Use of OCP’s to Eliminate Withdrawal Bleeding

Abstract & Commentary

Synopsis: Daily administration of a low dose oral birth control pill results in significantly fewer bleeding days.

Source: Miller L, Hughes JP. Obstet Gynecol. 2003; 101:653-661.

Miller and Hughes from the University of Washington randomized 79 patients to either cyclic or daily oral contraceptives containing 20 micrograms ethinyl estradiol/100 microgram levonorgestrel for 12 cycles. A subset of the patients also had pelvic ultrasound and endometrial biopsy. Among patients taking daily active pills, 49%, 68%, and 88% reported no bleeding during cycles 2, 6, and 12 respectively. Although spotting was increased initially among patients who took daily active pills, this decreased to the point that by month 9, the spotting was even less than in those patients who took the pills cyclically. Of note, adverse events as well as weight gain, blood pressure elevation, and blood count were similar between the groups.

Comment by Frank W. Ling, MD

This article is likely to generate responses such as "I knew that!" or "We’ve done that for years!" or "Why didn’t I think of that study?" Personally, I loved it. (Sounds like a movie review, doesn’t it?) The study is very well-designed: baseline data were collected, there was a "run in" month of drug administration to make sure that withdrawal bleeding could/would occur, it was randomized correctly, blinding of the sonographer and pathologist was used, etc.

We’ve all done it in our respective practices, but this study helps to highlight the safety and use of this technique of rendering a patient amenorrheic using daily active pills. For example, it may well be that if a patient takes active pills daily, the chance of a failure is reduced because of greater compliance. Unfortunately, for some patients, the different colors and the onset of menses can be confusing. Also, inhibition of ovulation may be improved with daily administration of a hormonally active pill. If the spotting is, in fact, less with continuous pills rather than cyclic pills, we will see patients who are more satisfied with their contraceptive choice with a resultant greater likelihood that they will recommend using contraception to friends, family, etc.

Some practical tips in using this technique may be of some help. I use this very often for endometriosis, reasoning that eliminating menstrual flow also eliminates the stimulation for proliferation/sloughing of endometriotic lesions. Is this evidence-based? Unfortunately, it is not, but it certainly helps in the management of some patients with pain suspected to be related to endometriosis. In a more general sense, this technique is very useful anytime a patient relates any significant symptom complex to the menstrual flow, whether it be pain, cramps, headaches, etc. Interestingly, patients commonly ask whether or not it is safe to do this, the concern being that not sloughing the endometrium may result in cancer. Explaining to them that the oral contraceptive is predominantly the hormone that protects the endometrium from hyperplasia usually reassures them adequately. Some will ask about their own personal need to feel cleansed by having a period intermittently. Again, patient education regarding the perceived need as opposed to the real need to pass the menstrual flow helps.

Finally, a practical administrative note: patients on certain insurance plans may need additional documentation to get this covered. Why? Because a pack of pills no longer lasts 28 days, but only 21. Insurance companies see the additional cost and may balk at coverage. Writing the prescription to specify that a daily active pill is being prescribed or that there should be no "pill-free interval" will help.

In summary, this is a very nicely-conducted study that sends us a useful clinical message.