Tailored regimens of combined hormonal contraception

Standard regimens of combined hormonal contraception involve using active (hormone) combined oral contraceptive (COC) pills or the contraceptive vaginal ring consecutively for 21 days, followed by 7 days of inactive pill or no vaginal ring (hormone-free interval). During the hormone-free interval, most users have a withdrawal bleed, and some experience symptoms (eg headache, mood changes).

Monthly hormonal withdrawal bleeds are of no clinical benefit. It is safe and effective to tailor regimens of combined hormonal contraception to alter the hormone-free interval and avoid or minimise a withdrawal bleed. This may benefit individuals with dysmenorrhoea, endometriosis, heavy menstrual bleeding, or premature ovarian insufficiency, and those who develop symptoms during the hormone-free interval.

Note: Offer advice on avoiding or minimising withdrawal bleeding by using tailored regimens of the COC or vaginal ring.

Options for tailored regimens of combined hormonal contraception are:

  • continuous use: no hormone-free interval
  • extended use: less frequent hormone-free intervals, including tricycling (eg 9 to 12 weeks of consecutive active pill or vaginal ring use, followed by a 4- to 7-day hormone-free interval)
  • shortened hormone-free intervals (eg a 4-day interval taken after each 21 days of active pill or vaginal ring use, or incorporated into an extended regimen).

Any monophasic combined hormonal contraceptive licensed for standard dosing is suitable for tailored use.

Specific formulations of COCs are available for:

  • extended use—84 days of active monophasic pills and 7 days of ethinylestradiol 10 micrograms, resulting in a withdrawal bleed every 3 months (eg Seasonique)
  • shortened hormone-free interval—24 days of active monophasic pills and 4 days of inactive pills (eg Yaz, Zoely); also available as a quadriphasic pill with 2 days of inactive pills (eg Qlaira).

There is no upper limit to the number of hormone-free intervals that can be skipped using COCs or the vaginal ring.

Although many users achieve amenorrhoea with continuous use of combined hormonal contraception, unscheduled bleeding can be problematic.

If troublesome breakthrough bleeding occurs for 4 or more days with continuous use of combined hormonal contraception, advise stopping the contraceptive for 4 days, provided the ring or active pills have been used for the last 21 days (otherwise defer the 4-day break until 21 days of use have passed).

If there is persistent unexplained bleeding, exclude other causes such as sexually transmitted infections (eg chlamydia), pregnancy, drugs that induce liver enzymes, and vaginal, cervical or uterine pathology.