Delaying your period through oral contraceptives

Wish your period didn't come every month? It doesn't have to if you adjust your schedule of birth control pills. A Mayo Clinic expert explains.

Rosalina Abboud, M.D.

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Heavy bleeding, painful cramping, uncomfortable bloating and a throbbing headache. Menstruation makes many women feel awful for at least a few days each month, exacting an enormous toll in sick days and disrupted plans.

Reducing the frequency of your periods or eliminating them altogether may sound like a dream come true. But is it safe?

Rosalina Abboud, M.D., an obstetrician and gynecologist at Mayo Clinic, Rochester, Minn., discusses the benefits and pitfalls of reducing the frequency of your menstrual period (menstrual manipulation) through the use of oral contraceptives.

Controlling the timing of menstrual periods is sometimes called 'menstrual manipulation.' What, exactly, does that mean?

Menstrual manipulation refers to changing the way you take birth control pills (oral contraceptives) so that you delay or stop menstruation. This is good news for women who are able to take oral contraceptives and who want more control over their menstrual cycles.

Most women live comfortably with monthly menstruation and even appreciate the predictability of a cycle that reassures them their bodies are working as they should. But for some, menstruation is so painful and debilitating that it disrupts daily activities.

When you take traditional 28-day oral contraceptives, you experience monthly bleeding — but it's not the same as having a regular period. Nor is the bleeding necessary for health. Oral contraceptives mimic a natural menstrual cycle. Some women find them more acceptable that way. Predictable monthly bleeding also reassures women that they aren't pregnant.

Why would you want to have less frequent periods?

Women have several different reasons for wanting less frequent periods. The option is worth considering if you have:

• Heavy, prolonged, frequent or painful periods
• Breast tenderness, bloating or mood swings in the seven to 10 days before your period
• A disability that makes it difficult to use sanitary napkins or tampons
• A condition worsened by menstruation, such as endometriosis, anemia, asthma, migraine or epilepsy
• Headaches, cramps or other menstrual symptoms during the placebo week of your birth control pill

In addition, menstrual bleeding is sometimes simply inconvenient. You may want to make sure you're not menstruating during your wedding or honeymoon. Or you may want to postpone your period until after an important exam, athletic event or vacation.

Are there any oral contraceptives on the market that you can take that lengthen your menstrual cycle?

Yes. Seasonale is a 91-day oral contraceptive regimen designed to give you only four periods a year. You take the active tablets continuously for 84 days — or 12 weeks — followed by one week of inactive pills (week 13). Your menstrual period occurs during week 13, about once every three months.

Seasonique, approved by the Food and Drug Administration (FDA) in 2006, is a similarly formulated oral contraceptive regimen. As with Seasonale, you get your period about once every three months. You take active pills for 84 days followed by seven days of pills containing a very low dose of estrogen, during which you experience menstrual bleeding. Using low-dose estrogen pills instead of inactive pills during week 13 could mean less bleeding, bloating or other hormonal side effects.

A new extended-use oral contraceptive — Lybrel — is also currently being studied. Lybrel is a low-dose combined oral contraceptive, meaning that the pills contain low doses of both a progesterone and estrogen, designed to be taken continuously for one year. That means you would take one pill daily for one year, with no breaks for hormone-free intervals.

If you want to use a 28-day oral contraceptive to delay your period, which oral contraceptive is best, and what's the recommended schedule?

The best type of pill and schedule to use for controlling your cycle has yet to be determined. Preferably, you'd use oral contraceptives that contain 20 to 35 micrograms of estrogen (ethinyl estradiol) and that are monophasic — containing the same amount of hormones in every pill.

To delay your period using a typical 28-day oral contraceptive, you might follow this schedule:

1. Take active pills six weeks in a row.
2. Discard the placebo week in the first pill packet.
3. Take the inactive pills and have your period during week seven.

If you don't have any unpredictable bleeding or other significant side effects, you may be able to take the active pills continuously for nine weeks in the next cycle and 12 weeks in the next.

However, if you do have persistent unpredictable bleeding or other significant side effects, go back to the previous schedule. Until you stabilize on your new extended oral contraceptives schedule, regular follow-up with your doctor is important to address any problems or concerns you might have.

Does it make a difference whether you take Seasonale, Seasonique or your currently prescribed oral contraceptive to delay your periods?

Seasonale and Seasonique are the only pills formulated as extended oral contraceptives approved by the FDA. Most of the studies on menstrual manipulation have used pills containing 30 to 35 micrograms (mcg) of ethinyl estradiol. Seasonale and Seasonique contain 30 mcg. The ideal amount of ethinyl estradiol is still unknown. Breakthrough bleeding may occur more often in oral contraceptives containing less than 30 mcg of ethinyl estradiol. Because many oral contraceptives contain 20 to 25 mcg of ethinyl estradiol, you might prefer Seasonale or Seasonique if you want to prevent breakthrough bleeding.

Why isn't the ability to delay your periods promoted more widely?

Not all doctors think it's a good idea to delay your periods. Even those who support the option may not mention it to their patients. If you want to try it, you may have to take the lead. Also, some women prefer to keep their natural cycle and like the reassurance that they aren't pregnant.

Will delaying your period cause side effects?

Limited studies have shown that for a small number of women, extended oral contraceptives have the same side effects as conventional oral contraceptives, such as breast tenderness, nausea, headache, mood changes, leg cramps, acne, bloating, weight changes and dark spots on the face.

Bleeding or spotting between periods (breakthrough bleeding) is common during the first three to four months after you start taking any oral contraceptive — particularly when you extend the number of days between periods. As your body adjusts to the hormones, though, this unpredictable bleeding should decrease. If it persists and becomes heavy or bothersome, call your doctor.

The likelihood of breakthrough bleeding increases whenever there's a fluctuation in the level of contraceptive hormones in your system. That can happen if you miss a pill, start a new medication that may interfere with the pill, or develop an illness with vomiting or diarrhea. The same circumstances may reduce the pill's contraceptive effect, so be sure to use a backup method of contraception for seven days afterward.

When on an extended schedule, it may be more difficult for you to tell if you're pregnant. Take a home pregnancy test or visit your doctor if you have morning sickness, breast tenderness or unusual fatigue.

If you take oral contraceptives, whether on a traditional schedule or an extended schedule, you're at increased risk of blood clots. Know the warning signs:

• Severe abdominal pain
• Chest pain
• Coughing up blood
• Shortness of breath
• Sudden and severe headache
• Eye blurring or loss of vision
• Severe leg pain

At what age can you begin delaying your period?

You can manipulate the timing of menstruation at any age, as long as you can take oral contraceptives. Reducing the frequency of periods is certainly an option for adolescents who miss school and sports because of frequent, irregular and painful periods.

Is it safe for all women to delay menstruation?

If you can take oral contraceptives and want to reduce the frequency of your periods, it's probably safe — especially if you have problems associated with menstruation.

Your doctor can screen you for conditions in which oral contraceptives may be risky. These include:

• High blood pressure
• A personal history of stroke, heart attack, blood clot or liver disease
• Migraine with aura
• Unexplained vaginal bleeding
• Cancer of the breast or uterus
• Family history of thrombosis

No oral contraceptive schedule — in fact, no oral contraceptive — is safe for women older than 35 who smoke. Oral contraceptives sharply increase the risk of heart attacks, blood clots and strokes in older women who smoke.

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