How to take your combined contraceptive pill

Monophasic combined contraceptive pills

Monophasic combined contraceptive pills provide the same dose of hormones in every pill. There are usually 21 hormone-containing pills in a blister strip.

Combined oral contraceptive (COC) pills were originally developed to mimic a woman's natural 28-day menstrual cycle by having a 7-day hormone break each month which leads to a period type bleed. With some brands of COC, this break is provided by taking 7 'dummy' pills. Some newer brands, e.g Zoely, contain 24 active pills and 4 'dummy' pills. During the 7-day break the ovaries begin to wake up, and only by restarting the next blister strip on time is contraceptive cover maintained, including for the break.

More recently, extended use regimes have been recommended, reducing the chance of the ovaries reactivating and reducing the amount and frequency of regular bleeding. There are several different options described below.

The following rules for pill taking apply to any of the 21-day, monophasic, combined pills.

Traditional combined oral contraceptive pill (COC) regime

Start the pill on any day of the month, if you know you are not pregnant.

If you are not sure if you may be pregnant (e.g. you have had sex without using contraception, within the last 21 days) you can still start the combined contraceptive pill, but you should take a pregnancy test 21 days after you last had unprotected sex. Taking the COC whilst in early pregnancy has not been shown to cause any harm.

Starting the COC: open a new pack of pills. Packs usually contain 3 pill blister strips. Take one pill every day, following the arrow round the blister strip until the strip is finished (usually 21 days).

Continuing the COC: take a pill at the same time every day. Choose a time of day you are likely to remember – for many women this is first thing in the morning when they wake up – you could keep your pills on your bedside table or near your toothbrush, so you see them straight away. Other women prefer to take them at bedtime. Some women like to use a mobile phone app or alarm to remind them to take their contraceptive pill.

Don't forget/miss pills: it's very important not to forget pills or to be late taking them. Try and take them at the same time each day. It's a good idea to get into a routine, then you are less likely to forget.

What to do if you forget/miss a pill: if you forget 1 COC pill, take it as soon as you remember – don't leave it out – even if you then take 2 pills together. Continue taking the remaining pills and your break as normal. Your contraceptive cover is not affected.

For 2 or more forgotten pills, you must follow the COC missed pill rules. You may need to consider using extra emergency contraception.

When does COC become effective? If you start the COC within the first 5 days of starting a period you can assume it will work straight away (Zoely only works straight away if starting on the first day of the period). If you start any later than this in the cycle, the COC will take 7 days to be effective. During these 7 days you should not have sex, or use a condom carefully if you do. Once 7 pills have been taken correctly, you have contraceptive cover and you can rely on the pill for contraception.

Don't forget sexually transmitted disease (STI) protection: COC does not protect you from STIs, so it is recommended to use condoms carefully and consistently with a new partner, at least until you have both had an STI screen. Having regular screening is extremely important, especially for your future fertility. Many women with STIs have no symptoms at all, so it's important to get tested. You can either visit a local STI clinic or order a home Chlamydia or STI test kit. Chlamydia testing is also available from sexual health clinics, GPs, young peoples clinics, and some pharmacies, or through Brook.

Common side effects when first starting COC: you may feel a bit sick, have sore breasts, headaches, or spot bleeding when you first start the pill but these are likely to settle down within the first 3 months, so try and keep going with the pills.

The 7-day break: after 21 days there are then either 7 days with no pills, or 7 days of different coloured dummy pills that do not contain hormones. During these 7 days the pill is still protecting you from pregnancy (but only if you restart the next pill blister strip on time). This means you can still rely on the pill and do not need extra contraceptive cover during the 7-day break. You will usually have a withdrawal bleed, similar to a period, but a lot lighter. 7 days later, on the same day of the week that you started the first pill blister strip, you start the second blister strip and, following the arrows, take the pills in order round this strip as before.

Restarting the next blister strip of pills: it's very important not to be late starting the new blister strip of pills. You must not have more than 7 days between strips of pills. If you do, you have lengthened the time off the pill and you could produce an egg (ovulate). So do make sure you set a reminder to restart your next pack of pills on the right day of the week.

The 4-day break: there are some newer pills, e.g Zoely, which contain 24 active pills and 4 'dummy' pills - giving only a 4 day hormone free break.

Extended pill regimes - other ways to take the pill

Having a 7-day break on your pill is now considered outdated.

There are several alternative ways to take the pill. It may seem confusing, especially for someone new to the pill, that these methods exist, but in fact they have much to commend them. These continuous dosing/extended regimes are endorsed by the Faculty of Sexual & Reproductive Healthcare. As they are newer regimes they are not mentioned in the manufacturers' patient leaflets and are 'off label' uses. The manufacturer is not liable in case of adverse events and Doctors take responsibility for the prescribing.

When the combined oral contraceptive pill (COC) was first developed, in the 1950s, it was believed that a regular monthly bleed was healthy and would reassure women. The standard routines for combined contraceptive pill use were therefore developed to mimic the natural monthly cycle, i.e. 3 weeks of contraceptive use, then 1 week off, during which hormone levels drop and a period-type bleed happens.

In more recent years, alternative extended use routines have been widely recommended. These reduce overall bleeding patterns. They can only be used with any combined contraceptive pills containing the same hormone balance all through the cycle.

Not having a monthly bleed is not harmful. It doesn't affect the health of the womb or future fertility. However, a bleed from time to time is needed, as the endometrium (womb lining) can build up and this may cause irregular bleeding in the long term, if not shed occasionally.

By extending the length of time you take your pill, and having less pill breaks, the pill becomes safer and easier to manage. The extended options for taking the pill are called extended pill regimes.

Extended pill regimes are safe and effective. The use of extended pill regimes has much to commend it including reduced overall bleeding and better contraceptive reliability.

Below are two extended pill regime options. These are a recommended alternative option if you are taking any 21-day, monophasic pill. Do not use if taking an everyday (ED) pill with 4 or 7 days of inactive dummy pills.

Tricycling

• Take the COC pill for 21 days as usual.
• When you get to the end of the pill blister strip, start a new strip the next day and keep going. Do not have the 7-day break.
• Continue for 3 pill blister strips.
• If you run 3 blister strips in a row like this, this is called tricycling.
• When you get to the end of the third blister strip, allow yourself a break. This break can be for 4 or 7 days.
• Choosing a 4-day break gives less chance for the ovaries to wake up and begin to release an egg.
• You should bleed in the break - although sometimes women do not bleed.
• Restart the next blister strip even if still bleeding.
• Start a new blister strip after the 4 or 7 day break and repeat, taking another 3 blister strips back-to-back.
• If the COC is not restarted on time, there is a risk of pregnancy if sex took place during the break.

Flexible extended use or tailored regime

• Take the COC pill for 21 days as usual.
• At the end of the blister strip, start another blister strip immediately and keep going.
• Keep taking your pill every day, until you start a period-type bleed. This could take 6 months or more.
• When you start the 'period' bleed, take a 4-day break from the pills, then restart even if you are still bleeding.
• You do not need to use extra contraception in the 4-day break - the COC is still protecting you.
• If the COC is not restarted on time, there is a risk of pregnancy if sex took place since it was last taken.

Notes

Combined pills can also be taken continuously without any breaks, but this may eventually lead to more spot bleeding than if a 4-day break is taken whenever a 3-4 day period-type bleed starts.

It is also possible to run only two packs of COC together to delay a period, for example if planning a holiday. The 7-day break should be taken after the two packs. If using an Everyday (ED) pill, throw away the dummy pills of the first pack before going straight onto the next pack.

If at any time you are late restarting the COC after the break, and you had sex since last taking a pill, you may be at risk of pregnancy and should consider emergency contraception.

Some women do experience light vaginal blood loss as their body adjusts to an extended use regime but this usually settles in a few months. If it persists then discuss with your GP as further tests may be needed.

Side effects of extended regimes

Studies have shown that there may be a slight increase in the frequency of unwanted spot bleeding or 'breakthrough' bleeding in the first few months of using an extended regime. This settles over time and the total days with bleeding compared to a traditional regime is usually less.

Multi-phasic combined contraceptive pills

There are a few combined contraceptive pills available where the pills contain different strengths of hormone throughout the month. They include Qlaira, Logynon, Logynon ED, TriRegol, and Synphase. These have been designed to more closely mimic the natural variations in a woman's hormones throughout the monthly cycle, and are sometimes preferred for better bleeding control.

Starting and taking the tablets from a multi-phasic pill blister pack is similar to a monophasic pill, but it is especially important to read the patient information leaflet supplied in the pill pack and carefully follow the arrows taking the different coloured pills, containing different levels of hormone, in the correct order. The full details about starting and taking the phased pills are in section 3 of the patient information leaflet. Please note that 9 Qlaira pills must be taken correctly to ensure contraceptive cover, whereas with most other combined contraceptive pills only 7 hormone pills are needed before the contraceptive is effective.

Qlaira and Logynon ED pill blister packs contain pills for every single day. However Logynon, TriRegol, and Synphase contain only 21 pills and there is a regular 7-day pill free break. As the pills vary in hormone strength it is not possible to tricycle or extend the use of multi-phasic pills.

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