Nine percent of women of reproductive age take the Pill worldwide. What most of them don’t know is that the seven placebo pills taken in the final week of the four-week cycle are unnecessary. That’s right – you do not have to have your period at all. Instead, you can take the Pill continuously for as long as you like. (Although it is always a good idea to check in with your health provider first.)
“It’s not actually necessary to take a break from the contraceptive pill for a withdrawal bleed, it doesn’t do any harm to skip this break or take the combined oral contraceptive pill continually,” Karin O’Sullivan, the Clinical Lead at FPA, a sexual health charity based in the UK, told IFLScience. “In fact, many women already do this when they go on holiday or if they tricycle packs.”
"Providing it is safe for women to take the combined oral contraceptive pill and there are no medical contraindications then it is safe for women to use any of the pill taking regimes," O’Sullivan added, whether that is traditional (with regular breaks), tricycling (a break every three packs), extended (no breaks), or flexible (taking breaks but not falling into one of the previous categories). There is no biological evidence that "giving your body a break" makes any difference. There is no build-up of hormones and when you stop taking the Pill, the effects are immediately reversible.
Let’s get things straight. The period you get when you’re on the Pill is not really a period at all. It’s a withdrawal bleed. This is the body’s response to the sudden drop in hormones that occurs when you stop taking the active pills and switch to the placebo pills. The difference between the withdrawal bleed and a regular period is that when on the Pill, the uterine lining (endometrium) doesn’t have the chance to build up. It remains thin. This makes the bleed lighter than a regular period – and much less necessary.
“I sometimes describe that as the difference between shag rugs, and a normal period to indoor-outdoor rugs when you’re on the Pill,” Susan Wysocki, Editor in Chief of journal Woman's Health Care, former President and CEO of the National Association of Nurse Practitioners, and President of iWoman’s Health, told IFLScience.
However, even if you do decide to take the Pill continuously, you may experience what is called break-through bleeding – that is bleeding or spotting between periods. This is not harmful, O'Sullivan says, but some people may choose to take a break and then resume the Pill again after a few days (flexible regimen). If you decide to persevere, these symptoms may dissipate with time.
"Breakthrough bleeding typically decreases over time, however, as your body adjusts to the new regimen," the Mayo Clinic explains, before adding "If breakthrough bleeding becomes heavy or lasts more than seven days in a row, contact your doctor."
But back to the placebo pills. If they are unnecessary, why do we have them and where did the idea come from in the first place?
It’s an infuriatingly complicated blend of social, economic, political, and even religious factors that hark back to the 1960s when the Pill first became available for reproductive purposes.
Today, affordable and easy-to-use pregnancy tests are a quick hop and a skip away at your local CVS store. This means a pregnancy scare can be quelled (or confirmed) within an hour of noticing a late period. There are also ultrasounds that can date a pregnancy to the week it was conceived. That was not the case 50 years ago. The break (and later, the placebo pills) were designed to trigger a withdrawal bleed and reassure the user that she was not pregnant in the absence of instant pregnancy tests and ultrasounds.
"There was a practical reason for designing the pill three weeks on, one week off but there really wasn’t a biological necessity for it from the perspective of birth control pill,” said Wysocki, who is also a former member of the American Sexual Health Association Board of Directors.
“The myth is that you must have bleeding when you’re taking oral contraception when in fact that was just engineered into the pill for these other reasons.”
It was also decided by the makers of the Pill that the addition of the withdrawal bleed would help woman accept their product as a form of contraception by making it feel more “natural”. They felt that women wanted to have periods, and would be uncomfortable with a birth control method that stopped them. Clearly, there weren’t very many women in the room.
“Studies have consistently shown that when women are told there are no harmful effects from not having a period while on the Pill, especially with regards to fertility, they choose to have less frequent periods or eliminate them entirely,” Nitu Bajeka, ObGyn and co-founder of Women for Women's Health UK, wrote in an article for HuffPost.
But it was not just the women who needed convincing that the Pill was natural. One of the creators of the Pill, John Rock, was a devout Catholic.
Rock himself had made a living teaching women how to manage their fertility cycle depending on whether or not they wanted to have children, performing hysterectomies and talking openly to his patients about sex, even the unmarried women – all of which was surprisingly progressive for the period. At the same time, he was aware of the deep-rooted social conservatism within the Catholic Church. As anyone who knows even the tiniest bit about Catholic dogma will tell you, contraception is considered a sin.
There was, however, a loophole. That is that a married couple would not be sinning if there was a natural reason keeping them from falling pregnant. (Hence the rhythm method.) Rock thought that if the Pill – which was, after all, just a top-up of hormones already produced in the body – could be marketed as “natural”, it might just win the approval of the Catholic Church. Historical spoilers: it didn’t, but it was still another reason for introducing a seven-day break and withdrawal bleed.
Over the past five decades, there have been developments in technology and progress on the sexual freedom front that would appear to make the placebo pills irrelevant. But even brands like Seasonale (which sells packs of 84 active pills to take continuously) include placebo pills. In the case of Seasonale, a withdrawal bleed is triggered four times a year, once per season.
There may no longer be the religious, social, and practical motivation, but there is another reason for sustaining the placebo myth – economic. Blame the insurance companies.
It may be true that the majority of gynecological professionals agree that it is not only perfectly safe to take the active pills continuously but preferable to do so, particularly if a health condition like endometriosis or dysmenorrhea are involved. Even a woman with milder menstrual symptoms might benefit from skipping her period altogether. But it also becomes more expensive. A woman can ask her doctor or family planner for additional packs of the Pill so that she can take them back to back, but most likely she will be the one hit with the extra cost.
“If you’re using four weeks of pill instead of three weeks of pill, at the end of the year you’re down two packs,” Wysocki said. “It’s an economic issue.”
"It’s not generally going to be offered as a first choice. The first choice is going to be whatever an insurance company and national health service etcetera is going to pay for."
The placebo pill is not the only birth control myth that just won't disappear. As a study earlier this year revealed that contrary to popular belief, the Pill does not affect a woman's preference in male partner.
You may want to take an occasional break from the Pill if that's what you feel is right for you, but it's good to know you don't need to. As always, if you are thinking about making a change to your medication, it is a good idea to speak to your health provider first and make sure you are taking the right pill for you.