Which oral contraceptive regimen can be taken continuously without a hormone‑free (placebo) interval?

Oral Contraceptives for Continuous Use Without Placebo

Any monophasic combined oral contraceptive (COC) containing the same dose of estrogen and progestin in every active pill can be used continuously by simply skipping all placebo pills and starting the next pack immediately after finishing the active pills. 1

How to Implement Continuous Use

The approach is straightforward: finish all active hormonal pills in your current pack, then immediately start a new pack the next day, discarding all placebo/hormone-free pills. 1 This method works with any monophasic COC formulation—you don't need a specially marketed "extended cycle" product.

Key Implementation Points:

• No backup contraception is required when transitioning to continuous use if pills have been taken correctly up to that point 1
• Seven consecutive days of active hormonal pills are necessary to reliably suppress ovulation, which is why continuous use (eliminating the hormone-free interval entirely) may actually enhance contraceptive effectiveness 2, 1
• This regimen is particularly beneficial for women who frequently miss pills, as it eliminates the risky extended hormone-free interval when ovulation risk increases 2, 1

Managing Breakthrough Bleeding

Unscheduled bleeding is common during the first 3-6 months of continuous use but typically decreases with continued use. 1, 3 This is the most important counseling point for patient adherence.

If Breakthrough Bleeding Becomes Bothersome:

• First-line management: reassurance and continuation of the regimen, as bleeding usually improves over time 3
• If treatment is desired: a short course of NSAIDs for 5-7 days during active bleeding episodes 3
• If bleeding persists and is unacceptable to the patient: take a planned 3-4 day hormone-free interval to allow withdrawal bleeding, then resume continuous use 1, 3

Critical Restrictions for Hormone-Free Intervals:

• Never use a hormone-free interval during the first 21 days of starting continuous use 1, 3
• Never repeat hormone-free intervals more than once per month, as this compromises contraceptive effectiveness 1, 3

Clinical Benefits of Continuous Regimens

Continuous use offers multiple advantages beyond contraceptive efficacy:

• Enhanced contraceptive protection by eliminating the hormone-free interval when ovulation risk is highest 1, 4
• Reduced menstrual-related symptoms including dysmenorrhea, menorrhagia, and premenstrual symptoms 4, 5, 6
• Particularly appropriate for women with anemia, severe dysmenorrhea, endometriosis, or bleeding disorders 1, 7
• May help manage conditions exacerbated by hormonal fluctuations, including migraines without aura, epilepsy, and irritable bowel syndrome 1

Important Caveats

Before attributing any new bleeding to the continuous regimen, always rule out pregnancy, sexually transmitted infections, and structural uterine pathology. 3 This is a critical pitfall to avoid—never assume all breakthrough bleeding is benign.

Women who find breakthrough bleeding unacceptable despite appropriate management should consider alternative contraceptive methods that are less user-dependent, such as IUDs, implants, or injectables. 1, 3

Commercially Available Extended-Cycle Products

While any monophasic COC can be used continuously, several FDA-approved extended-cycle formulations exist 6:

• 24/4 regimens: 24 active pills followed by 4 placebo days (ethinyl estradiol 20 mcg with either drospirenone 3 mg or norethindrone 1 mg) 6
• 84/7 regimens: 84 active pills followed by 7 placebo days (ethinyl estradiol 30 mcg-levonorgestrel 150 mcg), with some formulations providing low-dose ethinyl estradiol (10 mcg) during the 7-day interval rather than placebo 6
• Continuous regimens: ethinyl estradiol 20 mcg-levonorgestrel 90 mcg taken every day without any hormone-free interval 6

However, these specially marketed products offer no advantage over simply using any standard monophasic COC continuously by skipping placebo pills. 1, 4, 5