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Practice Practice Pointer

Tailored regimens for combined hormonal contraceptives

BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m200 (Published 03 February 2020) Cite this as: BMJ 2020;368:m200
  1. Zachary Nash, academic clinical fellow, obstetrics and gynaecology1 2,
  2. Annette Thwaites, academic clinical fellow, community sexual and reproductive health1 3,
  3. Melanie Davies, consultant gynaecologist1 2
  1. 1EGA Institute for Women’s Health, University College London, UK
  2. 2University College London Hospital, London, UK
  3. 3King’s College Hospital, London, UK
  1. Correspondence to Z Nash z.nash{at}ucl.ac.uk

What you need to know

  • Tailored regimens for combined hormonal contraceptives (CHCs) allow users to have fewer and/or shorter hormone-free intervals, with scheduled bleeds

  • All women who are medically eligible to use CHCs can be given the choice of a tailored regimen

  • Fewer and shorter hormone-free intervals maximise the non-contraceptive benefits of using CHC and may increase patient satisfaction with CHC methods

  • Tailored regimens offer theoretically greater contraceptive efficacy than traditional regimens and have similar safety profiles, although long term studies are lacking

Despite the advent of newer, more effective, longer acting methods of contraception, combined hormonal contraception (CHC) remains the most popular form of contraception in Europe and North America.1 CHC methods contain both oestrogen and progestogen and prevent pregnancy primarily through suppression of the hypothalamic-pituitary-ovarian axis to achieve anovulation. Oral CHC (“the pill”) is by far the most widely used form of CHC, with 151 million users worldwide.1 Alternative routes of administration are the patch or ring.

Traditionally, CHC has been prescribed as 21 days of hormone treatment (21 pills, or three 7 day patches, or one ring for three weeks) followed by seven days of no treatment or placebo—a hormone-free interval. Although designed to achieve a monthly withdrawal bleed, mimicking a physiological cycle, there is no evidence that a monthly bleed—or indeed any bleed—is required for safety. A number of studies report no evidence of endometrial thickening or histological abnormalities with continuous CHC use.2

In its 2019 guideline, the Faculty of Sexual and Reproductive Health (FSRH) supports the use of “tailored regimens,” highlighting that there is no health benefit from the seven day hormone-free interval and that a shorter interval or fewer intervals may increase contraceptive efficacy.3 Women should be advised, however, that using tailored CHC regimens is currently outside the manufacturer’s licence.

What alternative regimens are available?

Tailored regimens allow extension of …

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