Best Practice & Research Clinical Obstetrics & Gynaecology
8Continuous oral contraception: changing times
Section snippets
Drawbacks of the 21/7 regimen
While 21/7 OCs have been the mainstay over the 45-year history of the pill, reductions in dosage have led to a need to redesign the standard regimen with a focus on modifications in the 7-day HFI.
Modifying the 21/7 OC Regimen
OC regimens that extend the active pill interval beyond the conventional 21 days have been used for more than 20 years.22, 23, 24 However, prior to the introduction of a 91-day extended-regimen product in the USA in 2003, use of an extended regimen required creative prescribing on the part of healthcare providers with instructions on how to modify their 21/7 pill pack by eliminating the 7-day HFI and going immediately into the next packet of pills.
Newer OC regimens approved for use have
Reduction in menstrual bleeding
The duration and blood loss during scheduled (hormone withdrawal) bleeding after an extended cycle of hormonal contraception is of no greater duration or severity than blood loss experienced after 28-day cycles. For example, the median number of days of scheduled bleeding per episode was 2.5 days with the 91-day regimen and 2.8 days with the 28-day cycle in a comparative study of a 91-day OC regimen.27 Therefore, over a comparable 3-month study period, the 28-day cycle user would potentially
Patient preference
Changes in reproductive patterns such as marrying later, having fewer children and shorter intervals of breastfeeding has left modern women with many more menstrual periods than their predecessors.54 The resulting increased number of menstrual cycles over a lifetime has not been welcomed by all women. Monthly menstruation in women of reproductive age is necessary unless the patient is pregnant, using hormonal contraception, breastfeeding or has undergone hysterectomy.
Menstrual disorders are the
Safety of extended regimens
When the published data regarding extended regimens are examined in total, the safety profile is virtually the same as for 21/7 cycles. Despite concerns that extended cycles provide more cumulative oestrogen exposure over a month, adverse event profiles with extended cycles have been comparable to that reported with the conventional regimen. The safety of 91-day regimens has been demonstrated in both 1-year trials and longer-term 2-year studies.27, 28, 34
Metabolic changes, such as blood glucose
Summary
Oral contraceptives are the most common method of reversible contraception and have provided women with many non-contraceptive benefits. With the reduction in hormone content over the past few decades, the standard 7-day HFI has been shown to lead to unacceptable pituitary–ovarian escape leading to follicular development, endogenous oestradiol production, and possible ovarian cyst formation and ovulation. Hormone withdrawal symptoms as a result of the 7-day HFI can lead to discontinuation and
Acknowledgements
The author would like to thank Kathryn Martin for her invaluable assistance with this manuscript.
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Cited by (35)
The not-so-bitter pill: Effects of combined oral contraceptives on peripheral physiological indicators of emotional reactivity
2017, Hormones and BehaviorCitation Excerpt :Low dosage COC with ≤ 35 mcg EE are now standard (Bitzer and Simon, 2011). Reductions in dosage also resulted in calls for a redesign of the conventional 28-day regimen (21 days active/7 days placebo; Sulak, 2008). Shortening or eliminating the pill-free interval has been suggested to reduce hormone withdrawal symptoms and intermenstrual side effects (Burkman et al., 2011).
Continuous Norethisterone Acetate versus Cyclical Drospirenone 3 mg/Ethinyl Estradiol 20 μg for the Management of Primary Dysmenorrhea in Young Adult Women
2016, Journal of Pediatric and Adolescent GynecologyRandomized trial of the effect of tailored versus standard use of the combined oral contraceptive pill on continuation rates at 1 year
2013, ContraceptionCitation Excerpt :The introduction in the 1950s of a standard COC regimen, consisting of 21 daily pills followed by a 7 day pill-free interval (PFI) to induce withdrawal bleeding, reflected the prevailing cultural pressure to mimic the natural menstrual cycle rather than any pharmacological consideration. Withdrawal bleeding can be avoided by simply omitting the pill-free days, with several studies reporting variable benefits with different COC formulations in different groups of women [7,8]. Compared with standard COC use, women on continuous or extended use tend to report fewer menstrual-related symptoms, such as headache, breast tenderness and bloating, but continuous use can also lead to more nuisance bleeding [7].
Magnetic Resonance Imaging (MRI) of hormone-induced breast changes in young premenopausal women
2013, Magnetic Resonance ImagingCitation Excerpt :Current and recent use of OCs was associated with increased breast cancer risk in the largest meta-analysis of epidemiological studies to date [27]. However, many of the formulations that were commonly used by women in these studies have been replaced by new ones that include new progestins [28,29], reduced doses of estrogen and progestin [30], and varied administration schedules [31]. There are limited data about the effects of these new OC formulations on the breast tissue and breast cancer risk.
Menstrual Suppression for Combat Operations: Advantages of Oral Contraceptive Pills
2011, Women's Health Issues