Illustrated by Hannah Boonstra, BSc Executive Summary: Yes, the research indicates that it is safe to skip your sugar pill. Keep reading for a more in-depth exploration of the research of skipping sugar pills and the possible pros and cons.
I am a white settler cisgender woman living on the traditional, ancestral and unceded territory of the Coast Salish, Musqueam, Tsleil-Waututh, Squamish, Stó:lō, Stz’uminus peoples in what is now known as Vancouver, BC. The purpose of this article is to give clear, scientifically-backed answers regarding oral contraceptive pills (OCP) and its use. While this post intends to give clear information regarding all OCP users, it is important to note that Black, Indigenous, People of Colour (BIPOC), transgender, nonbinary & gender fluid OCP users have been historically underrepresented in OCP research. I acknowledge my experience as a white, cisgender woman shapes how I interpret OCP research and I hope to continuously learn in the case of error or misrepresentation. I would also like to acknowledge that I am not a medical professional and the content of this article is a summary of relevant academic publishings. Thanks for reading! :)
Oral contraceptive pills (OCP), also known as birth control pills, are one of the most common hormonal birth control methods, used by over 150 million women worldwide (1*). OCPs can be used by people with uteruses, of any gender identity, as well as by individuals receiving gender-affirming hormone therapy (e.g. testosterone) (2). Most OCP-users take a combined-hormone oral contraceptive (OC) daily for 21 days, which contains the synthetic hormones, estrogen and progestin. Different brands of OCPs have different cycle lengths. The cycles vary from 21 - 84 days (3). After taking all "active" pills, most OCPs include "sugar" or placebo pills, which do not contain active hormones. At this time, bleeding occurs. But what if you don’t take those sugar pills? Can you skip your periods?
Originally, OCPs did not include sugar pills and instead, women were instructed to take the pills for three weeks then take a break for a week to allow for bleeding, to mimic a “natural menstrual cycle”. Sugar pills were added to this regimen to ensure users would remember to take the pills. However, the bleeding that occurs in the sugar pill week is actually not a physiological period (i.e. the shedding of uterine lining) but is actually known as “withdrawal bleeding” from the lack of hormones (4). Medically, there is not a reason to cyclically endure withdrawal bleeding every month (you can read more into the history in this article*) (5). Nonetheless, the sugar pills have stuck around as a way to help the OCP-user maintain the routine of taking a pill everyday, and some brands include dietary supplements in the sugar pill, such as iron (6).
What if we want to go out and have a good time without having to pack away menstrual products like a squirrel heading into winter? Is it okay if I skip my sugar pill and take active pills? Will my uterine lining build up and gush out of me when I do finally take the sugar pills? Fear not, you will not become a bloody Niagara Falls. The hormone, progestin, prevents the uterine lining, or endometrium, from building up indefinitely throughout your cycle. Multiple studies have tested continuous OCP use, confirming efficacy of birth control and safety (see review by 3*). In most participants, the most frequent issue with continuous OCP use was breakthrough bleeding in the first 3 months of continuous use. Continued use of OCPs may gradually thicken the uterine lining and this may slough away in the form of spotting. However, by the end of a year of continuous OCP use, breakthrough bleeding was significantly less frequent (7*). This just means you may find yourself with irregular and small amounts of bleeding during the initial months of skipping the sugar pills.
As long as you're consistent with taking your daily dose as directed by your doctor, you are not increasing your risk of pregnancy, even when you're skipping your sugar pills. In fact, in two studies examining extended OCP use, the continuous-users showed a decrease in pregnancy rate versus individuals using a standard sugar pill cycle (8*-9*). This could be a result of better compliance (i.e. you get into the habit of taking the pill everyday, whereas with sugar pills it doesn't matter if you skip those). Also the constant hormone levels doesn't allow for accidental ovulation. Yay!
Actually, some benefits of continuous use of active OCPs (i.e. skipping your sugar pills) can include decreased incidences of pelvic pain, headaches, bloating, breast tenderness (for those who usually experience these symptoms in the sugar pill week). Additionally, continuous OCP use can help manage symptoms of premenstrual dysphoric disorder (PMDD), endometriosis and polycystic ovary syndrome (PCOS) (10*).
Some disadvantages of continuous OCP use have not been identified as researchers do not have much data regarding long-term safety. However, in a systematic review of continuous OCP use studies, continuous OCP use was found to be as safe as standard cycle OCP use (11*). Similarly, research has not found any significant impact on fertility with continuous OCP use (12*). Additionally, breakthrough bleeding could be annoying if you decide to wear white pants one day - though this is going to depend on you, your body, and your pill (3).
Cost-wise, you may spend more money on OCPs when skipping your sugar pills because you're using more packages in a year, but you would also save money on sanitary products and potentially missed work days, but that's a personal cost-benefit analysis to consider (10).
Ultimately, the science suggests that not bleeding every month is a viable option for all you uterus-havers out there!
Learn the difference between birth control pills and the hormones used and how to correctly take them.
*These sources do not specify the gender identity of the women included. Historical representation leads us to believe only cisgender women were included.
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References
United Nations. Contraceptive Use by Method 2019: Data Booklet [Internet]. UN; 2019. Available from: https://www.un-ilibrary.org/population-and-demography/contraceptive-use-by-method-2019_1bd58a10-en
Light A, Wang L-F, Zeymo A, Gomez-Lobo V. Family planning and contraception use in transgender men. Contraception. 2018 Oct;98(4):266–9.
Wright KP, Johnson JV. Evaluation of extended and continuous use oral contraceptives. Ther Clin Risk Manag. 2008 Oct;4(5):905–11.
Bleeding on the birth control pill [Internet]. [cited 2021 Jan 17]. Available from: https://helloclue.com/articles/sex/pill-your-period
FSRH Clinical Guideline: Combined Hormonal Contraception (January 2019, Amended November 2020) - Faculty of Sexual and Reproductive Healthcare [Internet]. [cited 2021 Jan 17]. Available from: https://www.fsrh.org/standards-and-guidance/documents/combined-hormonal-contraception
How to Use Birth Control Pills | Follow Easy Instructions [Internet]. [cited 2021 Jan 4]. Available from: https://www.plannedparenthood.org/learn/birth-control/birth-control-pill/how-do-i-use-the-birth-control-pill
Miller L, Notter KM. Menstrual reduction with extended use of combination oral contraceptive pills: randomized controlled trial. Obstet Gynecol. 2001 Nov;98(5 Pt 1):771–8
Anderson FD, Hait H. A multicenter, randomized study of an extended cycle oral contraceptive. Contraception. 2003 Aug;68(2):89–96.
Coutinho EM, O’Dwyer E, Barbosa IC, Zhi-Ping G, Shaaban MM, Aboul-Oyoon M, et al. Comparative study on intermittent versus continuous use of a contraceptive pill administered by vaginal route. Contraception. 1995 Jun 1;51(6):355–8.
Canadian Contraception Consensus. Journal of Obstetrics and Gynaecology Canada. 2004 Mar;26(3):219–54.
Edelman A, Micks E, Gallo MF, Jensen JT, Grimes DA. Continuous or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception. Cochrane Database of Systematic Reviews [Internet]. 2014 [cited 2021 Jan 4];(7). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004695.pub3/full
Barnhart K, Mirkin S, Grubb G, Constantine G. Return to fertility after cessation of a continuous oral contraceptive. Fertility and Sterility. 2009 May 1;91(5):1654–6.