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Hormonal contraception for suppression of menstruation

Andrew M Kaunitz, MD
Section Editor
Robert L Barbieri, MD
Deputy Editor
Kristen Eckler, MD, FACOG


Several available hormonal contraceptives can be used to reduce or eliminate monthly uterine bleeding. The safety and efficacy of these methods make them desirable for women who have medical indications for suppression of menstruation, as well as those who simply want the convenience of not having a monthly bleed (whether or not they desire contraception).

Use of hormonal contraceptives for suppression of menstruation is reviewed here. Evaluation and management of women with abnormal uterine bleeding, as well as general principles of use of hormonal contraceptives, are discussed separately. (See "Approach to abnormal uterine bleeding in nonpregnant reproductive-age women" and "Management of abnormal uterine bleeding" and "Overview of the use of estrogen-progestin contraceptives".)


Continuous or long-term use of hormonal contraception is associated with the same medical risks as cyclic use of these medications [1]. In contrast to women on cyclic regimens, women using continuous-dose regimens benefit from reduction of menstrual symptoms (eg, headache, genital irritation, tiredness, bloating, and pain) [2]. We educate our patients that unscheduled bleeding is common on extended regimens.

Menstruation (ovulation followed by withdrawal bleeding) is not physiologically necessary. In fact, most modern women experience many more menstrual cycles in their lifetime than women in prior generations because of earlier menarche, fewer pregnancies, reduced duration of breastfeeding, and later menopause [3]. Moreover, this frequent, regular ovulation may actually increase a woman's risk of some diseases, such as endometriosis and ovarian cancer.

The concept that monthly bleeding is healthy has been perpetuated by oral contraceptives (OC) that were initially designed to mimic the average length of a normal menstrual cycle. This "artificial" period had no medical benefits and the initial choice of 21/7 (monthly) OC formulations that result in withdrawal bleeding each four weeks was arbitrary.


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Literature review current through: Sep 2016. | This topic last updated: May 4, 2016.
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  1. Jacobson JC, Likis FE, Murphy PA. Extended and continuous combined contraceptive regimens for menstrual suppression. J Midwifery Womens Health 2012; 57:585.
  2. Edelman A, Micks E, Gallo MF, et al. Continuous or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception. Cochrane Database Syst Rev 2014; :CD004695.
  3. Lin K, Barnhart K. The clinical rationale for menses-free contraception. J Womens Health (Larchmt) 2007; 16:1171.
  4. den Tonkelaar I, Oddens BJ. Preferred frequency and characteristics of menstrual bleeding in relation to reproductive status, oral contraceptive use, and hormone replacement therapy use. Contraception 1999; 59:357.
  5. Andrist LC, Arias RD, Nucatola D, et al. Women's and providers' attitudes toward menstrual suppression with extended use of oral contraceptives. Contraception 2004; 70:359.
  6. Sulak PJ, Kuehl TJ, Ortiz M, Shull BL. Acceptance of altering the standard 21-day/7-day oral contraceptive regimen to delay menses and reduce hormone withdrawal symptoms. Am J Obstet Gynecol 2002; 186:1142.
  7. Schneider MB, Fisher M, Friedman SB, et al. Menstrual and premenstrual issues in female military cadets: a unique population with significant concerns. J Pediatr Adolesc Gynecol 1999; 12:195.
  8. Frankovich RJ, Lebrun CM. Menstrual cycle, contraception, and performance. Clin Sports Med 2000; 19:251.
  9. Jain V, Wotring V. medically induced amenorrhea in female astronauts. Nature Partner Journals Microgravity 2016.
  10. Kaplowitz PB, Oberfield SE. Reexamination of the age limit for defining when puberty is precocious in girls in the United States: implications for evaluation and treatment. Drug and Therapeutics and Executive Committees of the Lawson Wilkins Pediatric Endocrine Society. Pediatrics 1999; 104:936.
  11. American College of Obstetricians and Gynecologists Committee on Adolescent Health Care. ACOG Committee Opinion No. 448: Menstrual manipulation for adolescents with disabilities. Obstet Gynecol 2009; 114:1428.
  12. Braunstein JB, Hausfeld J, Hausfeld J, London A. Economics of reducing menstruation with trimonthly-cycle oral contraceptive therapy: comparison with standard-cycle regimens. Obstet Gynecol 2003; 102:699.
  13. Fels H, Steward R, Melamed A, et al. Comparison of serum and cervical mucus hormone levels during hormone-free interval of 24/4 vs. 21/7 combined oral contraceptives. Contraception 2013; 87:732.
  14. Sulak PJ, Scow RD, Preece C, et al. Hormone withdrawal symptoms in oral contraceptive users. Obstet Gynecol 2000; 95:261.
  15. Sulak PJ, Cressman BE, Waldrop E, et al. Extending the duration of active oral contraceptive pills to manage hormone withdrawal symptoms. Obstet Gynecol 1997; 89:179.
  16. Anderson FD, Hait H. A multicenter, randomized study of an extended cycle oral contraceptive. Contraception 2003; 68:89.
  17. Anderson FD, Gibbons W, Portman D. Long-term safety of an extended-cycle oral contraceptive (Seasonale): a 2-year multicenter open-label extension trial. Am J Obstet Gynecol 2006; 195:92.
  18. Kaunitz, AM, Reape, KZ, Portman, D, Hait, H. The impact of altering the hormone free interval on bleeding patterns in users of a 91-day extended regimen oral contraceptive. Abstract presented at Reproductive Health 2007, Annual Meeting of the Association of Reproductive Health Professionals, Minneapolis, MN, September 27, 2007. Contraception 2009; 76:157.
  19. Anderson FD, Gibbons W, Portman D. Safety and efficacy of an extended-regimen oral contraceptive utilizing continuous low-dose ethinyl estradiol. Contraception 2006; 73:229.
  20. Portman DJ, Kaunitz AM, Howard B, et al. Efficacy and safety of an ascending-dose, extended-regimen levonorgestrel/ethinyl estradiol combined oral contraceptive. Contraception 2014; 89:299.
  21. Archer DF, Jensen JT, Johnson JV, et al. Evaluation of a continuous regimen of levonorgestrel/ethinyl estradiol: phase 3 study results. Contraception 2006; 74:439.
  22. Teichmann A, Apter D, Emerich J, et al. Continuous, daily levonorgestrel/ethinyl estradiol vs. 21-day, cyclic levonorgestrel/ethinyl estradiol: efficacy, safety and bleeding in a randomized, open-label trial. Contraception 2009; 80:504.
  23. Johnson JV, Grubb GS, Constantine GD. Endometrial histology following 1 year of a continuous daily regimen of levonorgestrel 90 micro g/ethinyl estradiol 20 micro g. Contraception 2007; 75:23.
  24. Davis AR, Kroll R, Soltes B, et al. Occurrence of menses or pregnancy after cessation of a continuous oral contraceptive. Fertil Steril 2008; 89:1059.
  25. Barnhart K, Mirkin S, Grubb G, Constantine G. Return to fertility after cessation of a continuous oral contraceptive. Fertil Steril 2009; 91:1654.
  26. Sulak PJ, Kuehl TJ, Coffee A, Willis S. Prospective analysis of occurrence and management of breakthrough bleeding during an extended oral contraceptive regimen. Am J Obstet Gynecol 2006; 195:935.
  27. Machado RB, de Melo NR, Maia H Jr. Bleeding patterns and menstrual-related symptoms with the continuous use of a contraceptive combination of ethinylestradiol and drospirenone: a randomized study. Contraception 2010; 81:215.
  28. Stewart FH, Kaunitz AM, Laguardia KD, et al. Extended use of transdermal norelgestromin/ethinyl estradiol: a randomized trial. Obstet Gynecol 2005; 105:1389.
  29. van den Heuvel MW, van Bragt AJ, Alnabawy AK, Kaptein MC. Comparison of ethinylestradiol pharmacokinetics in three hormonal contraceptive formulations: the vaginal ring, the transdermal patch and an oral contraceptive. Contraception 2005; 72:168.
  30. Miller L, Verhoeven CH, Hout Ji. Extended regimens of the contraceptive vaginal ring: a randomized trial. Obstet Gynecol 2005; 106:473.
  31. Guazzelli CA, Barreiros FA, Barbosa R, et al. Extended regimens of the vaginal contraceptive ring: cycle control. Contraception 2009; 80:430.
  32. Barreiros FA, Guazzelli CA, Barbosa R, et al. Extended regimens of the contraceptive vaginal ring: evaluation of clinical aspects. Contraception 2010; 81:223.
  33. Speroff, L, Darney, P. A Clinical Guide for Contraception, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2005.
  34. Nilsson CG, Lähteenmäki PL, Luukkainen T. Ovarian function in amenorrheic and menstruating users of a levonorgestrel-releasing intrauterine device. Fertil Steril 1984; 41:52.
  35. Lukes AS, Reardon B, Arepally G. Use of the levonorgestrel-releasing intrauterine system in women with hemostatic disorders. Fertil Steril 2008; 90:673.
  36. Mirena package insert. http://labeling.bayerhealthcare.com/html/products/pi/Mirena_PI.pdf (Accessed on June 27, 2013).
  37. Liletta package insert. http://pi.actavis.com/data_stream.asp?product_group=1960&p=pi&language=E (Accessed on April 24, 2015).
  38. Skyla package insert. http://labeling.bayerhealthcare.com/html/products/pi/Skyla_PI.pdf (Accessed on April 24, 2015).
  39. Hidalgo M, Bahamondes L, Perrotti M, et al. Bleeding patterns and clinical performance of the levonorgestrel-releasing intrauterine system (Mirena) up to two years. Contraception 2002; 65:129.
  40. Kaunitz AM. Long-acting contraceptive options. Int J Fertil Menopausal Stud 1996; 41:69.
  41. Kaunitz AM. Injectable contraception. New and existing options. Obstet Gynecol Clin North Am 2000; 27:741.
  42. Roxburgh DR, West MJ. The use of norethisterone to suppress menstruation in the intellectually severely retarded woman. Med J Aust 1973; 2:310.
  43. Irvine GA, Campbell-Brown MB, Lumsden MA, et al. Randomised comparative trial of the levonorgestrel intrauterine system and norethisterone for treatment of idiopathic menorrhagia. Br J Obstet Gynaecol 1998; 105:592.
  44. Symons J, Kempfert N, Speroff L. Vaginal bleeding in postmenopausal women taking low-dose norethindrone acetate and ethinyl estradiol combinations. The FemHRT Study Investigators. Obstet Gynecol 2000; 96:366.