Continuous and Extended Combined Pill Regimens

Extended and continuous regimens remove or shorten the hormone-free interval of the combined pill. Extended use means taking active tablets for 42 to 84 days or more before a short break. Continuous use means taking active tablets daily with no break. Both keep ovarian suppression more complete than the usual 21 and 7 pattern, because follicular development in the hormone-free week is the usual source of ovulation escape after missed pills.

Regimens.

These patterns use a monophasic pill, because every active tablet must be identical. Use outside the usual pack schedule needs informed consent and documentation.

Effectiveness. Contraceptive efficacy equals or exceeds cyclic use. As a pill class, 8 pregnancies in 100 women in the first year with typical use and 0.3 with perfect use.

Return to fertility. Without delay after stopping.

Endometrial safety. Continuous suppression is not linked to endometrial hyperplasia; the endometrium stays thin.

Indications. Heavy or prolonged menstrual bleeding, dysmenorrhoea, endometriosis, premenstrual symptoms, menstrual migraine without aura, iron-deficiency anaemia from heavy bleeding, and patient wish to avoid withdrawal bleeds, including for travel or sport.

Eligibility. Categories are those of any combined pill.

• Category 4: migraine with aura; breastfeeding under 6 weeks; blood pressure 160/100 or more; ischaemic heart disease, stroke or complicated valvular disease; breast cancer; current or past deep vein thrombosis or pulmonary embolism; smoker 35 years or more with 15 or more cigarettes daily; diabetes with vascular disease; decompensated cirrhosis.
• Category 3: rifampicin, rifabutin, enzyme-inducing antiseizure medicines, blood pressure 140/90 to 159/99.

Investigations. Blood pressure and body mass index. No routine laboratory tests.

Counselling points for the clinician. Unscheduled bleeding is common in the first 3 to 6 months and falls with time; amenorrhoea is usual and harmless; absence of bleeding is not a sign of pregnancy, so symptoms or missed pills prompt a test; the regimen is not a medical need for a monthly bleed. Consent and no coercion.

Regimen line. Monophasic combined pill, oral, one active tablet daily at about the same time.

For packs with 21 active tablets, start the next pack the day after the last active tablet and omit the hormone-free tablets. For 28 tablet packs, discard the inactive tablets.

Start within 5 days of the start of menses with no backup; later starts need 7 days of backup.

Grace: missing 1 or 2 pills carries little or no risk. Backup 7 days after 3 or more missed pills.

Enzyme inducers: do not use. Postpartum: not before 21 days if not breastfeeding; breastfeeding from 6 months.

Tailored use. After at least 21 consecutive active days, take a 4 day break when bleeding has lasted 3 consecutive days. The break is never longer than 4 days. Restart active tablets after the break whether or not bleeding has stopped.

Planned break. After 42 to 84 days of continuous use, or at the patient’s choice, a break of 4 to 7 days is taken. It never exceeds 7 days.

Missed pills. Missed 1 or 2 pills: take one now and continue, no backup. Missed 3 or more pills: take one now, continue, backup 7 days, consider emergency contraception if sex in the last 5 days. If 3 or more pills are missed in the 7 days before a planned break, omit the break and continue straight to the next active tablets, with backup for 7 days. Vomiting within 2 hours of a pill: take another. Vomiting or diarrhoea for more than 2 days: apply the rule for 3 or more missed pills.

Supply. Up to 3 packs may be issued at a visit, which lasts about 9 weeks of continuous use with 21 active tablet packs. Plan visits for resupply accordingly.

Switching. From a cyclic pill, move to the extended pattern at the end of any active pack with no gap. To stop, take the usual hormone-free interval and switch method without a gap, or stop and use backup.

Follow up. At about 3 months and then yearly: blood pressure, weight, smoking, medicines, bleeding. Reassess from 40 years; at about 50 years a change to a progestin-only or non-hormonal method is usual practice.

Expected effects. Breakthrough spotting and bleeding, most frequent in the first 3 to 6 months, then declining; amenorrhoea in most long-term users; nausea, breast tenderness, headache.

Management of breakthrough bleeding. Check adherence and exclude pregnancy, infection, interacting medicines and cervical disease. Use the tailored 4 day break after 21 consecutive active days. If unacceptable, return to a cyclic regimen or change the progestin. Ibuprofen 800 mg orally three times daily for 5 days with food gives short-term relief (maximum 2.4 g daily; avoid in renal impairment, active peptic ulcer or significant liver disease; not used in pregnancy).

Serious complications and red flags. Risk of venous thromboembolism, stroke and myocardial infarction is not shown to differ from cyclic use. Severe abdominal pain, chest pain or breathlessness, severe or new headache, eye problems and severe calf pain: stop and refer urgently.

When to change method. Category 4 conditions, migraine with aura, enzyme-inducing medicines, or breakthrough bleeding that stays unacceptable after tailoring.

Referral and escalation. Persistent unexplained bleeding after 6 months or new pelvic pain needs examination and investigation. Emergency transfer for suspected thrombosis, stroke or myocardial infarction.