What You Need to Know
The adjustment of the menstrual cycle, or menstrual
active pills followed by a 7-day pill-free interval) are
suppression, via hormonal contraception allows women to
often prescribed.5 Researchers have studied extending the
have less frequent periods and avoid bleeding at
use of COCs to reduce menstrual bleeding since the late
inconvenient times in their lives. Menstrual adjustment also
1970s. The majority of studies show that the practice is
helps to suppress medical conditions that are exacerbated
well accepted by patients and confirm that menstrual
by menstruation and the cyclical variations in female
suppression offers a number of desirable benefits. The
hormones. Menstrual suppression has been practiced for
largest trial to date of an extended-regimen COC was
many years worldwide, and a number of surveys indicate
conducted with Seasonale (30 mg of ethinyl estradiol [EE]
that women are interested in eliminating menses completely
and 150 mg of levonorgestrel [LNG]) compared with a
or reducing its frequency to less than once a month.1,2
conventional-cycle regimen of Nordette® (30 mg of EE/
There is an absence of evidence to support regular
150 mg of LNG).4 The 1-year, multicenter, randomized,
menstruation as medically necessary, as well as an
parallel, open-label study enrolled 682 healthy women
absence of evidence to suggest that suppressing
aged 18–40 years who desired oral contraception. The
menstruation is deleterious to a woman’s health.
duration of withdrawal bleeding was comparable on both
regimens, but the frequency of scheduled bleeding was
Benefits of Menstrual Suppression
less with the extended regimen. The frequency of
unscheduled bleeding episodes was initially higher with
Menstrual benefits of suppressing periods include a
Seasonale than with Nordette but declined with each
reduction in dysmenorrhea, menorrhagia, premenstrual
syndrome, and perimenopausal symptoms (e.g., hot
flashes, night sweats, and irregular monthly periods).3
Continuous use refers to the administration of COCs for
an unlimited time without interruption to eliminate
Nonmenstrual benefits include a reduction in menstrual
menstrual periods. A number of studies have
migraines, endometriosis, and acne and an improved
demonstrated that continuous OC use is safe and
sense of well-being.3
eliminates menstrual periods in 53% of women by 12
months of use.6,7 LybrelTM is an FDA-approved continuous
Disadvantages of Menstrual Suppression
COC packaged as an entire year of active pills.
The major disadvantage of menstrual suppression is an
increase in breakthrough bleeding during the first few cycles
Use of COCs for Nonmenstrual Benefits
using a hormonal method as the body adjusts to the new
Several studies show that COCs can be prescribed to
hormone balance. Some women may be uncomfortable
relieve menstruation-related complaints, such as breast
suppressing menstruation and may have difficulty
tenderness, bloating, menstrual migraine, and
determining if they are pregnant, should pregnancy occur.
premenstrual syndrome or premenstrual dysphoric
disorder, as well as medical conditions such as
Methods of Menstrual Suppression
endometriosis and acne.3,8-9
Use of Combined Oral Contraceptives
Other Hormonal Methods
The most common way to reduce or suppress menstruation is
In addition to COCs, other contraceptive methods can be
to change the manner in which a monophasic combined oral
used on a similar schedule to suppress menstrual
contraceptive (COC) is taken. With this method, the placebo
bleeding.10 These methods are described in Table 1.
week from the standard 21/7-day cycle (i.e., 21 days of
active pills followed by 7 days of placebo) is eliminated and
a new pack of pills is started immediately thereafter.
Many women are still unfamiliar with the concept of
Extended use refers to a variety of patterns. For instance,
menstrual suppression.2 Providers and patients often use
Seasonale® is a dedicated extended-regimen COC
different language when discussing this topic. Clinicians
product indicated for 84 days of active pills followed by a
may employ the medical term, menstrual suppression, while
7-day pill-free interval to induce withdrawal bleeding.4
patients might better understand ‘not having a period.’
When conventional COCs are used, three pill packs (63
Clear dialogue on this topic is important.11 Below are some
What You Need to Know is a publication of the Association of Reproductive Health Professionals (ARHP) for
health care professionals, educators, and researchers working in the field of reproductive health.
strategies for introducing the concept of extended or
continuous hormonal use to patients and counseling patients
Combined oral contraceptives Extended or continuous cycles
who have elected to use such a method.
(including dedicated product
Introducing the Concept
Seasonale® and LybrelTM)
• Standard oral contraceptives (OCs) include placebo
Contraceptive vaginal ring
Studies not published, but
pills to mimic a woman’s natural menses, but when a
regimens similar to COCs
woman is on OCs, she does not have a natural
Studies not published about
patch (Ortho Evra®)
safety or efficacy, but
• There is no medical or health reason to bleed while on
regimens similar to COCs
• Menstrual blood does not build up when women are
Amenorrhea common with
using hormonal birth control.
long-term use—50% after
1 year, 90% after 2 years
• Safety appears comparable to that of conventional
decrease in blood loss;
approximately 20% of users
• Return to fertility after discontinuation is expected to be
amenorrheic by 1 year
the same as for conventional COC use.
21% of users are
contraceptive (Implanon ™)
amenorrheic in any 90-day
• Menstrual suppression can help alleviate menstruation-
COCs = combination oral contraceptives
• Such regimens are more convenient in general and
When to Call a Provider
during particular occasions, such as vacations and
• Contact a clinician if side effects such as ACHES—
Abdominal pain, Chest pain, Heavy bleeding, Eyesight
• Menstrual suppression eliminates the need to purchase
or vision changes, or Severe leg pain—occur.13
and carry as many hygiene products.
• Some regimens (e.g., the vaginal ring) may be less costly.
Glasier AF, Smith KB, van der Spuy AM, et al. Amenorrhea associated with
contraception—an international study on acceptability. Contraception 2003;67:1-8.
Andrist LC, Arias RD, Nucatola D, et al. Women’s and providers’ attitudes toward
menstrual suppression. Contraception 2004;70:359-363.
• Unpredictable breakthrough bleeding is initially more
Sulak PJ, Kuehl TJ, Ortiz M, Shull BL. Acceptance of altering the standard 21-day/
common than with conventional COCs. Bleeding will
7-day oral contraceptive regimen to delay menses and reduce hormone withdrawal
lessen as the body adjusts to the new hormone balance.
symptoms. Am J Obstet Gynecol 2002;186:1142-1149.
Anderson FD, Hait H, Seasonale-301 Study Group. A multicenter, randomized
• It often takes a few months before the desired effect of
study of an extended cycle oral contraceptive. Contraception 2003;68:89-96.
reduced bleeding is achieved. If the method is being
Association of Reproductive Health Professionals and National Association of Nurse
used to eliminate menstruation for a specific event, it
Practitioners in Women’s Health. Annual meeting registrant survey. August-
should be initiated well in advance of the event.
Archer, D. Menstrual-cycle-related symptoms: a review of the rationale for
continuous use of oral contraceptives. Contraception 2006;74:359-366.
• It may be more difficult to detect pregnancy with a
Turok, D. The Quest for Better Contraception: Future Methods. Obstet Gynecol Clin
suppressive regiment. Patients should be advised to look
N Am 2007;34:137-166.
for other signs of pregnancy besides a skipped menstrual
Sillem M, Schneidereit R, Heithecker R, Mueck AO. Use of an oral contraceptive
period, such as breast tenderness, nausea, fatigue, and
containing drospirenone in an extended regimen. Eur J Contracept Reprod Health
other signs, and to obtain a pregnancy test if unsure.
Vercellini P, Frontino G, DeGiorgi O, et al. Continuous use of an oral
• In some cases the regimens (e.g., pills, patches) may be
contraceptive for endometriosis-associated recurrent dysmenorrhea that does not
respond to a cyclic pill regimen. Fertil Steril 2003;80:560-563.
Kaunitz AM. Menstruation: choosing whether…and when. Contraception
How to Follow an Extended-Use Regimen
Barnhart, K. Remarks made at the Reproductive Health 2007 conference. Quoted
• Discuss when to have hormone-free days, if any.
in Differing attitudes found between women and doctors concerning menstrual
suppression [press release]. Philadelphia, Pennsylvania: University of Pennsylvania
• Discuss the schedule of the method, such as taking
School of Medicine; October 3, 2007. Available at http://www.eurekalert.org/
pub_releases/2007-10/uops-daf100307.php. Accessed on April 2, 2008.
COCs at the same time every day.
Gladwell M. John Rock’s error: what the co-inventor of the Pill didn’t know:
What to Expect
menstruation can endanger women’s health. The New Yorker 2000;March 13:52-63.
Association of Reproductive Health Professionals and the National Association of
Nurse Practitioners in Women’s Health. Extended and continuous use of
contraceptives to reduce menstruation. ARHP/NPWH Clinical Proceedings 2004.
• Blood may be dark brown (oxidized due to remaining
Accessed April 2, 2008 at www.arhp.org/extended
in vagina longer) rather than red (blood noted with
active bleeding). Blood may have a different texture.
Menstrual Suppression Updated April 2008