(Published September 2004)

Patient Counseling Strategies

One of the most common reasons that women stop using any hormonal contraceptive is that they are ill informed about breakthrough bleeding: when to expect it and what it means. It may be of particular concern when the oral contraceptive (OC) regimen is unfamiliar. Counseling can help allay patients’ fears and concerns.

To tailor counseling messages on extended or continuous contraceptive regimens to each woman, it is helpful for the health care provider to be familiar with patients’ frames of reference, such as their cultural and religious beliefs, family members’ views, and expectations of how the regimen would benefit them.

Presented below are some strategies for introducing the concept of extended or continuous hormonal use to patients, as well as how to counsel patients who have elected to use such a method. Following these strategies is a patient handout that answers commonly asked questions.

Introducing the Concept

• There is no medical or health reason to bleed while on hormonal contraceptives.
• Periods on the pill are “false periods” that were designed to make bleeding with the pill seem like a natural cycle. In women using birth control hormones, the uterine lining does not build up or need to be shed.
• Menstrual blood does not build up when women are using hormonal birth control.

Safety

• No serious side effects have been found in nine studies involving some 2,000 women.
• Three trials have shown that there is no harmful effect on the uterine lining.
• Conventional pill-use data are reassuring regarding breast cancer, although only future postmarketing studies will show if the same holds true for extended use.
• A return to fertility after discontinuation is expected to be the same as for conventional OC use.

Advantages

• Extended regimen contraception can help alleviate conditions such as painful periods, excessive bleeding, premenstrual syndrome, and menstrual-related migraine headaches.
• With conventional-use OCs, more side effects, such as bloating, headaches, and breast tenderness, may occur during the pill-free interval than during the active pill phase. Reducing or eliminating this pill-free interval may reduce these side effects.
• Extended and continuous regimens are more convenient in general and during particular occasions, such as vacations and athletic activities.
• Extended regimen contraception eliminates the need to purchase and carry as many hygiene products.
• These regimens (e.g., the vaginal ring) may be less costly.

Disadvantages

• Unpredictable breakthrough bleeding is initially more common than with conventional OCs. Bleeding will lessen as the body adjusts to the new hormone balance.
• It often takes a few months before the desired effect of reduced bleeding is achieved. If the method is being used to eliminate menstruation for a specific event, such as a honeymoon, it should be initiated well in advance of the event.
• It may be more difficult to tell whether you are pregnant. Look for other signs of pregnancy besides a skipped menstrual period, such as breast tenderness, nausea, fatigue, and other signs. If necessary, pregnancy tests can be performed.
• The regimens (e.g., pills, patches) may be more costly.

Female Reproduction Anatomy and Menstrual Physiology (See Patient Pull-Out)

• Roles of estrogen and progesterone and how they relate to the menstrual cycle
• How the standard birth control method works (see Patient Pull-Out for OCs)
• How extended regimen contraception works (see Patient Pull-Out for OCs)
• Hormonal options

Discussion After Decision Is Made

• When to have hormone-free days, if any
• Schedule of method, such as taking OCs at the same time every day

What to Expect

• Spotting
• Blood may be dark brown (oxidized due to remaining in vagina longer) rather than red (blood noted with active bleeding)
• Blood may have different texture

When to Call Provider

• Side effects such as heavy bleeding, nausea, vomiting, bloating, mood changes, headaches

Pregnancy Signs and Symptoms Other Than a Missed Period

• Breast tenderness
• Fatigue
• Nausea
• Frequent urination

Frequently Asked Questionson Extended Contraception

Following are answers to questions patients commonly ask about extended or continuous regimen contraception.

1. Is it safe to use contraceptives continuously?

• The studies on Seasonale^®, the new extended OC regimen, showed that side effects were comparable with the conventional 21/7 regimen. Extended OCs were also found to be safe with respect to the uterus (womb and its lining).
• Taking the pill continuously is not any riskier than taking monthly birth control pills, which are safe for most women.
• Today’s low-dose OCs have much less estrogen than they did years ago. They now cause fewer side effects, such as nausea and fluid retention. They also remain very effective in preventing pregnancy.
• Some women should not take the pill, including those with liver disease, severe high blood pressure, previous problems with blood clots in the legs or lungs, and women over 35 who smoke.

2. Is it safe not to have a period every month?

• Health care providers have stopped women’s periods—through the continuous use of contraceptives—to treat a condition called endometriosis for years. No significant problems with this have been reported.
• There were no health problems in the studies on Seasonale.

3. What happens to the blood when I don’t have a period?

• In women who are not using hormones, every month female hormones signal the uterus to build up its lining and blood supply to make a healthy, nurturing place for a fertilized egg to grow. If the egg does not join with a sperm to start a pregnancy, the lining is no longer needed, so you have a period. The blood that comes out is the built-up lining of the uterus.
• Birth control pills and other contraceptives contain hormones that stop the egg from being released from the ovary and stop the lining of the uterus from building up. This leaves little or nothing to be released from the uterus. Taking contraceptives continuously keeps the normal uterine lining from breaking down and bleeding. The lining remains thin and does not need to be flushed out each month.

4. What should I do if I have spotting?

• Spotting is from some of the thinned-out uterine lining breaking down. It is not a period. Spotting is normal and common at first, as your body adjusts to the steady hormone levels. Eventually spotting stops.
• Spotting can happen on and off for around months, sometimes for a little longer.
• The important thing is to take the pill or other contraceptive as I suggested. With the pill, it is important to take it as close as possible to the same time every day. If the spotting continues beyond a few months, seems heavy, is overly bothersome, or you have any other concerns, call me.

5. How often do I need to get a period?

• Women who take hormonal contraceptives do not need to have a period.
• In fact, women who breastfeed and don’t supplement feedings usually don’t get a period. They do not ovulate, so the lining of the uterus does not thicken.
• In some cultures, women breastfeed for two or three years continuously. During this time, they do not get a period. This is perfectly normal.

6. How will I know if I’m pregnant?

• Pregnancies are rare in women who take their contraceptive correctly. If you think you may be pregnant, you should have a pregnancy test. Use either a home pregnancy test that you can buy at the drug store or come in for a test. Most home pregnancy tests can tell you if you are pregnant after about 10 days of pregnancy. Many women suspect they are pregnant before they miss a period. Symptoms such as breast tenderness, feeling overly tired, and nausea can happen early in pregnancy—often before the first period is missed.

7. What are the differences between the health effects of hormone therapy (HT) and birth control pills?

• HT and the pill both release the hormones estrogen and progestin into the body.
• BUT: Women who take HT are generally older than women who use birth control pills, and older women have a higher risk for medical problems, such as heart disease, stroke, blood clots, and breast cancer. The Women’s Health Initiative showed that adding estrogen and progestin to their systems slightly increases these risks. Use of the pill is safe for most women.
• Premenopausal women whose bodies still make estrogen and progesterone can better handle the effects of added synthetic hormones that you get from the pill.