Taking the combined pill continuously – complete guide

Reviewed: May 26, 2021
There are two kinds of oral contraceptive pill: the combined pill and the progesterone-only pill (or mini pill). The mini pill is taken continuously, without a break, but the combined pill normally follows a 21/7 format: 21 days on the pill, seven day break, repeat.   New guidance issued in 2020, however, states that taking a combined oral contraceptive pill back to back is perfectly safe and, science suggests, actually more effective than taking it for 21 days at a time with seven-day breaks in between.  So if we can take the pill back to back, why haven’t we been doing it all along?  We’ll have a look at the evidence behind the new guidelines in a moment, but the take-home message is this: continuous pill taking is safe, more effective and, a lot less hassle!

What types of hormonal contraception can you take continuously?

Like we said earlier, the progesterone-only (mini) pill is taken continually anyway, so if you’re using something like Cerazette or Cerelle, just keep doing your thing. If you’re taking a combined oral contraceptive pill, however, like Microgynon or Rigevidon, or if you’re using another form of combined contraception, like the vaginal ring or the patch, listen up.

Is taking the pill back to back safe?

Research shows that taking the combined contraceptive pill back to back is absolutely safe; in fact, there’s no evidence at all that shows any health benefits associated with the seven-day break. The Family Planning Association now explicitly states that withdrawal bleeds hold no known benefits, and that there are no risks associated with missing them altogether.

Some women are understandably concerned about taking their pill continuously and missing their ‘period’. The reality, though, is that the bleed you experience during your seven-day break isn’t a period at all. 

Allow us to go back to basics for a second. When you aren’t taking hormonal contraception, the lining of your uterus thickens throughout the middle and end of your cycle, readying itself for an embryo to be implanted. When fertilisation doesn’t happen, the lining sheds, and this is your period. 

Combined hormonal contraception, on the other hand, prevents your ovaries from releasing an egg, and stops the lining of the uterus from thickening as it would during your ordinary cycle. The aptly-named ‘withdrawal bleed’ you experience during your seven-day break is just that: your body’s response to the withdrawal of the hormones contained in your pill.

In short, withdrawal bleeds are completely unnecessary in terms of their effect on your health or the effectiveness of your contraception. We know – mind-blowing. 

This is also true for the contraceptive patch and the vaginal ring, both of which administer oestrogen and progesterone in a 21/7 format. 

What are the benefits of continuous combined pill taking?

It can make your pill more effective

Even more interestingly, taking your pill continuously might actually improve how effective it is. When you take the pill, you’re essentially putting your ovaries to sleep, interrupting your cycle and preventing pregnancy. After the seven-day break, your ovaries ‘wake up’ again, so if you were to forget to take your pill for a couple of days afterwards, your risk of pregnancy would increase.

It can reduce the side effects

The side effects of taking your pill continuously shouldn’t be any different from those of taking the pill in general, but this type of ‘tailored’ contraception administration might alleviate some of the less desirable symptoms of your withdrawal week.

Like we said earlier, the bleed you experience during the break in your pill doesn’t actually need to happen; it provides no benefits to your health or the effectiveness of your contraception. While this bleed isn’t a period, it may come with some similar symptoms (pain, PMS, headaches) which are lessened or eliminated when you don’t have a break. You might still experience some bleeding or spotting with continuous pill taking, but this should lessen over time.

It’s easier to remember

It’s also easier to remember to take a pill every day (no more snoozing those phone alarms for a week every month), meaning there’s less risk of you forgetting a day and reducing its effectiveness against pregnancy.

This kind of pill-taking, where the pill is administered differently to the advice on the box, is called ‘tailored combined hormonal contraception’. It’s outside the manufacturer’s license, meaning they can’t direct you to take it in this way, but it is supported by the Faculty of Sexual and Reproductive Healthcare, who write the rules about how contraception is used in the UK. 

You won’t have any bleeds

We’re sure you don’t need us to list the benefits of not bleeding every month (no sanitary products, white jeans, yes please) but for most of us, the withdrawal bleed is mistakenly seen as a reassuring sign that our contraception is actually working.

Combined hormonal contraception, however – when taken correctly – is incredibly effective. Add to this the fact that your chances of missing a pill are reduced when it’s taken back to back, and the increased efficacy when your seven-day break is missed, and your chances of pregnancy are very slim. 

Withdrawal bleeds are also not a normal period and have been reported by women using combined methods of contraception who are pregnant. Women should not consider monthly bleeds on combined contraception to be reassurance that they are not pregnant.

So, if there’s no benefit to the 7-day break, why was the pill developed this way in the first place? 

Well, some say that it was to help get approval from the Pope, as the body would still be following its ‘natural’ rhythm. Mostly, however, it’s due to the fixed mindset at the time the pill was developed: having monthly bleeds was seen as ‘normal’ and, incorrectly, necessary

How long can keep taking the pill back to back?

Current research doesn’t point to any time limits for continuous pill taking; in fact, a 2018 paper actually recommended ditching the 7-day withdrawal altogether and adopting a continuous regimen. For women who prefer a monthly bleed, the researchers recommended a 4-day break, as this was deemed more effective in terms of pregnancy prevention than a 7-day withdrawal.

There is also no evidence to show that missing breaks occasionally is less safe than missing them altogether.  

Check out the ‘Pill taking’ highlight on our Instagram stories for an overview of this and a fascinating interview with Professor John Guillebaud, who has been campaigning for more education on back-to-back pill taking for years. 

What do I do if I keep getting breakthrough bleeding?

Some irregular bleeding and spotting are totally normal during the first few months of continuous pill taking. This does tend to lessen over time, though, and most women find that it becomes less of an issue when it does occur. 

If you’ve had spotting or bleeding for more than a few days, and it hasn’t settled after 21 consecutive days of beginning the pill (or three weeks after an earlier break), stop taking the pill for four days before beginning again. After the four days have passed, start again from the pill that matches the current day, throwing away the ones from the days you missed. 

You don’t need to contact your healthcare provider before trying this method, and it usually works to lessen or stop any bleeding or spotting. If it doesn’t settle, however, do get in touch with your GP so that they can check for other causes, such as sexually transmitted infections. 

If you do decide to take a four-day break, there’s no need to use any other forms of contraception; your pill will continue to protect you against pregnancy. 

My doctor/pharmacist hasn’t heard of continuous pill taking – what should I do?

The push for more women to have the option of taking the combined pill back to back is relatively recent, and it can take years for new research to reach GPs and other healthcare providers. 

If your doctor or pharmacist hasn’t heard of the new guidelines, download the Family Planning Association’s leaflet about combined contraception and take it with you. It talks about this between pages 11 and 12.

Don’t be shy in telling them that the guidance has changed; your healthcare provider will want to work with you to make sure you’re making the most informed choice!

In summary:

  • There are no benefits to the 7-day, hormone-free break, either for your health or the effectiveness of your contraception
  • You can safely miss your 7-day breaks on occasion or continually
  • Taking your pill back to back may improve its effectiveness
  • The pill’s 21/7 format was not designed to improve its effectiveness or to have any impact on health or side effects

References

Stewart, C. (2019). Methods of contraception used by women in the United Kingdom (UK) in 2018. Retrieved 25 May 2021 from https://www.statista.com/statistics/1063613/contraception-use-among-women-in-the-uk/

MacGregor E.A., Guillebaud J. (2018). The 7-day contraceptive hormone-free interval should be consigned to history BMJ Sexual & Reproductive Health 2018;44:214-220.

Guillebaud, J.,  MacGregor, A. (2017). Continuous pill taking – the 21st century way to take the pill. Retrieved 25 May 2021 from 

https://wilbrahamsurgery.nhs.uk/wp-content/uploads/2020/03/Patient-Information-Continuous-Pill-Taking-v9.pdf

Faculty of Sexual and Reproductive Health (FSRH). FSRH guideline Combined hormonal contraception. November 2020. 

FPA DOWNLOAD LINK https://www.fpa.org.uk/download/your-guide-to-the-combined-pill/#

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