2

• Severe uncontrolled hypertension
• Ongoing hepatic dysfunction
• Complicated valvular heart disease
• Migraines with aura
• History of thromboembolism or thrombophilia
• Positive antiphospholipid antibodies

The baseline risk of venous thromboembolism increases 3-4 fold with combined hormonal contraceptives, though this remains lower than pregnancy-associated risk 2

Special Populations Who May Particularly Benefit

Extended or continuous regimens are especially beneficial for women with: 2, 7, 6

• Severe dysmenorrhea (menstrual cramps)
• Endometriosis
• Menorrhagia (heavy menstrual bleeding)
• Bleeding disorders
• Menstrual migraines
• Premenstrual symptoms
• Epilepsy exacerbated by menses

Important Clinical Pearls

Pregnancy Exclusion

• Always ensure reasonable certainty that the patient is not pregnant before initiating or continuing extended regimens 8
• If a patient misses expected withdrawal bleeding and has not adhered to the prescribed schedule, rule out pregnancy before continuing 8
• If two consecutive periods are missed despite adherence, rule out pregnancy 8

Dosing Considerations

• Lower-dose estrogen pills (20 μg ethinyl estradiol) show more follicular activity when missed compared to 30 μg formulations, potentially increasing breakthrough bleeding risk 1
• Monophasic formulations are preferred for extended use over multiphasic regimens 3

Patient Counseling

• Withdrawal bleeding during the hormone-free interval is an artificial, medically unnecessary event 5
• Most women welcome less frequent menses or amenorrhea when given the option 7, 6
• Total bleeding days decrease with extended use despite initial increase in unscheduled spotting 5