NuvaRing Breakthrough Bleeding

Photo by feministhealth

If you are using NuvaRing, the vaginal contraceptive ring on an extended regimen, and you experience breakthrough bleeding or spotting [for at least 5 consecutive days], remove the ring for 4 days, store it, and then reinsert the ring. [Use a backup birth control method for those 4 days.]

Women Receive Insufficient Reproductive Health Information

When it comes to knowledge and understanding of using a continuous Pill regimen to skip or eliminate the menstrual period it looks like women and their doctors are talking past each other.

From a survey of 500 women and 300 physicians:

• 63% of women reported being “somewhat” or “extremely” interested in not having a period, but only 17% of MDs reported that their patients indicated they did not want a period.

• Only 20% of women reported they “strongly agree” or “somewhat agree” that having their period is not medically necessary, while 97% of MDs reported that continuous OC use is medically acceptable.

• Few women (12%) reported talking to their MD about eliminating or reducing their periods; of these, 71% reported that they raised the topic. However, 80% of MDs reported mentioning continuous OC use when discussing contraceptive options; when continuous OC use was discussed, 77% of MDs reported that they raised the topic.

The study concludes that women and their MDs have different understandings of the medical implications of menses inhibition, and women may be receiving insufficient information. Gee, you think?

I'm not exactly sure why we're having this problem. I do think it has a lot to do with 1) the short duration of a well care visit and the inability to spend enough time on patient education, and 2) the assumption that this information is so basic that patients already know about it. [I must admit this is an easy trap to fall into occasionally. Just the other day I assumed a woman knew what lochia was just because she was a multip. Very bad form on my part.]

Spending more time with the patient would be ideal, but, unless we figure out how to be in two places at the same time, I don't think that's a feasible solution. So the best way to go about it is to insure that women receive, and are familiar with, most of the background information before they come in.

If you already know the basics about the menstrual cycle, the Pill's mechanism of action, and the Pill brands and regimens used to skip the period, you can use the office visit to fine tune, to tailor your options to best suit your particular needs.

Now all that remains to be done is to find a way to insure all women are up-to-date on the basics of reproductive health.

Skipping Your Period With a Triphasic Pill, Update

Skipping your period with a triphasic pill brand, like Ortho Tri-Cyclen Lo or Trivora can be a bit of a challenge, for patient and physician alike.

To help out with this challenge, I have updated and expanded my previous posts on using a triphasic to skip a period.

Skipping Your Period With a Triphasic Pill, Part I is an introduction to the birth control Pill, and the various types of pills. Start with this post if you're not familiar with the basics.

Skipping Your Period With a Triphasic Pill, Part II covers using a triphasic Pill brand to delay, or skip the monthly bleeding. I go over five extended regimens in detail.

If you're a patient, print the regimens from Part II, or email them to your doctor, and use the information to discuss with your Ob/Gyn which regimen would be best suited to your needs.

Skipping Your Period, The International Edition

Studies suggest you have a greater tolerance for long intervals of skipping your period if you're a woman residing in Western Europe rather than in Asia or Africa.

Prefer never to have a period

Netherlands, Germany and Scotland - over 35%

Hong Kong, Nigeria and Shanghai - 6%, 13% and 15%

South Africa - 29% (white), 9% (black)

From a social survey of 1207 healthy women from Campinas (Brazil), Heidelberg (Germany) and Ann Arbor (USA) (~400 women from each country):

Prefer never to have a period

- one-third of USA and Brazilian women [about 38% and 33%, respectively]

- less than 10% of German women

Prefer to have a monthly period

- 15% of USA women

- 25% of Brazilian women

- 30% of German women

Prefer to have a period every six months

- ~ 15% of women in all three countries

In response to the question “if you could change the way you menstruate, what single change would be most valuable to you?”, half of all German women and one-third of USA women listed “having more precise control over the timing of menses” as their highest priority. “Having less pain” was the highest priority for a quarter of Brazilian women.

German women, on average, mentioned three times more positive features of menstruation compared to USA or Brazilian women.

Most positive features of menstruation

- being assured of not being pregnant; feeling healthier; and feeling lighter.

Most common negative features of menstruation (across all three countries)

- inconvenience; cramps; bad mood and premenstrual syndrome.

Skip Your Period and Period Control Options

Good AP article on the available options for period control, as well as some coming attractions.

Among the existing methods:

- Seasonale: 30 μg of estrogen (ethinyl estradiol, or EE)/150 μg of progestin (levonorgestrel), taken continuously for 84 days, followed by 1 week off.

- Ortho Evra patch: 0.75 mg estrogen (EE)/ 6.00 mg progestin (norelgestromin) [20 μg estrogen/150 μg progestin per day], one patch per week for 8 or 12 weeks in a row, followed by 1 week off.

- NuvaRing vaginal ring: 2.7 mg estrogen (EE)/11.7 mg progestin (etonogestrel) [15 μg estrogen/120 μg progestin per day], one ring in place for 3 weeks at a time, for 6 or 12 weeks total in a row, followed by 1 week off. [Alternatively, one ring can be left in place for 4 weeks at a time.]

- Depo-Provera [and Depo-subQ provera 104] shot: 150 mg progestin (medroxyprogesterone acetate) [104 mg progestin], one injection four times a year.

One more existing brand worth mentioning is Loestrin 24 Fe. The innovation here is the shortened placebo interval--one estrogen/progestin pill taken for 24 days, followed by one iron-containing placebo pill taken for 4 days. [Of course, if you're already taking the Pill, and you want a shorter placebo interval, you can use your existing brand to do that. Just take 4 placebo pills, instead of the usual 7, followed by a new pack.]

And some newer developments:

- Seasonique: 30 μg of estrogen [EE]/150 μg of progestin [levonorgestrel]), and 10 μg EE, one estrogen/progestin pill taken continuously for 84 days, followed by one estrogen-only pill for 7 days; no placebo interval.

- Lybrel: 20 μg ethinyl estradiol/90 μg levonorgestrel, one estrogen/progestin pill taken daily with no placebo intervals.

- Implanon*: 68 mg progestin (etonogestrel) [~40 μg progestin per day], one-rod implant lasting up to 3 years.

*Just like so many other methods before it (Mirena, Depo-Provera), Implanon has been available for over a decade outside the U.S.. This pretty much insures Implanon's status as a "cutting edge" method over here.

Skip Period Regimens

Skip a period, or skipping your period on Yasmin, tricyclics, and NuvaRing are among the most common terms used by the people who find my site via search engines. So, to help these visitors, as well as my regular readers, I've decided to do a post on the regimens used to skip a menstrual period. This way, you'll have all the information in one place.

Before we start, note:

I. What follows is just an outline of the "skipping your period" (extended) regimens.

II. If you use the Pill, it's best to use a monophasic brand.

TIP: To find out if the brand you're using is monophasic, look at the pack. For a 28-day pack, if 21 pills are the same color and contain the same amount of estrogen and progestin, and 7 pills are a different color and are inactive (placebo), it's a monophasic brand.

Note: The 28-day pack, shortened placebo interval (24/4), brands Loestrin 24 Fe and YAZ are monophasics. As are the 84-day pack brand Lybrel and the 91-day pack brand Seasonale. The other 91-day pack brand, Seasonique, is a biphasic.

III. Your menstrual period and withdrawal bleeding are not one and the same thing.

When you use a combination birth control method, like the Pill, you are not skipping a menstrual period. That's because, for as long as you use such a method, you don't have a menstrual period. What you are doing is shifting the frequency of the withdrawal bleeding episode from once a month to once every few months.

The monthly menstrual period and the monthly withdrawal bleed are distinct, unrelated events.

The monthly period is the body-directed shedding of a thickened uterine lining, under the influence of fluctuating endogenous hormone levels, at set intervals (~21 days). The monthly withdrawal bleed is the user-directed artificial destabilization of a thin uterine lining, as a result of deliberately manipulating the dosage of exogenous hormones in the Pill, at arbitrarily set intervals (21 days, 49 days, 84 days, 168 days, or 336 days).

A monthly menstrual period has a [single] biological purpose: to prepare the uterine lining for pregnancy. A monthly withdrawal bleed has no physiological or biological purpose. It's a designer trick, intended mostly to appease politicians and Popes. It's a historical artifact, not a biological requirement.

IV. The most common side effect with an extended regimen is breakthrough bleeding/spotting (BTB).

V. If you plan to skip your period for a special event, it's best to plan ahead.

Extended regimens work best (less/no BTB) if you plan ahead and give your body at least three months to get used to the new regimen. This applies to both these scenarios: a) you're already using one of the methods on a regular regimen and plan to switch to an extended regimen, or b) you're not using any method and plan to start using an extended regimen.

Of course, it's not always possible to plan ahead. So, if you need to skip your period sooner rather than later, ask your doctor about the high dose, progestin-only regimen (e.g., 5 mg norethindrone acetate, 1-3 times daily). This regimen can be started anywhere from 3 weeks (preferably), to 1 week before the event.

VI. Extended regimens offer the same pregnancy protection as regular regimens.

VII. The .pdf links used in the post are to a method's prescribing information.

VIII. Most of the regimens are based on clinical experience.

IX. Finally, your doctor gives you medical advice, your blogger gives you educational information.

Here are the methods and the regimens.

MONOPHASIC PILL (Yasmin)

Yasmin (.pdf) is a combination, monophasic--estrogen (0.03 mg ethinyl estradiol) + progestin (3 mg drospirenone)--birth control pill. All active pills (21 yellow pills) contain the same amount of hormones. The placebo pills, or "sugar" pills (7 white pills) are inert.

Regular regimen: To bleed once a month

Take one active pill [yellow pill for Yasmin] per day for 21 days, followed by one placebo pill [white pill for Yasmin] for 7 days (bleeding). After the last placebo pill start a new pack.

Extended regimen: To bleed once every three months

Take one active pill [yellow pill for Yasmin] per day for 84 days, followed by one placebo pill [white pill for Yasim] for 7 days (bleeding). After the last placebo pill start another 84-day, active pill, cycle. [You'll need four pill packs per cycle for this regimen.]

TIP: To vary the bleeding interval, vary the number of packs you use. For example, to bleed every month and a half you'll need two pill packs. Take one active pill per day for 42 days, followed by one placebo pill per day for 7 days (bleeding). Or, you can start with three pill packs, and take one active pill per day for 63 days, followed by one placebo pill for 7 days (bleeding).

TRIPHASIC PILL (Ortho Tri-Cyclen Lo)

Ortho Tri-Cyclen Lo (.pdf) is a combination, triphasic--estrogen (0.025 mg ethinyl estradiol) + progestin (0.180 mg/0.215 mg/0.250 mg norgestimate)--birth control pill. All 21 active pills (7 white, 7 light blue, and 7 blue) contain the same amount of estrogen. The amount of progestin varies: the 7 white pills have 0.180 mg; the 7 light blue pills have 0.215mg; and the 7 blue pills have 0.250 mg. The placebo pills, or "sugar" pills (7 green pills) are inert.

Regular regimen: To bleed once a month

Take one active pill [7 white + 7 light blue + 7 blue pills for Orto Tri-Cyclen] per day for 21 days, followed by one placebo pill [green pill for Ortho Tri-Cyclen] for 7 days (bleeding). After the last placebo pill start a new pack.

Extended regimen:

To skip one "period" (or delay the bleeding by one week)

A) Take one active pill [7 white + 7 light blue + 7 blue pills for Orto Tri-Cyclen Lo/Ortho Tri-Cyclen] per day for 21 days. When you get to the 7 placebo pills [green pill for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen] throw them out and instead take the third week of active pills from a new pack [7 blue pills for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen].

Once you're done, either start a new pack right away (skip bleeding) or wait one week and then start a new pack (delays bleeding by one week).

[Pack #1] 7 white pills + 7 light blue pills + 7 blue pills + [Pack #2] 7 blue pills.
Start a new pack right away/Wait one week, then start a new pack.

B) Take one active pill [7 white + 7 light blue + 7 blue pills for Orto Tri-Cyclen Lo/Ortho Tri-Cyclen] per day for 21 days, followed by one placebo pill [green pill for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen] for 7 days (bleeding). After the last placebo pill wait for one week*; don't take any pills. Then start a new pack and take the 21 active pills, followed by the 7 placebo pills. [This regimen shifts the bleeding episode by one week during the second month.]

*VERY IMPORTANT: You are not protected against pregnancy during the week you delay taking the next pack. You must use an alternate birth control method (condom, diaphragm, sponge, etc.).

7 white pills + 7 light blue pills + 7 blue pills + 7 green pills.
Wait one week (no pills). [No Pregnancy Protection!]
Start a new pack.

To bleed once every three months

1. Take one active pill [7 white + 7 light blue + 7 blue pills for Orto Tri-Cyclen Lo/Ortho Tri-Cyclen] per day for 21 days. When you get to the 7 placebo pills [green pill for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen] throw them out and instead start a new pack. Repeat the regimen with the new pack; use 4 packs total. Stop for one week [either don't take any pills, or take the 7 green pills] (bleeding) then restart.

7 white pills + 7 light blue pills + 7 blue pills.
Start a new pack (take active pills only). Repeat [4 packs total].
Wait one week, then start a new pack.

TIP: To vary the bleeding interval, vary the number of packs you use.

Note: This is the regimen most likely to trigger BTB.

2. Take one active pill [7 white + 7 light blue + 7 blue pills for Orto Tri-Cyclen Lo/Ortho Tri-Cyclen] per day for 21 days. When you get to the 7 placebo pills [green pill for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen] throw them out. Start a new pack backwards, after first discarding the 7 placebo pills from this new pack [7 blue + 7 light blue + 7 white pills for Orto Tri-Cyclen Lo/Ortho Tri-Cyclen]. Repeat the regimen with the next two packs; use 4 packs total. Stop for one week [either don't take any pills, or take the 7 green pills] (bleeding) then restart.

[Pack #1] 7 white pills + 7 light blue pills + 7 blue pills + [Pack #2] 7 blue pills + 7 light blue pills + 7 white pills + [Pack #3] 7 white pills + 7 light blue pills + 7 blue pills + [Pack #4] 7 blue pills + 7 light blue pills + 7 white pills.
Start a new pack backwards (take active pills only). Repeat [4 packs total].
Wait one week, then start a new pack.

3. Start with three new packs (or two). Take the first 7 active pills [white pills for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen] from each of the three packs, for a total of 21 pills. Then take the next 7 active pills [light blue for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen] from each of the three packs, or 21 pills total. Finally, take the last set of 7 active pills [blue pills for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen] from the three packs, or 21 pills total. Stop for one week [either don't take any pills, or take the 7 green pills] (bleeding) then restart.

[Pack #1] 7 white pills + [Pack #2] 7 white pills + [Pack #3] 7 white pills + [Pack #1] 7 light blue pills + [Pack #2] 7 light blue pills + [Pack #3] 7 light blue pills + [Pack #1] 7 blue pills + [Pack #2] 7 blue pills + [Pack #3] 7 blue pills.
Stop for one week, then restart.

SKIN PATCH (Ortho Evra)

Ortho Evra (.pdf) is a combination--estrogen (0.75 mg ethinyl estradiol) + progestin (6.00 mg norelgestromin)--birth control skin patch. It releases 0.020 mg of estrogen and 0.150 mg of progestin per day.

Regular regimen: To bleed once a month

Apply one patch and leave it on for 1 week. At the end of the week, remove the patch, discard it and replace it with a new patch. Do this for 3 weeks in a row. At the end of the third week, remove and discard the last patch and wait for one week; that's the patch-free week (bleeding). Once the week is over, restart the regular [3 weeks:3 patches on/1 week off] patch regimen.

Extended regimen: To bleed every few months

Apply one patch and leave it on for 1 week. At the end of the week, remove the patch, discard it and replace it with a new patch. Do this for 8 weeks (or 12 weeks) in a row. At the end of the eighth week (or twelfth week), remove and discard the last patch and wait for one week; that's the patch-free week (bleeding). Once the week is over, restart the the extended-use [8 weeks:8 patches (or 12 weeks:12 patches) on/1 week off] patch regimen.

Note: Use of the regular patch regimen [3 weeks:3 patches on/1 week off] entails a 60% higher exposure to estrogen than use of a typical combination Pill brand containing 35 μg of estrogen on a regular regimen [21 days on/7 days off]. Although the clinical relevance of this finding is unknown, you should be aware of it before starting an extended patch regimen.

VAGINAL RING (NuvaRing)

NuvaRing (.pdf) is a combination--estrogen (2.7 mg ethinyl estradiol) + progestin (11.7 mg etonogestrel)--birth control vaginal ring. It releases 0.015 mg of estrogen and 0.120 mg of progestin per day.

Regular regimen: To bleed once a month

Insert one ring and leave it in place for 3 weeks in a row. At the end of the third week, remove the ring, discard it and wait for one week; that's the ring-free week (bleeding). Once the week is over, restart the regular [3 weeks on/1 week off] ring regimen.

Extended regimen: To bleed every few months

Insert one ring and leave it in place for 3 weeks in a row. At the end of the third week, remove the ring, discard it and replace it with a new ring right away. Keep the new ring in for 3 weeks in a row. [That's 6 weeks total.] At the end of the third week, remove the ring, discard it and either:

a) wait for one week; that's the ring-free week (bleeding). Once the week is over, restart the extended-use [6 weeks on/1 week off] ring regimen.

b) replace it with a new ring right away. Leave the new ring in place for 3 weeks in a row. At the end of the third week, remove the ring, discard it and replace it with a new ring right away. Keep the new ring in for 3 weeks in a row. [That's 12 weeks total.] At the end of the third week, remove the ring, discard it and wait for one week; that's the ring-free week (bleeding). Once the week is over, restart the extended-use [12 weeks on/1 week off] ring regimen.

TIP: You can also insert one ring and leave it in for 4 weeks in a row, instead of 3 weeks.

[At the end of the fourth week, remove the ring, discard it and replace it with a new ring right away. The rest of the extended regimen is the same as above, except you leave the ring in for 4 weeks, instead of 3 weeks, in a row.]

Note: Use of the regular ring regimen [3 weeks on/1 week off] entails a 50% lower exposure to estrogen than use of a typical combined Pill brand containing 30 μg of estrogen on a regular regimen [21 days on/7 days off]. Although the clinical relevance of this finding is unknown, you should be aware of it before starting an extended ring regimen.


UPDATE: Right after I finished posting I noticed someone found this by using the search term "secrets to delaying menstrual period". Heh, there are no secrets. Just information.

ETA: I've updated the post.

Skip Period With Ortho Evra

Good news for birth control skin patch (Ortho Evra) users who want to use the patch to skip the monthly fake period:

A contraceptive patch that has been effective for the standard 21-day cyclic regimen appears to translate seamlessly into an extended regimen, results of a 112-day pilot study suggest.

...

The 123 women who completed the extended regimen applied a new patch weekly for 12 consecutive weeks, and then skipped a week to allow for bleeding. The 68 women who completed the study in the cyclic group applied a new patch weekly for 3 consecutive weeks, and then skipped a week to allow for bleeding.

Skipping Your Period and Google

I don't know if this is a common blogosphere occurrence, but I must say I receive the most interesting questions. A reader wanted to find out more information about skipping her period, or menstrual management (MM) so off to Google she went. And this is what happened:

90% of the results are about menstrual management for developmentally or intellectually disabled women! In fact, in the first three pages of Google hits, the only non-disability-related results are related to you; they all point to this blog or sites about your book.

I realize the menstrual management idea is relatively new and all, but is handling disabled women really the only context in which it's been discussed until now? Nothing about non-disabled women who just don't want their periods? I'm just blown away.

Actually, I had the same reaction when I discovered the dearth of MM information available to women; hence, my decision to write the book. While we wait for it to come out, let's try to fill this informational gap a little bit by, briefly, going over who can benefit from using MM, and then by looking at why you (and, apparently, Google) don't have enough MM information.

Before we start, I must nip this meme in the bud: the MM idea is relatively new. No, it's not! The only thing that's new is women *finally* getting some information about it.

First, the Pill was initially FDA-approved as a MM drug (in 1957), not a birth control one. That came later, in 1960. Second, using hormonal birth control to treat period-related problems (e.g., endometriosis) has been the standard of care for decades. Third, studies of women using the Pill to suppress the monthly [fake] period have been published as far back as the 1970s. [If you think the concept of Seasonale/a trimonthly bleeding episode is new, think again. The women in a 1977 British study used a similar, trimonthly regimen. Interestingly, 82% of those women welcomed the reduction in the number of periods.] And last, but not least, everybody from honeymooning brides to students, and farmers--women with no period-related problems--have been using MM for lifestyle reasons, also for decades (provided their physician was familiar with it). Apropos of physicians: a 2003 Gallup poll commissioned by ACOG (the American College of Ob/Gyns) found that female ob/gyns are nearly unanimous (99%) in the view that menstrual suppression--the daily use of the Pill to stop monthly periods--is safe for their patients. More than half of women ob/gyns have tried menstrual suppression themselves.

Bottom line: MM is not a new idea. It's been in use for decades.

1) Who can benefit from using MM?

A. Women who don't want to have monthly periods

(because they simply don't like to or because they live in societies that consider menstruating women "untouchable")

B. Women who lead an active lifestyle

(women in the military, women who enjoy active sports, women with physically demanding jobs--stay-at-home mothers taking care of small children, shift factory workers, residents and nurses, mail carriers, etc.)

C. Women with period-related health problems

(cramps, heavy periods, endometriosis, seizures, etc., as well as women with various disabilities)

D. Nonmenstruating women

(women using hormonal birth control no longer have menstrual periods, yet they still experience fake period-related health problems--cramps, migraines,etc.)

One important note: there's no connection between sexual activity and using MM. In other words, MM can be equally beneficial to nuns and mothers of five children. (So, if you had any naughty ideas, nice try, but no.)

Bottom line: although disabled women are one group who can benefit from using MM, they're just one of many. In fact, non-disabled MM users are the clear majority. So then, where's the MM information for non-disabled women? Apparently not on Google.

One thing just occurred to me: most physicians who know about MM aren't probably even aware that this information isn't widely available. I certainly wasn't until something happened--I looked for a good lay MM book to recommend--that made me joltingly aware. [In my colleagues' and my defense: I think we live in a bubble. The lay people we come into contact with, our patients, know about MM because we tell them. All the rest, co-workers and friends, also already know since the majority are medical professionals.] As to the health care professionals who don't know about MM, as well as women in general--how can they be expected to be aware of an information shortage when they're not aware the information exists to begin with?

2) Why isn't MM information widely available?

A. Health-care professionals

(too little time spent with patients, some don't know about MM, etc.)

In a survey of nurses and physicians, 43% said they don't prescribe MM drugs because patients don't ask for them and 4% don't prescribe them because of the extra counseling time involved.

B. The government and pharmaceutical companies

(bureaucracy, no interest in changing drug designation from off-label to "on-label", etc.)

A quick primer on the impact of an off-label designation. First, what do "off-label" and "on-label" mean? Here's an example: the antidepressant Zoloft is FDA-approved for treating depression. This is an "on-label" use. [Once a drug is FDA-approved, for whatever indication, physicians can prescribe it for another indication.] While using Zoloft, physicians notice that it's also very effective at treating premature ejaculation and start using it for that as well. This is an "off-label" use. Most drugs are used off-label, and the off-label use is often considered the standard of care. Only drugs that are FDA-approved can be used off-label.

How does the off-label designation impact you? In a major way. It keeps you out of the loop by law. Pharmas are not allowed to distribute information about off-label use directly to consumers. Most often, they don't even volunteer the information to physicians (they can, but usually, only if the physician initiates the inquiry). Unfortunately, since the drug is already FDA-approved and the physicians are already using it, legally, off-label, the drug manufacturer has little incentive to invest in changing the drug designation to "on-label". In other words, there's little incentive to keep you informed.

For example, before Seasonale was FDA-approved in September of last year, MM use of the Pill, although the standard of care, was off-label. In practical terms, this meant that, unless your health-care professional new about MM and elected to share the information with you, it would've been very hard for you to educate yourself about MM. Now that Seasonale is "on-label", you can get some MM information. As in, you can get information about Seasonale and nothing else. Not the over 10 other monophasic Pill brands* with the exact same composition as Seasonale, not about using a triphasic brand for MM (despite the fact that, according to the manufacturer, a triphasic brand is the one most used by American women), and most certainly not a peep about using NuvaRing, the vaginal ring, or other hormonal methods for MM. Remember, only Seasonale is "on-label"; the rest, although identical in the case of the other monophasics, are off-label. And you're not allowed to know anything about them, under threat of great physical harm. [I'm joking, of course. Or am I? After all, it's quite possible your pretty little heads will explode now as a result of exposing you to all this information.]**

C. The media and society

(the message that the menstrual period is more disgusting than any other known and widely advertised body function--acid reflux, gas, impotence, etc.; acceptable to discuss anal sex, vibrators, decomposing bodies, while mentioning the period, not so much)

*Monophasic Pill brands equivalent to Seasonale (same hormone content, different packaging):

Seasonale estrogen 0.03 mg + levonorgestrel 0.15 mg
Femigoa
Femranette
Levlen
Levora 0.15/30
Microgynon 30
Minidril
Monofeme 28
Nordette
Ologyn micro
Ovranette
Stediril 30

*Just so you know, in the book all you get is the actual data. The purpose of the book is to give you complete and correct information about MM, to allow you to know more and live better. It's not to expose you to my personal comments and opinions. Despite their brilliance, they're irrelevant to your health decisions. [That's why I have a blog, in case you were wondering. Wouldn't want to deprive the world of my opinions. And that's also the reason I blog more-or-less anonymously. I'm quite uncomfortable with physicians expressing their personal views right alongside medical information.]

Skipping Your Period With a Triphasic Pill, Part II

You can use a triphasic pill brand to skip a period. Before we review the regimens used to skip a period with a triphasic pill brand, let me clarify a few terms.

Triphasic, Skip a Period

Combination birth control pill - each active pill has a combination of estrogen (ethinyl estradiol) and progestin (synthetic progesterone). Each placebo ("sugar") pill is inactive; it does not have hormones.

Pill brands came in 21-, 28-, and 91-day packs. The 21-day pack has only active pills. The 28- and 91-day packs have an extra 7 inactive, or placebo pills.

The placebo pills are reminder pills. They're put in the pack to get you into the habit of taking a pill every day. They serve no other purpose.

Monophasic brand - all active pills have the same amount of estrogen and progestin. All active pills are the same color. In 28-day packs, the 7 placebo pills are a different color. That's two different colored groups of pills per 28-day pack.

Triphasic brand - the active pills have either the same, or two different amounts of estrogen, and two or three different progestin amounts. All active pills with the same amount of estrogen and progestin are the same color--usually three groups of colors per 28-day pack. The 7 placebo pills are a different color. That's four different colored groups of pills per 28-day pack.

For more on monophasic vs. triphasic, see Skipping Your Period With a Triphasic Pill, Part I.

Skipping a period - when you use a combination birth control pill--monophasic or triphasic--you don't have a menstrual period for the entire time you take the pill.

The monthly bleeding you experience while on the Pill is withdrawal bleeding, a chemically induced event. This artifice was introduced for political, religious, etc. reasons by the Pill inventors; it serves no known medical function.

The menstrual period and withdrawal bleeding are not one and the same thing.

Bottom line: When you use the Pill and you modify the regular 21/7 (21 days of active pills/7 days of placebo pills during which you experience withdrawal bleeding) to an extended regimen, like the 84/7 one, you are only changing the frequency of withdrawal bleeding; from monthly, to once every three months. The regimen change has no effect on your menstrual period since, while on the Pill, you don't have a menstrual period.

Triphasic, Extended Regimen

If you want to skip your period, using a monophasic Pill brand is best.

Why? Because all monophasic active pills have the same amount of hormones. This means steady hormone levels and less likelihood of nuisance side effects like breakthrough bleeding/spotting (BTB).

BTB is not dangerous to your health (for most women) but it's a significant inconvenience (not to mention a major reason women discontinue Pill use).

Because triphasic pill brands have varying hormone levels which fluctuate--usually, from week to week--you're more likely to experience BTB if you use a triphasic brand to skip your period.

So, what are you to do?

If you're not already on the Pill, start using a monophasic brand to skip your period.

If you're already using a triphasic brand and it suits you, no need to switch to a monophasic. Go ahead and use your existing triphasic brand. If it works, great! If not, you can always change to a monophasic brand later.

Now, if you're already on the Pill, a triphasic one, you're most likely on the regular regimen: 21 days of active pills, followed by 7 days of placebo pills during which time you experience an episode of bleeding.

In order to eliminate that monthly bleeding episode, or shift its frequency (to, say, once every three months) you have to modify the regular 21/7 regimen you've been using. You need to use an extended regimen, and you have several options to chose from.

Before we go on to the actual regimens, note the following:

- no matter which regimen you chose, you're still protected against pregnancy (provided you don't miss any pills, of course)

- the regimen recommendations to follow are based on clinical experience (there are no formal studies on triphasic extended regimens)

- since Ortho Tri-Cyclen* is a commonly used triphasic brand, I'll use it to illustrate the various extended regimens

*There are 28 pills in the pack. Four groups of 7 pills, each group a different color:

White pills (seven)- each pill has 0.035 mg estrogen (ethinyl estradiol) and 0.180 mg progestin (norgestimate)

Light blue pills (seven)- each pill has 0.035 mg estrogen and 0.215 mg progestin

Blue pills (seven)- each pill has 0.035 mg estrogen and 0.250 mg progestin

Green pills (seven)- each pill is a placebo pill (no hormones)

Notice how the amount of estrogen is the same throughout the month, while the progestin amount keeps increasing.

And now, without further ado, the triphasic regimens.

Triphasic Regimens

To skip one period or delay it by one week:

A) Take the 21 active pills (first three weeks of pills). When you get to the 7 placebo pills (last week of pills) throw them out and instead take the third week of active pills from a new pack.

(Ortho Tri-Cyclen) Take 7 white pills + 7 light blue pills + 7 blue pills. That's 3 weeks and 21 pills. When you get to the 7 green pills, discard them, and take 7 blue pills from a new pack instead. Once you're done, either wait one week and then start a new pack (delays bleeding by one week), or start a new pack right away (skip bleeding).

7 white pills + 7 light blue pills + 7 blue pills + 7 blue pills (from a new pack)
Wait one week, then start a new pack/Start a new pack right away.

B) Take the 21 active pills and the 7 placebo pills (four weeks). Wait for one week**. Start a new pack and take the 21 active pills, followed by the 7 placebo pills. [This regimen shifts the bleeding episode by one week during the second month.]

**VERY IMPORTANT: You are not protected against pregnancy during the week you delay taking the next pack. You must use an alternate birth control method (condom, diaphragm, sponge, etc.).

7 white pills + 7 light blue pills + 7 blue pills + 7 green pills
Wait one week (no pills). [No Pregnancy Protection!]
Start a new pack.

To delay bleeding for months:

1. Take the 21 active pills (first three weeks of pills). When you get to the 7 placebo pills (last week of pills) throw them out and instead start a new pack.***

7 white pills + 7 light blue pills + 7 blue pills
Start a new pack (take active pills only).

***This is the regimen most likely to trigger BTB.

2. Take the 21 active pills (first three weeks of pills). When you get to the 7 placebo pills (last week of pills) throw them out. Start a new pack backwards, after first discarding the 7 placebo pills from this new pack.

[Pack #1] 7 white pills + 7 light blue pills + 7 blue pills + [Pack #2] 7 blue pills + 7 light blue pills + 7 white pills {+ [Pack #3] 7 white pills + 7 light blue pills + 7 blue pills}

3. Start with three new packs (or two). Take the first 7 active pills from each of the three packs (three weeks total). Then take the next 7 active pills from each of the three packs (three weeks). Finally, take the last set of 7 active pills from the three packs (three weeks). Stop for one week, then restart.

[Pack #1] 7 white pills + [Pack #2] 7 white pills + [Pack #3] 7 white pills + [Pack #1] 7 light blue pills + [Pack #2] 7 light blue pills + [Pack #3] 7 light blue pills + [Pack #1] 7 blue pills + [Pack #2] 7 blue pills + [Pack #3] 7 blue pills
Stop for one week, then restart.

So, there you have it. These are some of the regimen options you have if you want to use a triphasic Pill brand to skip your period.

As you can see, using a triphasic for an extended regimen can be a bit confusing. Also, you're more likely to experience BTB. So, even if you're already using a triphasic on a regular 21/7 regimen, consulting with your physician about switching to an extended regimen is most helpful.

Skipping Your Period With a Triphasic Pill, Part I

I've been getting a lot of questions about using a triphasic birth control pill brand and skipping a period. Before we discuss what regimen you use to skip your period with a triphasic Pill brand, let's make sure we're all clear on the differences between the various pill brands.

We'll discuss extended triphasic regimens in a subsequent post.

There are two groups of birth control pills:

A. Nonsteroidal (centchroman)

B. Steroidal (estrogen/progestin)

A. Nonsteroidal Birth Control Pill

This type of birth control pill contains a substance called centchroman.

The pill is taken once-a-week (twice-a-week for the first 3 months of use), the brand names are Centron or Saheli, and its main advantage is that users don't experience the side effects associated with the steroid (estrogen/progestin) pill. Its main side effect is delayed menses (in less than 10% of cycles). Of course, if the reason you're using a birth control pill is to skip your period, this is a feature not a drawback.

In any case, since this pill isn't available in the U.S., let's move on to the other Pill group, the steroidal one.

B. Steroidal Birth Control Pill

Pills in this group contain estrogen and/or progestin. The pill is taken once-a-day, and there are many brand names. More importantly, pills in this group can be further subdivided, based on what type of hormone (estrogen/progestin) they contain.

There are two main types of birth control pills in this group:

B.1. Progestin-only Pill (progestin)

B.2. Combination Pill (estrogen and progestin)

B.1. Progestin-only Pill

As the name implies, these pills have only one hormone, a progestin. A progestin is either a natural or man-made (synthetic) hormone with properties similar to the natural hormone progesterone.

Progestin-only pill brands are divided into "mini" pill brands, and full-dose brands (not available in the U.S.). As a rule, "mini" pill brands come in 28-day packs, and full-dose ones come in 20-day packs.

Progestin-only brands are not your first choice when it comes to skipping your period.

B.2. Combination Pill

These pills have two hormones, a combination of estrogen and progestin.

Combination Pill brands are further subdivided into mono-, bi-, and triphasic; some come in a 21-day pack, others in a 28-day one, and the newer ones, Seasonale and Seasonique, comes in a 91-day pack. Finally, based on the amount of estrogen, brands are classified as very low-dose (15 mcg or 20 mcg), low dose (35 mcg), and high dose (50 mcg).

All the pills in a 21-day pack are active. An active pill is a pill which has hormones. The 28- and 91-day packs have 7 days of inactive or placebo ("sugar") pills. These pills don't have hormones.

The mono-, bi-, and triphasic designation refers to the amount of hormones in the pill pack.

Monophasic

Brevicon

Each active pill in the pack has the same amount of estrogen and progestin. Also, all the active pills are the same color. This color is a different color than that of the 7 placebo pills found in the 28- and 91-day packs.

Biphasic

Mircette

For most brands, all the active pills in the pack have the same amount of estrogen, but two strengths of progestin.

A 21-day biphasic pack has pills of one strength and color taken for seven or 10 days, then a second pill with a different strength and color for the remainder of the cycle.

A 28-day biphasic pack has an extra seven placebo pills of a third color.

For a 28-day brand like Mircette, a pack has 21 pills of one strength [20 mcg ethinyl estradiol (EE)/0.15 mg desogestrel] and color, 2 placebo pills of a different color, and 5 pills with only estrogen, of a different strength [10 mcg (EE)] and color.

Of note, Mircette is one of the few available sequential brands with a shortened placebo interval: 2 days vs. 7 days. The shortened placebo interval has to do with withdrawal bleeding (fake period) which is different from menses (real period). [More on birth control pill brands with no or shortened placebo interval.]

Triphasic

Ortho Tri-Cyclen Lo

The active pills have either the same or varying amounts of estrogen, and varying amounts of progestin.

A 21-day pack has pills with three different colors and strengths. First, pills of one strength and color are taken for five to seven days. Then pills of a different strength and color are taken for the next five to seven days. Finally, a third strength and color pill is taken for the reminder of the cycle.

A 28-day pack (look under triphasics) has an extra seven placebo pills of a fourth color.

So, there you have it. Lots of birth control pill types, and brands. The important thing to remember is this:

To skip a period a monophasic brand is best.

A monophasic combination Pill brand is best because all active pills contain the same amount of hormones. Less hormonal fluctuation, due to the steady hormone levels, means you're less likely to experience nuisance side effects like irregular bleeding (breakthrough bleeding/spotting).

TIP: Regardless of which type of brand you use--monophasic or triphasic--starting an extended regimen at least three months in advance of the time you plan to skip your period allows your body to get used to the new regimen, and minimizes irregular bleeding.

If you use a monophasic Pill brand, to skip a period you take the 21 active pills, discard the 7 placebo pills, and start a new pack right away.

If you use a triphasic Pill brand you have several regimen options. One of them is to use the same regimen used for the monophasic brands--take the 21 active pills, discard the 7 placebo pills, and start a new pack right away. [Note: this regimen is mostly likely to be associated with irregular bleeding.]

Skip...Period...Honeymoon

I noticed a lot of people who search for "How can I skip my period for my honeymoon" (or a variant of that) are directed here. Since I don't actually have an explicit post on how to skip your period during the honeymoon, I feel like I'm letting down all those poor brides-to-be. So, in the interest of smooth nuptials and honeymoons, here's a quick primer on how to skip the menstrual period.

Track Your Periods

First, get in the habit of tracking your periods so you can anticipate the start of your next period. Best to have at least 6 months of data to establish a pattern.

Plan In Advance

Second, if your period is scheduled to start during your honeymoon, the ideal time to start managing your period is at least 3 months in advance. The main reason to do this is in order to cut down/eliminate breakthrough bleeding and spotting.

Decide What Method To Use, And Use A Skip Period Regimen

Third, what you do next depends on the method of birth control you plan to use (or are already using).

Today, let's limit ourselves to women who already use birth control, a hormonal method, the Pill.

As you probably know, there are 6 methods in the hormonal group:

1. Pill (two-hormones and one-hormone)

2. Skin patch (Ortho Evra)

3. Vaginal Ring (NuvaRing)

4. Implant (Implants)

5. Shot (Injections/Shots [two-hormones and one-hormone])

6. IUD (Hormone-releasing Intrauterine Device (IUD))

For women who use a combination (two hormones) Pill brand:

Identify the type of Pill

You need to figure out what type of Pill you're taking: a 21-day, 28-day, or 84-day (Seasonale) brand.

Also, make sure it's a monophasic brand (all active pills--the pills that have hormones--in the pack have the same amount of hormones.)

TIP: An easy way to figure that out if your brand is monophasic--in a 21-day pack, all pills are the same color; in a 28-day pack, you only have two pill colors (21 pills are one color, and seven pills are a different color).

Change the way you take the Pill

You need to change the way you take the Pill. (Remember, it's best if you start this change at least three months before the planned event.)

You need to switch from a regular 21/7 regimen, to an extended regimen.

Let's use the 84/7 extended regimen as an example.

For the 21-day pack, when you finish the pack, don't wait for one week to start a new pack; start a new pack right away. Do this for four packs in a row (the fourth pack is the one you take during the actual honeymoon).

For the 28-day pack, you have 21 active pills (all have hormones, and all have the same color), and 7 inactive (or placebo, or "sugar") pills (these pills don't have any hormones, and they're all the same color, a different color than the active ones). Once you finish the 21 active pills, throw away the seven placebo pills; start a new pack right away. Do this for four packs in a row (fourth pack during the honeymoon).

For the 84-day pack (Seasonale), take the 84 pink pills.

That's it. Of course, this only scratches the surface of menstrual management and I do plan to have additional posts on this topic. (I just finished writing a book on this subject, and that wasn't enough. Now I'm blogging about it. Somebody stop me!) Like what is the difference between the real and the fake period (withdrawal bleeding). You have no idea how much confusion and misinformation surrounds this very basic concept!

Last, but not least, it goes without saying that you should never base health decisions on the postings of an anonymous blogger (no matter how lovely the blogger). Rather, use the information as a starting point for an in-depth, personalized discussion with your own Ob/Gyn.

Seasonale: Fewer periods. More possibilities.

That's the slogan for the new Seasonale* TV ad.

I saw the Seasonale ad last night for the first time and I must say, it was well done--mostly a woman in a white dress with red dots...she twirls around...the spots lift off the dress...everybody's happy.

What impressed me most was the fact that it's one of the few times I've seen something period-related on TV that didn't come with the obligatory disclaimer (a la "Brace yourself, this is a commercial about your period."). Also, they called the period, a period. No cutesy euphemism (Yasmin has a TV ad where they mention that the brand can improve symptoms associated with "that time of the month". And what time of the month would that be?)

*Seasonale is the only birth control pill brand specifically packaged for continuous use. It's an 84/7 regimen (84 days on active pill/7 days on placebo pill).

Of course, there are about 10 other pill brands with the same hormone content as Seasonale. The problem is they're not labeled with instructions for the 84/7 regimen.

I'll post more on this subject as soon as I'm done with the task at hand. And speaking of current tasks, I might even post something about those wacky publishing world deadlines. I mean, over 250 pages to review/edit in 7 days--who comes up with these rules? At least I'm used to on-calls and staying up for 2-3 days in a row, but what about normal people; how do they manage?

Here's a short poem that didn't make it into the book. I liked it [can you say pedestal?] but it wasn't deemed pertinent. What do you think?

O woman! lovely woman! Nature made thee
To temper man: we had been brutes without you.
Angels are painted fair, to look like you;
There's in you all that we believe of heaven, -
Amazing brightness, purity, and truth,
Eternal joy, and everlasting love.

Thomas Otway - Venice Preserved (act I, sc. 1) 1682

Timing The Menstrual Period

When it comes to skipping the menstrual period (to benefit your health, and/or lifestyle), what do female Ob/Gyns have to say?

[W]omen ob-gyns are nearly unanimous (99%) in the view that menstrual suppression -- the daily use of oral contraceptives to stop monthly periods -- is safe for their patients. More than half of women ob-gyns have tried menstrual suppression themselves.

(Read the entire article; topics range from period control, to elective cesarean delivery, to hormone therapy.)

So, 99% of women Ob/Gyns think that not having a period for months to years at a time (menstrual suppression) is safe. What do you think? Or, maybe a better question might be:

Are you familiar with menstrual suppression and menstrual management?