How to Prevent Monthly Periods with Birth Control Pills
To prevent monthly menstrual periods, use combined oral contraceptives in an extended or continuous regimen by taking active hormone pills for more than 28 consecutive days, skipping the traditional 7-day hormone-free interval. 1, 2
Recommended Regimen
Start with monophasic combined oral contraceptives containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate, taken continuously without hormone-free intervals. 1 This approach:
- Induces regular shedding of a thinner endometrium, effectively suppressing menstruation 1
- Provides additional benefits including improvement in acne and reduced risk of endometrial and ovarian cancers 1
- Has equivalent contraceptive efficacy and safety compared to traditional 28-day cycling 3, 4
What to Expect: Bleeding Patterns
Unscheduled bleeding and spotting are common during the first 3-6 months but decrease significantly over time. 1, 2 Specifically:
- Initial increase in unscheduled bleeding days occurs early, but absolute total bleeding days decrease from the first cycle 5
- Over time, unscheduled bleeding decreases to rates similar to conventional-cycle regimens 5, 3
- Eleven out of twelve randomized trials found bleeding patterns were equivalent or improved with extended/continuous cycles over time 4
Managing Breakthrough Bleeding
If unscheduled bleeding occurs during extended use:
- Reassure the patient that bleeding is common in the first 3-6 months and generally not harmful 1, 2
- Add NSAIDs for 5-7 days during bleeding episodes to reduce blood flow acutely 1, 2
- Consider a hormone-free interval of 3-4 consecutive days for heavy or prolonged bleeding, but NOT during the first 21 days of extended regimen use and not more than once per month 1, 2
Pre-Treatment Requirements
Before initiating combined oral contraceptives:
- Measure blood pressure (women with systolic ≥160 mmHg or diastolic ≥100 mmHg should not use combined hormonal contraceptives) 6
- Rule out pregnancy, sexually transmitted infections, and structural lesions 1, 2
- Assess thrombotic risk factors (combined oral contraceptives increase venous thromboembolism risk three to fourfold) 1, 2
Additional Benefits of Extended Regimens
Extended and continuous regimens provide:
- Decreased estrogen-withdrawal symptoms including headaches, genital irritation, tiredness, bloating, and menstrual pain 3, 4, 7
- More reliable ovulation suppression, likely improving contraceptive efficacy 7
- High user acceptability and satisfaction 4, 7
- Reduced menstruation-related absenteeism from work or school 3, 4
Follow-Up Care
- No routine follow-up visit is required 1
- Patients should return for side effects, concerns, or if they want to change methods 6, 1
- Monitor blood pressure at follow-up visits 6
- Assess satisfaction with the method and any health status changes 6, 1
Important Safety Caveat
Combined oral contraceptives increase the risk of venous thromboembolism three to fourfold (up to 4 per 10,000 woman-years). 1, 2 Women with multiple thrombotic risk factors or history of VTE should not use this method.
If Bleeding Persists
If bleeding persists beyond 6 months or the woman finds it unacceptable, counsel on alternative contraceptive methods such as the levonorgestrel-releasing IUD, which also suppresses menstruation. 1, 2