Combined hormonal contraceptives taken continuously for more than 28 days compare favorably to traditional cyclic hormonal contraceptives.

Edelman A, Gallo MF, Jensen JT., Nichols MD., Grimes DA

Published Online:

August 8, 2010

Traditional combined hormonal contraceptives (pills, patch, ring) are administered daily for 21 days, followed by a hormone-free week. During the hormone-free week, uterine bleeding occurs. In recent years, other approaches to taking combined hormonal contraceptives have been developed. These include taking the CHCs for longer than 28 consecutive days. Some of the regimens plan occasional breaks in CHC use, while others do not. Since these newer approaches to CHC use have attracted growing attention, we performed this review to compare them to traditional CHC dosing regimens. We searched for all randomized controlled trials on this question in any language; we found eight that met our criteria. The continuous and traditional regimens appeared similar, as judged by bleeding, discontinuation rates, and reported satisfaction. The studies were too small to address efficacy, rare adverse events, and safety. Continuous dosing (for more than 28 days) appears to be a reasonable approach to CHC use.

Abstract (click to read)

Background:

The avoidance of menstruation through extended or continuous administration (greater than 28 days of active hormone) of combination hormonal contraceptives (CHCs) has gained legitimacy through its use in treating endometriosis, dysmenorrhea, and menstruation-associated symptoms. Avoidance of menstruation through continuous use of CHCs for reasons of personal preference may have additional advantages to women, including improved compliance, greater satisfaction, fewer menstrual symptoms, and less menstruation-related absenteeism from work or school.

Objectives:

To determine the differences between CHCs (pills, patch, ring) dosed continuously (greater than 28 days of active hormone) compared with traditional cyclic dosing (21 days of active hormone and 7 days of placebo). Our hypothesis was that continuously administered CHCs have equivalent efficacy and safety but improved bleeding profiles, amenorrhea rates, adherence, continuation, participant satisfaction, and menstrual symptoms compared with cyclic CHCs.

Search strategy:

We searched computerized databases (Cochrane Central Register of Controlled Trials, PUBMED, EMBASE, POPLINE, LILACS) for trials using continuous or extended CHCs (oral contraceptives, contraceptive ring and patch) during the years 1966 to 2009. We also searched the references in review articles and publications identified for inclusion in the protocol. Investigators were contacted regarding additional references.

Selection criteria:

All randomized controlled trials in any language comparing continuous (greater than 28 days of active hormones) versus traditional cyclic administration (21 days of active hormones and 7 days of placebo) of CHCs for contraception.

Data collection and analysis:

Titles and abstracts identified from the literature searches were assessed for potential inclusion. Data were extracted onto data collection forms and then entered into RevMan 5. Peto odds ratios with 95% confidence intervals were calculated for all outcomes for dichotomous outcomes. Weighted mean difference was calculated for continuous outcomes. The trials were critically appraised by examining the following factors: study design, blinding, randomization method, group allocation concealment, exclusions after randomization, loss to follow-up, and early discontinuation. Because the included trials did not have a standard treatment (type of CHC and time length for continuous dosing), we could not aggregate data into meta-analysis.

Main results:

Eight randomized controlled trials met our inclusion criteria. Study findings were similar between 28-day and extended cycles in regard to contraceptive efficacy (i.e., pregnancy rates) and safety profiles. When compliance was reported, no difference between 28-day and extended cycles was found. Participants reported high satisfaction with both dosing regimens, but this was not an outcome universally studied. Overall discontinuation and discontinuation for bleeding problems were not uniformly higher in either group in most studies. The few studies that reported menstrual symptoms found that the extended cycle group fared better in terms of headaches, genital irritation, tiredness, bloating, and menstrual pain. Seven out of the eight studies found that bleeding patterns were either equivalent between groups or improved with continuous-dosing regimens over time. Endometrial lining assessments by ultrasound were done in a small number of participants but all endometrial stripe measurements were less than 5 mm.

Authors' conclusions:

Evidence from existing randomized control trials comparing CHCs given continuously (greater than 28 days of active combined hormones) to traditional monthly cyclic dosing (21 days of active hormone and 7 days of placebo) is of good quality. However, the variations in type of hormones and time length for continuous dosing make a formal meta-analysis impossible. Future studies should choose a previously described type of CHC and dosing regimen. More attention needs to be directed towards participant satisfaction and menstruation-associated symptoms.

This record should be cited as:

Edelman A, Gallo MF, Jensen JT., Nichols MD., Grimes DA. Continuous or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD004695. DOI: 10.1002/14651858.CD004695.pub2

Assessed as up to date:

September 4, 2009

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Primary Review Group:

Fertility Regulation Group

Health topics:

Gynaecology > Contraception > Combined oral contraception

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Combined hormonal contraceptives taken continuously for more than 28 days compare favorably to traditional cyclic hormonal contraceptives.

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