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

Overall 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

How to Use Contraceptive Method for Extended Use

• 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