Current science on birth control pills w/out breaks?

March 20, 2024 9:30 AM

Our teenage daughter has PMDD, as I did. It is severe enough that I'm interested in finding out, well, what if she didn't ovulate? At all. What is the current science of the safety of taking birth controls without breaks for adolescents? Her hormones are vicious, as were mine (I'm menopausal).

I heard an IUD may be an option? But I have heard horror stories about the pain of insertion, and I never had one and don't really know how they work. I would not put her through something like that without meaningful pain management but it might be better than asking her to take a pill every day.

posted by A Terrible Llama to Health & Fitness (23 answers total)

My teenage daughter just started this about four months ago. Her pediatrician would have prescribed them but she wanted to see an GYN to discuss all options. She'll be 15 in May. The doctor was very kind and great with answering all questions, including about skipping periods. She recommended against starting with the IUD for now, unless we expected issues with compliance in taking the pills on time and regularly. Even then, she recommended using the ring before the IUD. I THINK but am not toally sure this has something to do with the delivery of hormones and the specific kind in the pill/ring being good for bone development, etc? I don't remember the exact explanation about why it's fine to not ovulate, but we were both convinced that it was fine enough.

She's taken four months of pills, skipping the placebo week, and I see a difference in her mood swings, and so does she. Her periods have gotten lighter each month but isn't completely gone yet. The doctors said that can take a while especially in younger teens.
posted by dpx.mfx at 9:49 AM on March 20, 2024

I've been on Depo-Provera for a long time and I haven't had a period whatsoever. It's worked great for me and I just get a shot every few months. I don't know if it's "right for her" or not, but that's also an option besides the IUD.
posted by jenfullmoon at 10:31 AM on March 20, 2024 [1 favorite]

This is anecdotal, and I am an adult woman with endometriosis who does not have symptoms of PMDD so my experience isn't directly relevant to you. I have had the Mirena IUD in the past and I am taking continuous pills now.

Mirena problems: I only got about 3 years out of it, maybe a little less. It did great for that short amount of time, but I started having symptoms of my endo break through. I believe the hormone just wasn't strong enough over a long enough time to have the systemic effect that my body needed to curtail, for instance, my gut symptoms. I also don't believe I would have been ready, with my body, for an IUD insertion or removal as a teen. Barely acceptable now. When I realized that IUDs weren't going to be as long term for me as they are on paper, I went back to the pill.

I think that was about 10 years ago? Maybe 8? And I have been taking hormonal birth control pills continuously for that entire time. I can count the number of gap weeks I've skipped in all that time with one hand. (I asked my doctors about this after the IUD because I had skipped the occasional period when I was younger with pills with success.)

This has been working great for me. My gynecologist is on board and so is my primary care internist. I do get funny looks (and, though rarely, admonishments) from intake nurses at appointments when they ask for the date of my last cycle and I'm like "n/a" but that's their problem to deal with. My docs even write my 90 day birth control script for a 4 pack (default is 3) so it actually covers 3 months of active pills. (Actually, my pill packs don't even have a placebo week!)

Anyway, my point is that this can be entirely safe, entirely normal, and can produce very good results for people who do better with a continuous hormone supply to control symptoms. When you're talking to doctors about this, my advice is to find a doctor who is already on board with prescribing continuous birth control. Your questions are about is this safe for my daughter, specifically, who is a teen in a growing body. You shouldn't have to do the work of convincing a care provider that it's okay to do at all.

Because oh boy, I have certainly had gynecologists (and worse, nurse practitioners providing women's healthcare) try to trot out the shame or "it's just not natural!" or some other such bullshit back in my younger occasional skip days. Your kid doesn't need to be exposed to that.
posted by phunniemee at 10:38 AM on March 20, 2024 [4 favorites]

FYI, she can use Nuvaring continuously, if daily pills are too annoying. You just put in a new ring instead of taking a week off. That's what I do, and I haven't gotten my period in over a decade. It's been lifesaving.
posted by unknowncommand at 10:44 AM on March 20, 2024 [2 favorites]

Just wanted to plug my BC method of choice, the Nexplanon implant. It's progestin only, inserted in the arm, and can stop ovulation. I got it as an alternative to the IUD to avoid insertion pain. Many report lighter and less intense periods, with 1 in 3 people reporting their period completely stopped. Others have frequent or irregular breakthrough bleeding but for most it tends to lessen the intensity.
posted by rabbitbookworm at 10:49 AM on March 20, 2024 [4 favorites]

I've been taking pills with no placebo for close to 20 years, since I was an (older) teen myself. I have had exceedingly good results and basically complete resolution of all my menstruation-related issues. It works well enough that I've never bothered to try anything else, so I guess I can't make a comparison, but know that this is a good option for lots of people.
posted by goodbyewaffles at 10:50 AM on March 20, 2024

My daughter and I looked into this because she was getting bad cramps even on birth control (which she was taking to lessen cramps) and everything we found online said there are no issues with taking birth control pills continuously and no particularly good reason not to do it. (The only possible issue is that sometimes people start getting breakthrough bleeding after taking pills continuously.) When she first asked her regular nurse practitioner about going on continuous birth control she said it wasn't possible. It sounded like she just wasn't aware of current thinking on the subject. So I made an appointment for my daughter at a women's center, figuring people who deal with nothing but women's reproductive systems would be up on all the latest research and options and the person she saw there said it was definitely a fine option. She has been on continuous birth control for more than a year now with no issues.
posted by Redstart at 10:51 AM on March 20, 2024 [1 favorite]

From my limited reading, there's no down side. I remember reading somewhere that the reasons for the placebo week were only to placate the Pope, or to remind women that they're women, or something patriarchal like that.

One factor you might want to consider is that without a period she won't get the monthly "verified: not pregnant" signal. And if she did get accidentally pregnant (antibiotics that interfere with pill, forgetting, etc), it might delay realization of that fact. There are ways to deal with that, of course, from a secondary BC method to taking a pregnancy test every couple of months just to be sure. That's what I did - I really did not want to be pregnant!
posted by Dashy at 11:08 AM on March 20, 2024 [3 favorites]

I'm on my third Mirena, and like phunniemee mentioned above, the hormonal component does often run out early (I mentioned this to my doc recently, and she confirmed her other patients have reported the same thing). Mirenas used to be proscribed to be replaced every 5 years, but in recent years the FDA has approved changing that to 7 and now 8 years. I think my last one's hormone dose wore off around 5 years for me (but it still was effective in preventing pregnancy). I still think this would be a great option for your kid when she's older and understands better how her body reacts to supplemental hormones. Insertion is pretty rough, but then it lasts for years. For me, super worth it. Some GYNs are better about offering sedatives, etc., to people for whom insertion may be particularly intolerable/traumatic, and you can definitely talk about that in advance.

Before my first Mirena, I was on Nuvaring for several years. You're meant to keep the ring in for 3 weeks, then take a week off. After a few years, I'd noticed how many day off it was before I would bleed, and then I started leaving it in for a couple extra days to skip the period. It's been 15 years, but I think I was taking it out on a Friday and then starting the new one on Monday, but keeping to an overall 28-day cycle. For me, this prevented any bleeding/spotting, prevented pregnancy and also managed the health issues that I take hormones for (not PMDD, but other stuff). YMMV, IANAD, this is not medical advice, ask your own doctor, etc.

Dashy's point that accidental pregnancy could be a concern is valid, especially if she's on daily pills and not perfectly compliant. That's something worth talking about. I have friends who stash pregnancy tests (among other things) in a known location just in case their teens (or their friends) need one, and replenish as needed, and I think doing something similar is a kindness to teenagers who are new to the experience of having a pregnancy-capable body. At the very least, it's worth talking about symptoms of regular hormone cycles, birth-control-influenced cycles and early pregnancy, and what to do/check if she feels like her body is doing something unusual. Some of those things would also be signals that her current birth control medication isn't a great fit.
posted by katieinshoes at 11:17 AM on March 20, 2024 [1 favorite]

I also came here to recommend the Nexplanon implant. It hasn't completely stopped my periods, but it has made them much much less crampy (say from a 7/10 with OTC meds for 3-4 days/month to a 2/10 with only 1 or 2 doses of OTC meds/month) and much lighter (pantiliners only). I have never been pregnant and have never been able to get an IUD inserted due to the pain/difficulty the doctor has had. I would definitely recommend any method over an IUD.
posted by epj at 11:19 AM on March 20, 2024 [1 favorite]

I'm not clear from your comment if she has previously been on birth control. If not, one thing to keep in the back of your mind is that people with strong hormonal responses, don't always respond well to be birth control so perhaps try something that is easily reversible?

I had terrible periods as a teen and PMDD. My mom is a family planning nurse and put me on a low dose pill and I... lost my damn mind. Crying, rage, despair the works. Over the years I've tried pretty much every form of hormonal birth control and all have triggered something similar. I ended up sticking with condoms. (The day my husband and I decided we were done having kids and he got snipped was a very happy day.)

I think it's awesome that you are trying to help your daughter figure this out. Wishing both of you the very best and fingers crossed that a solid solution presents itself.
posted by jeszac at 11:21 AM on March 20, 2024 [6 favorites]

Find a doctor who specializes in PMDD and get a treatment plan based on bloodwork and assessment.

PMDD is not just "vicious hormones" and suppressing ovulation is almost never the first line of treatment and you should not experiment on a young human body until you maybe find something that kinda works - I know we all had no choice but to do so for the past 1000 years but there's actually some science now - because you want THE thing that works correctly for your child's brain and body at this particular developmental stage, and you want it baselined and monitored.

She should probably also be assessed for endometriosis, which is frequently comorbid and should be taken into consideration as part of the treatment plan. (It's basically impossible to confirm endo without visual inspection of the abdominal cavity, and hopefully they do not do that to teens unless things are life-threatening, but I do believe there's differential diagnostic criteria now.)

I've lost too many friends permanently, and have too many friends who have lost too much of their lives, from the misogyny that has shadowed PMDD up until basically 15 minutes ago, in science time. Get real answers. Get the gene testing for SSRI treatment if that's the direction her care providers are considering. Get real treatment. Do not experiment.
posted by Lyn Never at 11:22 AM on March 20, 2024 [8 favorites]

Offering a Nuvaring data point: I used it for 3 years in my 30s and always found it intensely uncomfortable. Maybe I never put it in quite right, maybe my cervix is slightly unusually formed, but I was always always always aware of it inside me. I have friends who have loved it and use it continuously as described in some of the comments here, but it was never a good solution for me.

I wasn't trying to skip periods so I don't have anecdata about how that works (although my friend who loved it best did continuous use and never had periods. Hers took a while to come back when she went off the ring and she had a hard time getting pregnant, no idea whether those two things were related.)

I like Lyn Never's comment above, I think your daughter deserves really good and appropriate care on this.
posted by Lawn Beaver at 12:41 PM on March 20, 2024

I've taken the mini-pill or other birth control continuously for years, and it is awesome! I used to be absolutely miserable during my period. Different pills work for different people, of course, so she may need to try a few different kinds. I do need an alarm to remind me to take it regularly, though.
posted by chaiminda at 2:03 PM on March 20, 2024

IUDs can be inserted under sedation and often are for pediatric cases. You’ll probably need to shop around a bit for a gynecologist who can do it (MeMail me if you’re in the NY area and I can give you a name), but it’s absolutely possible and I would highly recommend it for a teenager if you go the IUD route.

I had an IUD insertion under sedation after a failed replacement. In the failure, I actually did have the cervical lidocaine that is often something folks demand for “some pain relief”, but in my case having yet another thing poking my cervix is what made the experience unbearable and left me in a really bad state emotionally and physically for the next 48 hours. In contrast, the sedated experience was done in under an hour, I tolerated the anesthesia well, my insurance mostly covered the additional cost, and the main downside of needing someone to escort me home afterwards doesn’t even apply with a teenager because of course you’re going to be there to escort her home afterwards.
posted by A Blue Moon at 2:03 PM on March 20, 2024

Note: the GYN is seeing my daughter back next month (four or five months after going on the pill) to asses, and specifically to discuss if she would benefit from a some kind of antidepressant/antianxiety medicine, possibly during certain weeks. She actually recommended that as the first line for mood swing/panic attacks, except that my daughter hates her period so much she pressed the issue. So, obviously, you need someone to evaluate the specific situation but there is help to be found.
posted by dpx.mfx at 3:05 PM on March 20, 2024

Response by poster: Get real treatment. Do not experiment.

I appreciate all the sentiment and thoughtfulness in this comment but I am informed on the topic. I lived through it--for decades.

Unfortunately, most care providers are not. Counselors are not. The school is not. Her doctor is not.

This is a subset of a 'be your own doctor' burden that I feel like many people with esoteric or unusual conditions carry. I'll vent about my husband's Lyme disease sometime, or about how I only got treatment for PMDD when I realized what it was and found British studies on it. When I was like, 45 years old and had already buried friendships, jobs, who knows what else, not realizing why my brain would go haywire on a demonstrably routine basis.

Or a hundred other things...my doctor wanting to take my gallbladder out within five minutes of talking to me, going through a series of really awful tests and fears, only to find a doctor who - swear this is true - had me jump a couple of times and tell me I had abdominal scar tissue from my c-section. That was over five years ago. My gallbladder is still in place, the abdominal pain went away. I'd irritated the scar tissue doing landscaping.

There is a good organization in Boston handling PMDD awareness at a clinical level and training, informing people, but the question I'm asking is not a matter of 'experimenting'. Not even remotely.

It's very hard to find PMDD informed physicians or therapists, and if they are not PMDD informed they can make the resulting mental health issues much worse. They don't know how to take things in stride, address self-care and support. They don't know how to put things in perspective, because they go to crisis mode and resulting protocols.

I am sure it's easier in larger cities, but where we are, I do have to do this legwork, and no, I don't trust them.

If I could get real treatment she would absolutely have it today. Or three, four years ago.

That would have been nice!
posted by A Terrible Llama at 4:47 PM on March 20, 2024 [6 favorites]

If taking pill continuously or not, if you absolutely do not want to get pregnant a second form of birth control is imperative. It is not foolproof even if you don’t miss a pill.
And I am another case of 20 years continuous low dose BC pills. Stopped when ready to have my kids and no issues with that.
posted by gryphonlover at 8:00 PM on March 20, 2024

I appreciate your frustration, Llama.

Coming back to share an anecdote about a friend in a similar situation to you -- she had PMDD, never properly diagnosed, and eventually had a hysterectomy at around 40 because of endometriosis. Her daughter now also has PMDD, and had a string of mental health crises her first couple of years of high school.

The daughter has been doing AMAZING on regular birth control pills for the past year. She told me she tried one pill (progesterone-based, I believe) briefly, was very unhappy with the results, and then changed to something with different hormones, and things have been smooth sailing since then. She is taking them continuously. I don't know whether she would have a different/worse experience if she did take the placebo pills each month, because she never tried that.

Before this, she was prescribed tons of different meds to try to stabilize her mood with no lasting success, but I think she's off of most (maybe all? not sure) of those now that she's on a hormone treatment that works for her PMDD. She's still an exasperating teenager, but she's a happy, friendly, able-to-live-a-normal-life teenager at last. I don't need to tell you what a revelation it is -- you know it from your own experience.

But from what I've observed from the PMDD teen in my life, I'd say first figure out what hormones work well for your daughter in pill form, and if she wants something longer-acting, that'll give you good information about which other BC options to consider. If, like with my friend, progesterone-based BC isn't effective treatment, then Mirena and Depo-Provera probably aren't good choices, but NuvaRing might be.
posted by katieinshoes at 9:20 PM on March 20, 2024

It is severe enough that I'm interested in finding out, well, what if she didn't ovulate? At all.

Just to clarify—you don’t ovulate at all on combined oral contraceptives (which is most pills, the Nuvaring, and probably some others I’m forgetting) with traditional use, i.e., if you don’t take them continuously, stop after 28 days and bleed. Birth control containing estrogen and progestin works primarily by suppressing ovulation through artificially stable hormone levels.

I think what you’re asking is actually, what if she took birth control continuously with no placebo pills or breaks in order to hopefully have no bleeding. This is totally safe and a great idea! People do it for decades, even. There’s no medical reason to have a periodic bleed on hormonal contraception because it prevents the buildup of uterine lining.

(It almost sounds like you’re saying combined oral contraceptives don’t suppress ovulation unless they’re used continuously to have no bleeding, which is NOT the case!)
posted by Violet Hour at 11:36 PM on March 20, 2024 [3 favorites]

(LMAO, obviously the Nuvaring isn’t taken orally! Don’t do that! I meant combined hormonal contraceptives!)
posted by Violet Hour at 11:45 PM on March 20, 2024

Response by poster: Just to clarify—you don’t ovulate at all on combined oral contraceptives (which is most pills, the Nuvaring, and probably some others I’m forgetting) with traditional use, i.e., if you don’t take them continuously, stop after 28 days and bleed.

Thanks for the clarification; it's been a while. You're right, I totally spaced. I haven't had a period since Trump got elected and most years after thirty I was sort of pregnancy indifferent/ambivalent because of life circumstances.
posted by A Terrible Llama at 2:11 AM on March 21, 2024

Best answer: You might want to check out what Sarah Hill says in This Is Your Brain on Birth Control: The Surprising Science of Women, Hormones, and the Law of Unintended Consequences. It seems to be one of the scientific syntheses of research.
posted by mortaddams at 9:43 PM on March 21, 2024 [1 favorite]