But have we really been doing it wrong for 60 years?
The press reported this week that since the contraceptive pill was first launched – and this was 60 years ago! – we could have been doing it differently! They also stated that one of the reasons behind this was to please the Pope!
Let’s try and put this medical conundrum into understandable terms, and try to prevent confusion!
Firstly, if you take the pill, do not stop taking it – keep going!
Nothing has changed in terms of pill safety, effectiveness, side effects, or reliability. The Combined Oral Contraceptive Pill (COC) remains the favourite form of hormonal contraception for UK women. Taking the pill results in numerous health benefits.
What’s it all about?
In essence, the issue is all about how best to take the pill, and why, after all these years, this advice has changed.
It also relates only to monophasic pills, and not to the everyday ED pills.
This scenario relates only to the Combined Pill – which contains both hormones oestrogen and progestogen, and not to the Progestogen-only pill (POP) which is, and has always been, taken every day, without any 7-day break.
The history of pill taking
When the COC was developed, almost 60 years ago, it was packaged by the pharmaceutical companies to mimic the monthly cycle. This meant women took one pill every day for 21 days and then had a 7-day break, during which they would bleed. It was felt that women liked to see a monthly bleed, as this was natural for them, and by bleeding, they felt reassured they were not pregnant.
In fact, women only bleed in the 7-day break because the pill hormones have been withdrawn. This is the body’s reaction when you stop taking contraceptive hormones. It’s a natural body response. If you carried on the pill and didn’t have the 7-day break, you would not bleed. (The bleed on the pill is not a true period at all – it is more correctly termed – a withdrawal bleed – but many women do not understand this to be the case.)
As the years have gone by, it was realised that women could run packs of pills together, and avoid bleeding once a month. For many women this was very convenient. Running 3 packs of pills together is called tricycling.
Advantages of taking the pill and missing out the 7-day break
It was then recognised, that there were additional advantages to missing out the 7-day break.
Women who took their pills continuously, did not have to worry about the 7-day break.
When women make a mistake with taking their pills, a common error is forgetting to restart the pack after the 7 day break, on the correct day. This can lead to unplanned pregnancies. If women don’t need to stop and start their pills, this is likely to result in increased pill efficacy.
Some women also complain of side effects during the 7 day break, such as headache, mood swings and tiredness. In addition some women take the pill to relieve heavy, painful periods. By getting rid of the 7 day break, there is no need to have many periods at all – and all these symptoms will be absent.
How can the way the pill is taken, be allowed to change, especially if this is what is in the product licence?
With medicine, when a drug/medicine is first licenced and marketed, everything known about the product at that time, goes into the product licence. However, as time passes, and clinical experience with a product grows, it is often realised that a medicine can be used in a different way, to give clinical benefit. If a body of professionals agree that this is the case, and the practice is accepted, drugs can be used in a different way to what is stipulated within the product licence. This is called unlicenced or “off label” use.
If you read the Patient Information Leaflet in a box of pills, it will still say to take the pill for 21 days and have a 7-day break. However, your doctor/nurse may advise you to tricycle your pill, or even take it continuously. This is an unlicenced use, but is perfectly acceptable clinical practice, and for all the above reasons may have health benefits. It is actually very good advice.
However until now, there has been some hesitancy on the part of medical staff to endorse these regimes, plus confusion as the written information about taking the pill which exists, often does not mention tricycling – or any other extended pill regimes. Patients and their healthcare providers have remained confused.
Who has produced the new pill taking recommendations? Why have they done this?
The Faculty of Sexual and Reproductive Healthcare (FSRH), are the recognised body of experts who issue evidence-based clinical recommendations for the UK, about contraception. FSRH produced a new statement very recently, in January 2019 about the use of the pill.
This is an evidence-based statement, and officially endorsed the practice of taking the pill differently – by what are called ‘extended use regimes’. This means that UK healthcare providers now have a definitive recommendation to work to, and can have confidence in recommending these pill regimes, to all women wishing to use the pill.
In fact, the FSRH document is not just about the pill. The hormones within the pill are also now available in a contraceptive patch, and a vaginal ring. So these three methods are all methods of combined hormonal contraception – that is – they all contain both hormones oestrogen and progestogen. Women have a choice of contraception and can opt for one of these alternative methods if it suits them better.
Like the Combined Pill – the contraceptive patch (Evra) can be tricycled, or used continuously, as can the vaginal ring (Nuvaring).
It has been suggested that historically, the Pope did not agree with the use of the combined pill as a method of contraception, and that the 7-day break was inserted to please him! In fact this was never the case.
Is it safe to take the pill continuously, and without a regular 7-day break?
The FSRH have listed the existing medical evidence to support the use of extended pill regimes in their document. They have concluded that from the research available, these extended regimes are safe.
In studies comparing groups of women taking the pill by the standard regime, compared to those using an extended regime, the extended use regime has been demonstrated to be equally acceptable.
All women who take the pill have small risks of cardiovascular disease (heart attacks and strokes) and thrombosis (blood clots), but these risks do not seem to be increased by taking the pill using an extended pill regime.
It is not possible to say categorically that unplanned pregnancy rates are lower in women on extended pill regimes, as the medical studies are difficult to compare. However the physiological basis of removing the 7-day break, is likely to result in improved contraceptive efficacy.
There was no delay in return of ovulation after stopping and no difference in women’s ability to become pregnant after stopping an extended pill regime.
Extended pill regimes
The FSRH recommends that when women are prescribed the pill, they are given information about the standard way to take the pill, as well as how to take the pill using extended pill regimes. This should be supported with written / digital information.
The standard and extended pill regimes are listed below. For information see How to take your contraceptive pill.
| Name of pill regime | Time period of use | Number of hormone free days |
|---|---|---|
| Standard | Pill for 21 days or, 3 patches, or 1 vaginal ring | 7 |
| Shortened hormone-free interval | Pill 21 days or, 3 patches, or 1 vaginal ring | 4 |
| Extended use – tricycling | 9 weeks (21 pills x 3, or 9 patches, or 3 vaginal rings – all used consecutively) | 4, or 7 |
| Flexible Extended Use | Continuous use (pill use for >21 days, or patches, or vaginal rings, used until bleeding occurs) | 4 |
| Continuous use | Continuous use of active pills, patches or rings | None |
Final thoughts
In conclusion, evidence based directives from specialist organisations such as the FSRH, have been produced after a robust and exhaustive consultation process, for very good reasons. Safe use of contraception, and avoiding contraceptive failure are imperative. If changing the way we take the pill can improve the efficacy of the pill, improve side effects and help minimise unplanned pregnancies, this has to be good advice. Now the challenge is to relay this message to women taking the pill, and to their healthcare providers.
If you are a pill taker, and have read this blog post, we hope you will feel confident to change the way you take your pill and opt for one of these extended pill regimes.
You can get practical advice and support about doing this from your GP, nurse, or from your local Sexual Health Clinic.