Alteration of the Hormone-free Interval in Oral Contraception

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

The majority of oral contraceptives (OCs) involve a regimen of 21 days of active pills followed by 7 days of placebo pills. The 7-day hormone-free interval (HFI) typically results in hormone withdrawal bleeding and was intended to mimic the natural menstrual cycle. In recent years, with increased recognition that the 28-day cycle is not a physiologic necessity, interest has focused on the role of the HFI in oral contraception and methods of altering it.¹

Understanding the Hormone-Free Interval

No health-related or physiologic benefits are associated with monthly withdrawal bleeding in a woman taking OCs.^1,2 During the 7-day HFI of a typical 28-day OC regimen, exogenous estrogen and progestin are cleared 2 to 3 days after a patient completes active pills, levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) increase, and ovarian follicular growth occurs.^3,4 As a result, the possibility for ovulation during the HFI (escape ovulation) increases with each hormone-free day.⁴ By decreasing the HFI or by using low-dose estrogen rather than placebo, the risk for escape ovulation is reduced, possibly improving contraceptive efficacy.⁵

Hormone-Free Intervals: Is Shorter Better?

Studies have demonstrated that conventional 28-day OC regimens that utilize a 7-day HFI fail to induce complete ovarian suppression.^3,4 Recent studies have focused on the safety and efficacy of extending active combination OC therapy and reducing or eliminating the HFI (see Table^3,6-11).

Spona et al were the first to report less ovarian activity in women randomized to a shorter HFI.¹² When the duration of active pills was increased to 23 and the HFI was decreased from 7 to 5 days, the risk of breakthrough ovulation when pills were omitted was decreased.¹²

Hormone Withdrawal Symptoms

Hormone withdrawal during the HFI may be associated with bothersome symptoms such as headaches, migraines, pelvic pain and cramping, breast tenderness, bloating, and bleeding problems.¹³ Sulak and colleagues evaluated the timing, frequency, and severity of hormone-related symptoms in women using OCs, in particular comparing the symptoms women experience during active pill phases with those experienced during the HFI. As many as 70% of the women experienced pelvic pain and cramping during the traditional 7-day HFI, compared with 21% of women taking active pills. In addition, more women experienced headaches and breast tenderness during the HFI, and more reported the need for analgesia. The study concluded that almost all symptoms, including headache, pain, breast tenderness, bloating, and swelling, were considerably worse during the 7-day HFI, compared with 21 days of active hormones.

Results from a recent study conducted by Legro et al have demonstrated that continuous OC therapy may be more effective than conventional 28-day OC regimens in reducing menstrual pain and controlling episodes of heavy bleeding and other menstrual-related symptoms.¹⁴ Continuous OC regimens provide greater suppression of activity in the ovaries and endometrium; this suppression is associated with improvement of menstrual symptoms.¹⁴ Furthermore, the researchers suggest that continuous OC therapy may be beneficial in treating chronic medical conditions (eg, polycystic ovarian syndrome and endometriosis) in which greater suppression of the ovaries and endometrium are desired.

Reducing or Eliminating the HFI

Research regarding the impact of a 7-day HFI and recent modifications to OC regimens have piqued the interest of many healthcare professionals and their patients.^15,16 In April 1998, the FDA approved Mircette (Duramed) as the first OC to use a shorter HFI. Each packet of Mircette contains 21 active tablets of 0.¹⁵ mg desogestrel/20 mcg ethinyl estradiol (EE), 2 placebo tablets, and 5 tablets of 10 mcg EE. In 2003, the FDA approved Seasonale (Duramed), the first extended OC regimen, and subsequently approved other OC regimens that either reduce the number of HFI days for each cycle (Loestrin 24 Fe, Yaz) or eliminate the HFI (Seasonique, Lybrel) (Figure). These formulations may decrease the HFI withdrawal symptoms experienced by women using OCs, reduce menstrual bleeding, and maximize ovarian follicular suppression.^17-21

The Pharmacist's Role

Pharmacists are in a pivotal position to provide women with the necessary information to make informed choices about OCs. Extended and continuous regimens give women more choices to accommodate their individual needs, especially those women who experience hormone withdrawal symptoms. Because many women discontinue OCs due to symptoms attributed to the typical 7-day HFI, the use of extended and continuous regimens may be an ideal choice. Patients seeking advice on OCs should be encouraged to see their gynecologists to assess if they are an appropriate candidate.

When counseling women about OCs, pharmacists should provide the patient with thorough information about proper use and adverse effects and risks associated with the use of OCs. Patients should be reminded that extended and continuous OC regimens have been associated with episodes of breakthrough bleeding and spotting during the first 3 to 4 months of therapy and that the incidence typically subsides as therapy continues. To minimize these episodes, patients should be reminded to take the pill at the same time each day.

References

1. Sulak P. Continuous oral contraception: changing times. Best Practice and Research Clinical Obstetrics and Gynecology. 2008 Apr; 22(2):355-74.
2. Lin K, Barnhart K. The clinical rationale for menses free contraception. Journal of Women's Health. 2007 Oct;16(8):1171-80
3. Vandever MA, Kuehl TJ, Sulak PJ, et al. Evaluation of pituitary-ovarian axis suppression with three oral contraceptive regimens. Contraception. 2008 Mar;77(3):162-70
4. Baerwald, AR, Olatunbosun PA, Peirson RA. Ovarian follicular development is initiated during the hormone free interval of oral contraceptive use. Contraception. 2004 November; 70:371-377
5. Mishell DR Jr. Rationale for decreasing the number of days of the hormone-free interval with use of low-dose oral contraceptive formulations. Contraception. 2005 Apr; 71:304-5.
6. Schlaff WD, Lynch AM, Highes HD, Cedars MI, Smith DL. Manipulation of the pill free interval in oral contraceptive pill users: the effect on follicular suppression. American Journal of Obstetrics and Gynecology. 2004 Apr; 190(4):943-51.
7. Birtch RL, Olatunbosun OA, Perison RA. Ovarian follicular dynamics during conventional vs. continuous oral contraceptive use. Contraception 2006 March; 73(7):235-43.
8. Kwiecien M, Edelman A, Nichols MS, Jensen JT. Bleeding patterns and patient acceptability of standard or continuous dosing regimens of a low dose oral contraceptive: a randomized trial. Contraception. 2003 Jan;67(1):9-13.
9. Willis S, Kuehl TJ, Spiekerman AM, Sulak PJ, . Greater inhibition of the pituitary--ovarian axis in oral contraceptive regimens with a shortened hormone-free interval. Contraception. 2006 Aug;74(2):100-3.
10. Sillem M, Schneidereit R, Heithecker R, Mueck AO. Use of an oral contraceptive containing drospirenone in an extended regimen. European Journal of Contraception and Reproductive Health Care. 2003 Sep;8(3):162-9.
11. Miller L, Hughes JP. Continuous Combination Oral Contraceptive Pills to Eliminate Withdrawal Bleeding: A Randomized Trial. Obstetrics and Gynecology. Volume 101, Number. 4, April 2003
12. Spona J, Elstein M, Feichtinger W, et al. Shorter pill free interval in combined oral contraceptives decreases follicular development. Contraception 1996;54:71-7.
13. Sulak P, Scow RD, Preece C, Riggs MW, Kuehl TJ. Hormone Withdrawal Symptoms in Oral Contraceptive Users. Obstetrics and Gynecology 2000 Feb; 95(2):261-6.
14. Legro RS, Pauli JG, Kunselman AR, et al. Effects of continuous versus cyclic oral contraception. A randomized controlled trial. Journal of Clinical Endocrinology and Metabolism. 2008 Feb; 93(2):420-9.
15. Rosenberg MJ, Meyers A< Roy V. Efficacy, cycle control and side effects of low and lower dose oral contraceptives: A randomized trial of 20 micrograms and 35 micrograms estrogen preparations. Contraception. 1999 Dec; 60(6):321-9.
16. Nelson A. Communicating with patients about extended-cycle and continuous use of oral contraceptives. Journal of Women's Health. 2007 May; 16(4):463-70.
17. Anderson, FD, Hait H and the Seasonale 301 Study Group. A multicenter randomized study of an extended cycle oral contraceptive. Contraception. 2003; 68:89-96
18. Anderson, FD, Gibbons W, Portman D. Safety and efficacy of an extended regimen oral contraceptive utilizing continuous low dose ethinyl estradiol. Contraception. 2006 Mar; 73(3):229-34.
19. Archer DF, Jensen JT, Johnson JV, et al. Evaluation of a continuous regimen of levonorgestrel/ethinyl estradiol: phase 3 results. Contraception, 2006;74:439-445.
20. Bachmann G, Sulak PJ, Sampson-Landers C, Benda N, Marr J, Efficacy and safety of a low-dose 24-day combined oral contraceptive containing 20 ?g ethinylestradiol and 3 mg drosperinone. Contraception. 2004;70:191-198.
21. Nakajima ST, Archer DF, Ellman H. Efficacy and safety of a new 24-day oral contraceptive regimen of norethindrone acetate 1 mg/ethinyl estradiol 20 ?g (Loestrin? 24 Fe). Contraception. 2007;75:16-22.