'Seriously, you mean I don't have to have a period every month whilst on the Pill?'
'That's correct, you don't have to bleed every month if you don't want to. In fact, you can safely take the Pill continuously without a break for as long as you are on the Pill'
Every time I give young women this information, I hear the reaction above, followed by 'Why have I not been told this before?' This is what prompted me, as a doctor for over 30 years and a Consultant Obstetrician and Gynaecologist to try and explain this simple way of taking the Pill (Combined Oral Contraceptive Pill or COCP) - one that really can improve the lives of many women.
There is no scientific reason to have a monthly bleed whilst on the Pill. The bleeding that occurs is a withdrawal bleed and not a physiologic menstrual bleed. When the Pill was first introduced over 50 years ago, it was presumed that for women to accept the Pill, they would want to have a regular menstrual bleed. However, studies have consistently shown that when women are told there are no harmful effects from not having a period while on the Pill, especially with regards to fertility, they choose to have less frequent periods or eliminate them entirely. Other methods of hormonal contraception such as the implant, Mirena coil and progesterone-only pill also work on the principle of no cyclic withdrawal bleed.
Choosing not to have cyclic bleeds while on the Pill is very different from a situation where a woman misses her periods several months in a row. The latter requires medical attention as it may be because she is pregnant, a sign of approaching menopause or of menstrual suppression caused for example by an eating disorder or Polycystic Ovarian Syndrome (PCOS).
These days, women living in economically-developed countries generally have far more periods (more than 400 cycles) than their ancestors did (often as few as 20 periods) in a lifetime. In previous centuries, women started their reproductive career soon after the onset of menstruation, and were either pregnant or breastfeeding for most of their (much shorter) life. Many women died in childbirth and the fortunate few who reached menopause still had far fewer periods than the woman of today.
While we should not revert to archaic ways of living, having these extra periods can have drawbacks.
The Pill, especially when taken continuously, can help manage conditions such as endometriosis, anaemia, menstrual migraine and premenstrual symptoms. Women also find they are less tired, have less bloating and menstrual pain. Those with physical disabilities or cognitive impairment may find this method of taking the pill particularly helpful.
There are benefits on a day-to-day basis too. Taking the Pill continuously is particularly helpful for women with heavy and/or painful periods. For young women sitting important exams, female athletes and for those travelling or in busy professions, the freedom from menstrual pain and the nuisance of bleeding every month makes it a very convenient option. There is also an added cost-saving factor.
'Does taking the Pill back to back make period pains worse when I eventually have a bleed?' The answer to this commonly-asked question is that unless there is some other underlying cause, periods should be no more painful or heavy as when one has a monthly bleed as there is no build-up of blood that has to be released.
'I don't like taking Pill back to back because I feel a bleed is reassurance that I am not pregnant'. I tell women that they can safely take the Pill continuously without any negative consequences for contraception, so there is no need for that monthly bleed. The Pill when taken properly is a highly effective birth control method and has a very low (0.3%) failure rate. Almost all Pill failures are due to missing taking a pill or the Pill not getting absorbed because of an upset tummy or vomiting. Women should also be reassured that future fertility is not compromised in women taking the Pill, either continuously or with a monthly bleed.
Some women experience unwanted spotting on the Pill but this usually settles after a few months in most cases. If it doesn't, medical advice should be sought and returning to a monthly bleed may be a solution.
It is important to know what kind of pill one is on before taking it continuously. For example is it a 21-day Pill or a pill to be taken every day (with the last seven being 'dummy' pills)? If in doubt, the woman must have a discussion with her doctor first. The most common pills tend to be monophasic 21-day pills where one pill is taken each day for 21 days and then no pills are taken for the next seven days. So if taking this kind of pill back to back, a new pack is started every three weeks.
My advice to women before starting the Pill is to emphasise that it is really important to see their doctor so a detailed medical history can be taken. The Pill can be prescribed safely in most healthy women of a normal weight from their teens until menopause, although women tend to choose other methods as they complete their family or grow older. The Pill is not a safe or suitable option for women with pre-existing medical conditions like thrombosis or migraines or in smokers over 35 who are also obese. Other methods of contraception will need to be considered in these situations.
So if you are on the Pill, feel free to make the most use of it by taking it continuously. It is actually the better way of taking the Pill.
Dr Nitu Bajekal, FRCOG
Consultant Obstetrician & Gynaecologist