CONTRACEPTION
A number of refinements in access to, or use of, hormonal contraception deserve our attention
Extended cycles can be achieved with any monophasic OC in an off-label manner. Simply instruct the patient to take one active tablet for 42 consecutive days (known as “bicycling”) or for 63 consecutive days (“tricycling”), followed by 4 to 7 pill-free days.
Unscheduled bleeding with the 63-day regimen appears to be similar to the rate associated with the 21-day regimen.35 An extended-cycle regimen can be modified according to how often the user wants withdrawal bleeding.
Eliminate the withdrawal week
Perhaps the most radical extended-cycle regimen is continuous use of active pills with no placebo or withdrawal interval. This option is safe and acceptable to women, according to two small randomized trials and two prospective trials, but larger studies are needed to confirm these results.37-40 Continuous use for 1 year is associated with less bleeding, higher rates of amenorrhea, and similar side effects, compared with conventional regimens.37,38 Patient acceptance and satisfaction also are high,39 with most women choosing to keep taking the pill continuously. Lybrel, an OC designed for this purpose, contains 20 μg of ethinyl estradiol and 90 μg of levonorgestrel and is intended to eliminate menses through 1 year of continuous use.
Reduce breakthrough bleeding
For women who experience unscheduled bleeding while taking an OC continuously, one option is to stop taking pills when breakthrough bleeding occurs and initiate a hormone-free interval. This approach was studied in a randomized trial in which women were scheduled to take an OC continuously for 168 days.40 Women who had persistent unscheduled bleeding for longer than 7 days were randomized to a 3-day hormone-free interval or continuation of the active pills. Those who continued taking active pills had more bleeding over the long term, and a large percentage found it necessary to institute a delayed hormone-free interval.
This option may be particularly useful for women who experience persistent breakthrough bleeding on a continuous regimen.40
