Clinical Review

Using contraceptives to alter bleeding patterns

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Troublesome symptoms during the hormone-free interval can be alleviated by reducing that interval to 4 days.

Until recently, OCs typically contained 21 days of estrogen plus a progestin and 7 hormone-free days. The rationale for this design was to mimic an average cycle length of 28 days. Also, by limiting active pills to 21 days, spotting and breakthrough bleeding were minimal after several months of use. The drawback of this design is its association with monthly hormone-withdrawal symptoms. A study of these symptoms in OC users confirmed that pelvic pain, headaches, breast tenderness, bloating, swelling, and the use of pain medicines were more common during the 7-day hormone-free interval, compared with the 21 active days (TABLE 2).2


Hormone withdrawal symptoms in oral contraceptive users2

SYMPTOMDuring 21 active-pill daysDuring 7 hormone-free days
Pelvic pain21%70%
Breast tenderness19%58%
Use of pain meds43%69%
*P value was <.001 for all symptoms.>

Extending active pills delays menses

Extending the duration of active OC pills delays menses and reduces hormone-withdrawal symptoms.

  • In a series of 50 patients with menstrual disorders who were offered extension of their active tablets to delay menses, 75% were stabilized on an extended regimen, with the most common pattern being 12 weeks of active pills.3 About one quarter of the patients discontinued OCs or returned to the standard regimen—3 weeks of active pills.
  • In a follow-up study of 292 patients on OCs who experienced hormone-withdrawal symptoms, 92% of women who were offered extension of their active pills agreed to try the lengthened pattern.4 Of the women who accepted the extended regimen, 19% discontinued OCs, and 13% extended active pills but then returned to a standard regimen. One hundred seventy-two patients (59%) maintained the extended pattern. The typical pattern was 12±12 weeks of active pills, with a median of 9 weeks and a range of up to 104 consecutive weeks. Patients also were given the option of decreasing the number of hormone-free days. The typical hormone-free interval was 6±2 days, with a median of 5 days and a range of 0 to 7 days.
What do women want? A snapshot of patient and physician preferences

How do women feel about menses? That was 1 of the questions posed during a recent Harris poll of 491 women between the ages of 18 and 49. When asked whether they relied on monthly menstruation to let them know they were “healthy,” two thirds said no; further, 44% said they would prefer less-frequent menses. More than 25% of respondents reporting missing a professional, social, athletic, or family-oriented event due to their period, menstrual cramps, or other menstrual-related symptoms.

In a separate survey of 46 female clinicians conducted by the Association of Reproductive Health Professionals (ARHP), more than 57% reported being asked by patients about manipulating menses, and 70% had prescribed extended oral contraceptive (OC) regimens. Among 63 female nurse practitioners who also were surveyed, 73% had been asked by patients about extended OC regimens, and 85% had prescribed them.

When queried about factors that made clinicians likely to prescribe an extended regimen, more than 80% cited patient requests and therapeutic purposes (e.g., lifestyle concerns).

For more information, visit the ARHP Web site at

Factors to consider for extended OC regimens

When extending OC regimens, clinicians need to consider several factors.

If patients are taking OCs for the first time, the best course may be to rely on the standard regimen for the first 2 months because of the high incidence of breakthrough bleeding and spotting when OCs are initiated. After this time, if the patient has hormone-withdrawal symptoms or simply wants to delay menses, she can try extending the active pills.

The patient must be warned that although she can go off pills for up to 7 days, the hormone-free interval should never be any longer.

Active pills can be extended in several ways. The patient can take pills for a specific number of consecutive weeks (such as 6, 9, or 12 weeks). Or, she can simply continue taking consecutive active pills until breakthrough bleeding occurs. She then should observe a 7-day (or shorter) hormone-free interval and restart the OCs.

Troublesome symptoms during the hormone-free interval can be alleviated by reducing that interval to 4 days. The patient must be warned, however, that although she can go off pills for up to 7 days, the hormone-free interval should never be any longer.

Making sure the patient understands and is comfortable with this extended regimen is extremely important.

Future options

Although current contraceptive methods allow clinicians to address patient preferences about menstrual patterns, even more options may well be available in the future. Studies of an 84-day/7-day OC regimen are underway.

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