Continuous Use of Combined Contraception

Thank you to our practice pharmacist Najla Salamsi for writing the blog post below.

She explains recent changes in the way that health professionals advise women to take their combined contraceptive pills, patches and rings. The take home message is that having a break from your contraceptive every month is not necessary. Women can choose to take their contraception continuously so as to not have a period at all (strictly speaking, it is a withdrawal bleed … not a period) - or for several months at a time, which allows them to choose when to have their period. Please read below for more information or arrange an appointment with Najla or with your GP should you want to talk about it some more.

Combined hormonal contraceptives (CHC) is a type of contraception that contains two types of hormones: oestrogen and progestogen.  These hormones prevent pregnancy mainly by stopping ovulation (the release of an egg from one of the ovaries). They also cause other changes in the body that help prevent pregnancy.  The three forms of CHC available include tablets “the pill”, patches applied to the skin and vaginal rings.

Standard CHC regimens

Combined oral contraception (the pill) The majority of COC in the UK is designed to be taken as 28-day cycles, with 21 consecutive daily active pills followed by either seven pill-free days or taking seven inactive tablets – known as a hormone free interval (HFI).  During this HFI, most women will have a withdrawal bleed.

Combined patch One patch is applied to the skin and worn for 7 days to suppress ovulation. Thereafter the patch is replaced on a weekly basis for two further weeks. The fourth week is patch-free to allow a withdrawal bleed. A new patch is then applied after seven patch-free days.

Combined vaginal ring One ring is inserted into the vagina and left in place continuously for 21 days. After a ring-free interval of 7 days to induce a withdrawal bleed, a new ring is inserted.

New guidance from the Faculty of Sexual and Reproductive Health (FSRH)

In January 2019, the FSRH released new guidelines suggesting that the withdrawal bleed that occurs during the 7 day hormone free interval does not represent physiological menstruation and has no health benefit for the woman.  Additionally, the FSRH advised that the 7 day HFI has the following disadvantages:

·         Withdrawal bleeding may be heavy, painful or simply unwanted.

·         The HFI may be associated with symptoms such as headache and mood change.

·         As ovarian suppression is reduced during the HFI,  errors in pill-taking (or patch or ring use) around that time could result in extension of the HFI increasing the risk of ovulation, and thus potential risk of pregnancy

As such, the FSRH have advised that women can safely take fewer (or no) hormone-free intervals to avoid monthly bleeds, cramps and other symptoms and potentially reduce the risk of escape ovulation and resulting contraceptive failure. The FSRH state that although such regimens are outside of the manufacturer’s license, the FSRH support their use and advise they are as safe and as effective for contraception as standard regimens.  Such “tailored” regimens involve:

·         Continuous use of CHC (no HFI)

·         Extended use of CHC (less frequent HFI); timing of HFI can be fixed or flexible

·         CHC regimens in which the HFI is shortened (the shortened HFI may be taken after each 21 days of CHC use or incorporated into an extended regimen).

If you are an existing user of combined contraception or are considering starting on it and would like to discuss this further, please book an appointment with the Practice Pharmacist or your GP.

For more information regarding the different forms of combined hormonal contraception, please access the following:

https://www.fpa.org.uk/sites/default/files/the-combined-pill-your-guide.pdf

https://www.fpa.org.uk/sites/default/files/contraceptive-patch-your-guide.pdf

https://www.fpa.org.uk/sites/default/files/contraceptive-vaginal-ring-your-guide.pdf