Menstrual suppression through the extended or continuous use of the oral combined contraceptive pill is becoming a popular option for many women. Traditional use of the OCP with 21 hormone pills and 7 placebo pills, allowing for a withdrawal bleed, was designed to satisfy the social and religious pressures of the 1950's and mimic a woman's natural menstrual cycle.¹ A withdrawal bleed has no physiological basis.

Review of the Research

A recent Cochrane review of the Continuous or extended cycle versus cyclic use of combined oral contraceptives for contraception2 looked at 6 randomised controlled trials and found that the pregnancy rates and safety profiles were the same for both methods. There was no difference in compliance or discontinuation rates and satisfaction with bleeding patterns was similar. Most studies reported either equivalent or less bleeding with the continuous method compared to the traditional method.

Continuous OCP use results in a thin endometrium due to the progestin effect and is more effective at suppressing pituitary activity than cyclic pill taking.² The few studies that looked at menstrual symptoms found that the extended cycle group suffered less headaches, dysmenorrhoea, genital irritation, bloating and tiredness. Contraceptive effectiveness and rare adverse events were not assessed due to the inadequate size of the trials and it was concluded that more research into the longterm health effects was indicated. No studies have assessed the potential adverse risks eg thromboembolic events or breast cancer associated with continuous compared to cyclical use.

Are there advantages?

Using the OCP to avoid menstruation has definite medical uses eg management of endometriosis, dysmenorrhoea, anaemia, menorrhagia and menstrually related symptoms such as migraines and PMT.Menstrual suppression is also popular for reasons of personal preference such as less interference with activities and individual choice such as a dislike of menstruation.

Are there disadvantages?

Initially unscheduled or "break through" bleeding is more common in the continuous users than with the traditional method. However there appears to be a decrease in the total number of bleeding days with the continuous method and there is a significant improvement in the incidence of break through bleeding after the first 3 -6 months of continuous use.³ Pregnancy may be more difficult to recognise but it is reassuring that there are no known associations between the OCP and specific congenital abnormalities.³

What about the cost?

Many women regard menstrual suppression as "unnatural." It is important to explain to them that a withdrawal bleed is not a natural period, that there is no medical or health reason to have the bleed and that there are many natural states when periods stop eg during pregnancy, breast feeding and menopause. In fact, the regimens used in the research studies showed that in many cases there is still spotting, so overall there is not complete menstrual suppression.

Explaining that there is no "build up" of menstrual fluid may also be necessary. The progestin in the OCP keeps the endometrium thin making it unlikely to result in heavier periods. Return to fertility after discontinuation appears to be similar to the traditional method.

Marketing

Extended use method is marketed overseas as Seasonale (0.03mg EE, 0.15 mg levonorgestrel) with 84 hormone pills and 7 placebos and Seasonique with 84 pills containing 0.03mg EE, 0.15mg levonorgestrel and 7 pills containing 0.01mg EE .

Continuous use is marketed as Lybrel in USA (0.02EE, 0.09mg levonorgestrel).Continuous and extended OCP use appears to be a safe and effective method of contraception that increases the choices available not only in contraception but also in control of the menstrual cycle.

REFERENCES
1. Gladwell M. John Rock’s error. [Online, 2000] Available at: http://www.gladwell.com/pdf/johnrock.pdf. Accessed on 6 June 20112.
2.  Edelman AB, Gallo MF, Jensen JT, Nichols MD, Schulz KF, Grimes DA. Continuous or extended cycle versus use of combined oral contraceptives for contraception. Cochrane Database Syst Rev 2005; 3:CD004695.
3. Edelman AB. Menstrual nirvana: Amenorrhoea through the use of continuous oral contraceptives. Curr Women’s Health Rep 2002; 2(6):434-438. 
 
Disclaimer
The information in this Factsheet has been provided for educational purposes only. FPNSW has taken every care to ensure that the information is accurate and up-to-date at the time of publication. Individuals concerned about any personal reproductive or sexual health issue are encouraged to seek advice and assistance from their health care provider or visit an FPNSW clinic.