Dr. med. Regula E. Bürki FACOG

Fachärztin für Gynäkologie Schänzlistrasse 33 Regula.Buerki@hirslanden.com 3000 Bern 25 www.regulaburki.medem.com (English) Fax+41 (0)31 337 80 46 www.regulabuerki.ch (Deutsch) Tel.+41 (0)31 337 80 45

Using Birth Control Pills to Change Your Periods Is your pill period due on the same day as that marathon you finally qualified to run? Is it due the same week as your diving vacation or your camping trip? Or do you just hate your periods and would rather not have any or as few of them as possible? This article will give you some tips on how to use birth control pills to modify your periods. The Effect of Birth Control Pills on Menstruation Every month between menarche, the first period, and menopause, the last period, the ovaries produce an egg. Before ovulation, while the egg matures, the ovaries secrete the hormone estrogen; this causes the uterine lining to grow. After ovulation and release of the egg, the ovaries begin to secrete a different hormone called progesterone. Progesterone prepares the uterine lining for the arrival of a fertilized egg and aids the early pregnancy in sticking to the wall of the uterus and continuing to grow. This process is called implantation. Progesterone also is necessary for the orderly shedding of the uterine lining during menstruation (if there is no conception in a given month). Menstruation begins when the ovaries stop producing progesterone as they start growing a new egg for the next month. The length of this cycle of egg and hormone production is rather constant for an individual, but can vary from 25 and 35 days between different women. Ovarian function is under the control of the pituitary gland, which sends “memos” in the form of hormones called gonadotropins (FSH, LH) to the ovaries to tell them what to do. Birth control pills contain both estrogen and progesterone. When the pituitary gland notices that there is already estrogen and progesterone in the body, it does not send any gonadotropins out; the ovaries remain inactive, and produce neither eggs nor any significant amount of hormones. The hormones contained in the pill also make the uterine lining grow. Menstrual-like bleeding starts when the woman stops taking the active hormone containing pills or switches to placebo (sugar) pills. This is not really a menstrual period, but is called (hormone) withdrawal bleeding. Because the newer birth control pills contain very low hormone doses, the uterine lining they produce is thinner. As a consequence, there is less bleeding per cycle and the duration of bleeding may be shorter as well. Most women experience less cramping on birth control pills because the amount of prostaglandin released by the uterine lining during menstruation is reduced. Prostaglandin is a tissue hormone that promotes cramping and pain. Birth control pills were invented by a catholic physician, who did not want to emphasize their effect of suppressing ovulation, but rather stressed their usefulness in regulating the menstrual cycle, reduce menstrual cramps, and bleeding. In fact, he personally lobbied the Pope to endorse them for that indication. The Pope did not agree. To stress the regulation of the menstrual cycle and because women are used to monthly cycle, the pill cycle was set up as 21 active (hormone containing) pills, followed by 7 days of no pills or placebo pills. Bleeding is scheduled during this 7 day interval. There is, however, nothing magic or even particularly natural about this 28 day/4 weeks pill cycle at all. It is not medically necessary to shed the uterine lining every month.

Using Birth Control Pills to Reduce the Number of Periods a Year: Many women have known for years that it is possible to skip the placebo pill of a pack of birth control pills and go directly to the next pack. The active pills can either be used continuously or for several months at a time, followed by no more than 7 days of no pills or placebo pills. . For most women, this works perfectly for months and even years at a time, and the only thing they give up is the monthly bleeding as a reassuring sign that they are not pregnant. Doctors have also prescribed extended cycle or continued use regimens for women who have medical conditions that are made worse by menstruation, such as endometriosis, clotting disorders, anemia, PMS, certain types of migraines, epilepsy and arthritis. Over the last few years several studies have been published documenting the safety of using birth control pills in this manner. The US Food and Drug Administration (FDA) recently approved a pill packaged for a 91 day extended cycle under the brand name of Seasonale®. It contains 84 active pills (for 12 weeks) and 7 placebo tablets. While only this one particular product has been packaged this way and is the one that has been tested most extensively, other birth control pill brands work just as well. Some doctors feel that monocyclic products containing an identical hormone dose in all pills work better than triphasic products that contain three different colored pills with different hormone doses. While these extended cycle or continued use regimens work well for about three quarters of women, about 25% experience a lot of unscheduled breakthrough bleeding and spotting; they eventually give up and return to a more predictable 28 day cycle, with 21 active pill followed by 7 placebo pills. Sometimes the body will adjust to a shorter extended use regimen of 6 rather than 12 weeks, which is still almost half as many periods a year. The good news is that the spotting tends to be less and less frequent as time goes on, as long as you do not miss any pills. Any time you forget to take a pill, you greatly increase your chance of breakthrough bleeding (and of course pregnancy as well). Using Birth Control Pills to Move the Menstrual Period to a More Convenient Date If you are taking your pills on a monthly schedule, because you don’t mind having a period every month and like the reassurance every month that you are not pregnant; or if you tried taking the pills on a longer cycle, but had too much breakthrough bleeding, you can still use the pills to move your period off an inconvenient date. There are two ways to do this: The first is to continue with active pills for another week or two and thus postpone the pill period. Then you stop for 7 days and have a withdrawal bleed and start with a new pack of pills. Your next withdrawal bleed should now fall according to the new pill pack. This generally works well, but some women will start spotting or even bleeding during the extra week(s) they have added to the first pill pack. If you do not want to take the chance of any unplanned bleeding or spotting, this second way may work better for you: Instead of delaying the bleeding, you can have it come a week early. By stopping the active pills after two weeks instead of taking all 21 pills you cause the bleeding to start within a couple days of stopping the pills. You wait 5 to 7 days and start a new pack. Your next period will now come according to the schedule of the new pack. If you need to move your period by two weeks, you can do this two months in a row. That will work better than to move it two weeks in one pill cycle. The effectiveness of the pill as a birth control method will not be compromised by these modifications in the pill schedule, as long as you do not go longer than 7 days without active pills. If you start a new pill pack late or miss one or more pills during the first week of a new pill pack, your chance of ovulating is approximately 25%. Other non-surgical options of avoiding monthly bleeding include progesterone containing IUDs and Depo-Provera® injections. Both methods take up to a year to stop the bleeding and neither works for more than about 50% of women.

Non-contraceptive Benefits of Birth Control Pills

Cycle-related: • Less irregular cycles • Less cramping • Less bleeding • Less anemia • Fewer ovarian cysts

Cancer reduction: • Ovarian • Endometrial • Colorectal