We're taking the pill wrong

The need for women to take a seven-day “period” break is a myth, according to top academics, and it could be doing more harm than good

24th October 2017

Women are putting themselves at risk of pregnancy and getting no health benefits from having a break in their pill, according to family planning academics.

In fact, the “21st century way” to take the contraceptive pill is to take the packets back-to-back, according to Professor John Guillebaud.

The emeritus professor of family planning and his co-campaigner Professor Anne MacGregor launched a campaign in favour of continuous use at the annual RCGP conference for GPs last week. Evidence was shown that taking a break from the contraceptive pill increases the risk of unplanned pregnancy and has no clear scientific foundation. Taking the pill continuously allows a greater margin of human error and puts a stop to periods.  

So why do GPs recommend 21 days on and seven days off? And why do women put up with periods if menstruation is optional?

The Overtake spoke to Professor John Guillebaud about his campaign.

No scientific evidence

In the 1950s, gynaecologist John Rock made the decision to implement a seven-day break from the contraceptive pill with no scientific basis. He had two reasons for imitating the natural menstrual cycle by intermittently ceasing to suppress the ovaries, neither of which were scientific.

“He thought women would feel more normal and they do,” Professor Guillebaud explains.

“In the last 200 years, we have the notion that it is normal to bleed once a month. This is an incorrect notion. Up to 200 years ago, most sexually active woman would rarely see a period, due to pregnancy or breastfeeding. It is more normal not to bleed,” he said.   

the entire world was in the mindset that periods were completely normal. Inertia has meant that is has mostly stayed that way

Rock was also trying to persuade the Pope that the pill was acceptable for Catholics to use.

“In the 60s, the official Catholic line was no artificial contraception allowed and he hoped that the then Pope would accept just the pill because it seemed more normal. He didn’t and John Rock gave up his religion.”

There was no evidence that un-suppressing the ovary for seven days was a safe thing to do. In fact, have known for 40 years that, in 20% of women, the ovary does not remain dormant and becomes close to ovulation during the pill-free break, putting women at risk of unplanned pregnancy.

Professor Guillebaud argues that there is indisputable evidence that the seven-day break can reduce the pill’s effectiveness yet it is a practice that most women follow on the recommendation of their GP.

“Even then, the entire world was in the mindset that periods were completely normal. Inertia has meant that is has mostly stayed that way,” he said.

For a method that was “based arbitrarily on the calendar and not on science,” the pill-free break is embedded in our modern understanding of the contraceptive pill.


Greater margin for human error

A key benefit of continuous use of the contraceptive pill is that up to seven pills can be missed without the risk of pregnancy.

“This is a huge advantage because people do get pregnant from missing pills. Some people will still get pregnant even if they don’t miss any pills. That’s very few – about three in 1000. This is because the seven-day break is too long to let the ovary wake up. The failure rate of ordinary pill takers is 90 in 1000. It is very easy to forget a pill.”

“You have seven days where you are purposefully told to forget the pill and if you happen to miss a pill straight after that – you risk pregnancy,” Professor Guillebaud said.

Continuous use of the pill – 365 days a year – ensures that the ovaries are kept dormant by a steady stream of hormones. Minimising the window for human error and eliminating a series of confusing “rules” for missed pills would make taking the pill a much smoother process.  

Periods are not necessary

Many women view their periods as a necessary evil. They are inconvenient, annoying and the pain is often debilitating. However, Professor Guillebaud argues that they are totally unnecessary and that women do not have to bleed monthly.  

We have also been making life unnecessarily difficult

“Periods have no health benefits whatsoever – nobody has ever proved an advantage to bleeding. The only benefit is in your head because it’s reassuring to know that you’re not pregnant,” he said.

The bleeding that occurs during the seven-day break is an artificial, withdrawal bleed, not a physiological menstruation. There may be psychological side-effects of a period, such as relief from pre-menstrual tension, but Professor Guillebaud believes that no benefit of periods can be scientifically proved.

“We have been making the pill unnecessarily weak when it could be much stronger against pregnancy. We have also been making life unnecessarily difficult,” he said.  

Many women are likely to agree.  

Make continuous use the first choice

The continuous use of the combined pill is an “off license” prescription, which means it is not in line with the product license of the pill and not how medical authorities recommend it to be taken.

The National Institute for Health and Care Excellence does suggest a “shortened pill-free interval of 3-4 days” to “reduce the risk of contraceptive failure.”

The primary aim of the recent campaign is to make continuous use the norm. In the 2017 edition of their book, Contraception: Your Questions Answered, Professor Guillebaud and Professor MacGregor advocate that continuous use is not only an option, but a good option.  

Explaining the purpose of their campaign, Professor Guillebaud said: “If they ask their GP, patients are told that continuous use is a perfectly reasonable thing to do. We are saying that it should be the first choice. The campaign is an attempt by two doctors to try and change the whole planet. We want every woman in the world who is on the pill to be given the option to take the pill continuously and not to have periods as a first choice.”

The second recommended choice is to reduce the frequency of periods to four per year by taking three packets back-to-back – this is called tri-cycling and the infrequent break provides reassurance that everything is normal. The third choice should be to follow 21 pills with a shorter, four-day break. Although a week off is easier to remember, Professor Guillebaud recommends the My Pill app where you can schedule reminders of different lengths.

“The evidence shows that if you have a 4-day gap instead of 7 days, the pill is stronger against pregnancy. It is weakened by the 7-day break being too long,” he said.   

The dust settles

The pill is the only contraceptive where people are told to not take it for a whole week, 13 times a year.

“You’re told to use condoms every time you have sex and an IUD is in place all the time. The pill has this strange thing where we are told not to take it for a week at a time, regardless of the lack of evidence that it is safe,” Professor Guillebaud said.  

He adds that people who take the pill continuously must accept that they will no longer have regular periods.

“You might get unexpected bleeding but the dust settles. Occasionally, if it doesn’t settle and you’re bleeding more than you want to, take your own break to stabilise the situation.”  

The campaign aims to spread this message to all GPs in Britain and raise awareness about advantages of continuous use of the pill. Professor Guillebaud also encourages women to directly ask their GPs about taking the pill continuously.

“At the end of the day – most people are very happy to not bleed. You can stop buying tampons/pads and you can have sex every night of the year.”

24th October 2017