Combined Oral Contraceptives for Continuous Use

Introduction to Continuous Regimens

• The American Academy of Pediatrics recommends that the contraceptive vaginal ring (NuvaRing) can be used continuously by replacing it every calendar month (up to 35 days) rather than the labeled 28-day cycle, making it an excellent option for extended use 2

Clinical Indications for Continuous/Extended Use

• The American College of Obstetricians and Gynecologists indicates that anemia, heavy menstrual bleeding, and Von Willebrand disease or other bleeding diatheses are primary indications where continuous COC use reduces blood loss 2
• Severe dysmenorrhea and endometriosis respond well to extended or continuous regimens, as suggested by the American College of Obstetricians and Gynecologists 2, 3

Managing Breakthrough Bleeding

• Unscheduled spotting or bleeding is the most common adverse effect during the first 3-6 months of extended or continuous use, but this bleeding is not harmful and decreases with continued use, according to the Centers for Disease Control and Prevention 4
• Patients must understand that breakthrough bleeding does not indicate contraceptive failure, as stated by the Centers for Disease Control and Prevention 4

Contraceptive Effectiveness Considerations

• The Centers for Disease Control and Prevention recommends that if COCs are started within the first 5 days of menstrual bleeding, no additional contraceptive protection is needed 5
• If started >5 days since menstrual bleeding began, use backup contraception (condoms or abstinence) for 7 consecutive days, as recommended by the Centers for Disease Control and Prevention 5, 1

Important Caveats

• The American College of Obstetricians and Gynecologists advises that COCs should not be prescribed for patients with severe uncontrolled hypertension, ongoing hepatic dysfunction, complicated valvular heart disease, migraines with aura, thromboembolism, or thrombophilia 1
• For women with risk factors for thromboembolism, consider progestin-only methods as alternatives, as suggested by the American College of Obstetricians and Gynecologists 1