What is the recommended treatment regimen to delay menses?

Treatment Regimen to Delay Menses

To delay menstruation, continue taking active combined oral contraceptive pills (containing 30-35 μg ethinyl estradiol) without the hormone-free interval, skipping the placebo pills and immediately starting a new pack of active pills. 1

Recommended Approach

Initial Method Selection

• Use monophasic combined oral contraceptives containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate as the preferred formulation for menstrual manipulation 2, 3
• Extended or continuous regimens involve taking active pills for 3-4 months consecutively, followed by a 4-7 day hormone-free interval only when desired 3
• This approach is safe and effective, with decades of clinical experience demonstrating successful endometrial suppression for several months 4, 5

Practical Implementation

• Patients can skip the placebo pills (hormone-free interval) for 3-4 consecutive days to temporarily induce bleeding if needed, but this should not be done during the first 21 days of use and not more than once per month 1, 3
• For Sunday start regimens: continue taking one white (active) tablet daily without interruption, bypassing the placebo week entirely 6
• For Day 1 start regimens: follow the same principle of continuous active pill use 6

Managing Breakthrough Bleeding

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

Treatment Options for Breakthrough Bleeding

• Add NSAIDs for 5-7 days during bleeding episodes to acutely reduce blood flow 2, 3
• If breakthrough bleeding becomes problematic, allow a 3-4 day hormone-free interval to temporarily induce bleeding and thin the endometrium, but avoid this during the first 21 days of continuous use 1, 3
• Before treating breakthrough bleeding, rule out underlying conditions including pregnancy, sexually transmitted infections, medication interactions, cigarette smoking, or new pathologic uterine conditions such as polyps or fibroids 1, 2

Important Counseling Points

Pre-Treatment Discussion

• Counsel patients before initiation that unscheduled bleeding is expected in the first 3-6 months but is not harmful and decreases over time 1, 2
• Reassure patients that withdrawal bleeding with traditional pill cycles is medically unnecessary and that amenorrhea with continuous use does not require treatment 3, 4
• Studies demonstrate that 80-100% of women achieve amenorrhea by 10-12 months of continuous use 7

Safety Considerations

• Assess thrombotic risk factors before prescribing, as combined oral contraceptives increase venous thromboembolism risk three to fourfold 2, 3
• Monitor blood pressure at follow-up visits 2, 3
• Smoking is not a contraindication in women under 35 years old 3

Backup Contraception Requirements

• If starting combined hormonal contraceptives more than 5 days after menses begins, use backup contraception for 7 days 1
• When switching from another method, backup contraception for 7 days is needed only if starting more than 5 days after menses 1

Alternative Considerations

If continuous combined oral contraceptives are not suitable or bleeding persists despite treatment and is unacceptable to the patient, consider alternative methods including the levonorgestrel-containing IUD or depot medroxyprogesterone acetate 1, 3