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New Problems That May Require Switching Methods
May or may not be due to the method.
Unexplained vaginal bleeding (that suggests a medical condition not related to the method) or heavy or prolonged bleeding
- Refer or evaluate by history and pelvic examination. Diagnose and treat as appropriate.
- She can continue using COCs while her condition is being evaluated.
- If bleeding is caused by sexually transmitted infection or pelvic inflammatory disease, she can continue using COCs during treatment.
Starting treatment with anticonvulsants, rifampicin, rifabutin, or ritonavir
- Barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, lamotrigine, rifampicin, rifabutin, and ritonavir may make COCs less effective. Combined hormonal methods, including combined pills and monthly injectables, may make lamotrigine less effective. If using these medications long-term, she may want a different method, such as a progestin-only injectable, or a copper-bearing or LNG-IUD.
- If using these medications short-term, she can use a backup method along with COCs for greater protection from pregnancy.
- Regardless of her age, a woman who develops migraine headaches, with or without aura, or whose migraine headaches become worse while using COCs should stop using COCs.
- Help her choose a method without estrogen.
Circumstances that will keep her from walking for one week or more
- If she is having major surgery, or her leg is in a cast, or for other reasons she will be unable to move about for several weeks, she should:
- Tell her doctors that she is using COCs.
- Stop taking COCs and use a backup method during this period.
- Restart COCs 2 weeks after she can move about again.
Certain serious health conditions (suspected heart or serious liver disease, high blood pressure, blood clots in deep veins of legs or lungs, stroke, breast cancer, damage to arteries, vision, kidneys, or nervous system caused by diabetes, or gall bladder disease). See Signs and Symptoms of Serious Health Conditions.
- Tell her to stop taking COCs.
- Give her a backup method to use until the condition is evaluated.
- Refer for diagnosis and care if not already under care.
Suspected pregnancy
- Assess for pregnancy.
- Tell her to stop taking COCs if pregnancy is confirmed.
- There are no known risks to a fetus conceived while a woman is taking COCs (see Question 5).
| Extended and Continuous Use of Combined Oral Contraceptives |
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Some COC users do not follow the usual cycle of 3 weeks taking hormonal pills followed by one week without hormones. Some women take hormonal pills for 12 weeks without a break, followed by one week of nonhormonal pills (or no pills). This is extended use. Other women take hormonal pills without any breaks at all. This is continuous use. Monophasic pills are recommended for such use (see Question 16).
Women easily manage taking COCs in different ways when properly advised how to do so. Many women value controlling when they have monthly bleeding—if any—and tailoring pill use as they wish.
Benefits of Extended and Continuous Use
- Women have vaginal bleeding only 4 times a year or not at all.
- Reduces how often some women suffer headaches, premenstrual syndrome, mood changes, and heavy or painful bleeding during the week without hormonal pills.
Disadvantages of Extended and Continuous Use
- Irregular bleeding may last as long as the first 6 months of use—especially among women who have never before used COCs.
- More supplies needed—15 to 17 packs every year instead of 13.
Extended Use Instructions
- Skip the last week of pills (without hormones) in 3 packs in a row. (21-day users skip the 7-day waits between the first 3 packs.) No backup method is needed during this time.
- Take all 4 weeks of pills in the 4th pack. (21-day users take all 3 weeks of pills in the 4th pack.) Expect some bleeding during this 4th week.
- Start the next pack of pills the day after taking the last pill in the 4th pack. (21-day users wait 7 days before starting the next pack.)
Continuous Use Instructions
Take one hormonal pill every day for as long as she wishes to use COCs. If bothersome irregular bleeding occurs, a woman can stop taking pills for 3 or 4 days and then start taking hormonal pills continuously again.
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