information women need to know in order to use the combined oral contraceptive pill appropriately

Last edited 03/2020

Key messages for women considering use of tailored combined hormonal contraception regimens

• the evidence from studies is that combined hormonal contraception (CHC) is as safe and at least as effective for contraception if it is taken as an extended or continuous regimen as it is when it is taken in a traditional 21/7 cycle
  
  
• a woman who is using CHC does not need to have a monthly withdrawal bleed to be healthy.
  
  
• there is no build-up of menstrual blood inside a woman who uses CHC for an extended time without a break; extended CHC use keeps the lining of the womb thin
  
  
• withdrawal bleeds during cyclical use of CHC have been reported by women who are pregnant; women should not consider monthly bleeds on CHC to be reassurance that they are not pregnant
  
  
• by using extended or continuous CHC the frequency of withdrawal bleeds and associated symptoms (e.g. headache, mood change) is reduced; this could be useful for women who have heavy or painful bleeding or problematic symptoms associated with the hormone-free interval (HFI)
  
  
• the ovaries start to become active during the traditional 7-day HFI. Fewer and/or shorter breaks in CHC use could mean that the risk of pregnancy could theoretically be lower with extended or continuous regimens than if a 7-day break is taken every month
  
  
• there can be irregular bleeding or spotting in the first few months of CHC use, particularly with extended or continuous regimens; this does not usually mean that there is any medical problem and it generally improves with time
  
  
• the evidence from studies is that using extended or continuous regimens of CHC does not affect the return of a woman’s fertility when she stops CHC.

Women using combined hormonal contraception: key indications for medical review
Key symptoms that should prompt women to seek urgent medical review

• calf pain, swelling and/or redness
• chest pain and/or breathlessness and/or coughing up blood
• loss of motor or sensory function

Key symptoms that should prompt women to seek medical review

• breast lump, unilateral nipple discharge, new nipple inversion, change in breast skin
• new onset migraine
• new onset sensory or motor symptoms in the hour preceding onset of migraine
• persistent unscheduled vaginal bleeding

New medical diagnoses that should prompt women to seek advice from their contraceptive provider (and review of the suitability of CHC)

• high blood pressure
• high body mass index (>35 kg/m2)
• migraine or migraine with aura
• deep vein thrombosis or pulmonary embolism
• blood clotting abnormality
• antiphospholipid antibodies
• angina, heart attack, stroke or peripheral vascular disease
• atrial fibrillation
• cardiomyopathy
• breast cancer or breast cancer gene mutation
• liver tumour
• symptomatic gallstones

For full details consult the reference below (1).

Reference:

• FSRH (July 2019). Combined Hormonal Contraception
• Faculty of Sexual & Reproductive Healthcare Clinical Guidance. Missed Pill Recommendations.Clinical Effectiveness Unit; May 2011.