New UK guidelines advise giving up placebo pills for women on birth control.
Most packages of combination birth control pills contain 21 active pills and 7 placebo pills.
But how important is it for women to use those placebo pills or take a break from active pills each month?
According to updated guidelines released in the UK by the Faculty of Sexual and Reproductive Healthcare (FSRH), it’s just as safe and effective for women to skip the placebo interval and take combination birth control pills on an extended or continuous basis.
The conventional 21/7 cyclic regimen was designed to mimic a natural menstrual cycle. During the placebo interval, women experience a withdrawal bleed that’s similar to a natural period.
But there are no health benefits associated with a monthly placebo interval or withdrawal bleed.
For many women, there may even be benefits to skipping it.
“I think a lot of people get scared that you have to have a period every month, but when you’re on pills, that’s just not the case,” Dr. Kimberly Gecsi, an obstetrician-gynecologist at University Hospitals Cleveland Medical Center, told Healthline.
“Are you someone who feels more comfortable if you have regular bleeding or would you prefer to not have a period? Both are totally normal and healthy and fine to do when you’re on [combination birth control] pills,” she said.
Rather than using a 21/7 cyclic regimen of combination birth control pills, some women follow a 24/4 cyclic regimen. In this approach, the placebo interval is shortened to four days.
Other women prefer an extended-cycle regimen, in which they skip the placebo interval and withdrawal bleed for multiple months.
One common approach is to take three months’ worth of active pills, followed by seven days of placebo pills.
Other women choose to follow a continuous regimen, in which they take active pills on an ongoing basis, with no placebo intervals or withdrawal bleeds.
All of these regimens reduce the risk of pregnancy, but certain approaches may appeal more to some women than others.
“The best contraceptive for a woman is one that she feels comfortable with and one she’s going to use,” Gecsi said.
“If you really want to have a monthly bleed, then a cyclic regimen might be better for you,” she continued. “If you don’t want to have a monthly bleed, then an extended-cycle or continuous regimen might be better.”
If you take combination birth control pills, there are potential benefits to skipping the placebo interval and taking active pills on an extended or continuous basis.
For instance, the withdrawal bleeds that occur during placebo intervals can be heavy or painful.
In some cases, the drop in hormones during a placebo interval can also trigger or worsen symptoms of pain or mood disorders.
For example, some women experience menstrual migraines or symptoms of depression when they stop taking active pills.
To limit these symptoms, women can follow an extended-cycle or continuous regimen of combination birth control pills rather than a cyclic one.
In addition to these potential health benefits, many women find it more convenient to forgo the monthly withdrawal bleed that occurs on a cyclic regimen.
“It can be very helpful to be able to time your periods around a major event, a vacation, an athletic competition, a big exam, or things like that,” Dr. Paula Bednarek, an associate professor of obstetrics and gynecology at Oregon Health & Science University (OHSU), told Healthline.
“So there’s some ways in which it can really benefit a person at important times of their life,” she continued, “and it can also be much simpler, more convenient, and more pleasant.”
When women take a continuous regimen of combination birth control pills, they don’t get regular withdrawal bleeds.
But they’re more likely to experience sporadic spotting or breakthrough bleeding at unexpected and potentially inconvenient times.
That’s why some women prefer to follow a cyclic or extended-cycle regimen, with a scheduled withdrawal bleed every month or every few months.
“You’ll at least know — that week I’ll have my period,” Bednarek said, “as opposed to, ‘I don’t know when I’ll get some spotting.’”
Some women prefer a cyclic or extended-cycle regimen because it feels more “natural” or comfortable to them.
“They want to have a regular bleed,” Gecsi said. “It reassures them that they’re not pregnant or they just feel better with it.”
Ultimately, the decision to use one regimen of combination birth control pills or another often boils down to personal preference.
“I guess that’s the main message, is that [extended-cycle and continuous regimens] are an option, it’s a safe thing to consider, and it’s something that any healthcare provider would be happy to talk to them about,” Bednarek said.
“I think the biggest message is that you choose what’s right for you,” she added.
If you decide to use an extended-cycle or continuous regimen of combination birth control pills, you will need to take more active pills over the course of a year.
Depending on the specific type of pills that you take and your insurance coverage, there might be added costs to following an extended-cycle or continuous regimen.
“When the concept first started years ago, that was definitely an issue,” Bednarek said, “and as a physician, I would have to write on the prescription an explanation for why a patient might need those several extra pill packs over a 12-month period, and there were some [insurance] plans where it was not easy to get it covered.”
“I haven’t had any patients have trouble with that in recent years, so I don’t believe that it’s a major problem now,” she continued, “but I can’t say that’s true everywhere.”