Continuous Birth Control Pills for Cramps

Frederick R. Jelovsek MD, MS

Is The Pill Safe?

"My daughter just turned 17. About 1 1/2 years ago we put her on the pill to help the incredible pain she goes through every month with her period. It helped for about 4 months and that's all. We have continually asked her Gyn if there is anything stronger than Vicodin (already prescribed) and Naproxen (doesn't work either)....all they say is that they can put her on the pill continuously without the break, so she just won't get her period. This CANNOT be healthy! What about all the OTHER side effects of the pill? It doesn't seem they are taking those into consideration!" J.G.

The Answer

Your doctor is treating your daughter under the diagnosis of primary dysmenorrhea or "painful menses". Intrauterine pressure generated with some menstrual cramps have been measured as high as 300 mm Hg. A uterine contraction during labor only gets as high as about 80 mm Hg so you can see that a bad menstrual cramp can easily be 4 times as painful as laboring with a baby.

Before we go on to address treatment, however, endometriosis is often reported in adolescents and if the pain just seems to persist too strong too long, you may need to ask your doctor about diagnostic laparoscopy to see if any endometriosis is present and also to dilate the cervix at the same time. While continuous oral contraceptive pill regimens can treat endometriosis, there are other therapies that might be used if there was a certain knowledge (not just guessing) that endometriosis was present.

As far as pain medicines for dysmenorrhea, the non steroidal anti inflammatory drugs (NSAIDs) are the best because they block the formation of prostaglandin which causes the severe uterine contractions. They have to be taken on a regular basis during menses, however, not just when your daughter can't stand the pain. See our discussion in this newsletter about NSAIDs.

A common problem with medications that doctors see is that an adolescent (or even an adult) looking for instant relief, waits until the pain builds up and then decides a pain medicine is needed. When she then takes an NSAID like Aleve(R) (she should take 2 or 3 at once, not just one like the bottle says) the onset of blocking the cause of the pain does not take place for several hours. So by that time she has concluded the pain medicine does not work. Instead, she should take two tablets regularly twice a day as soon as she senses that the cramps are going to start. The expectations should not be for total pain relief, but merely to lower the magnitude to the point where she can cope with the cramps until the period is over. Vicodin (R) and other narcotic pain medicines are not very effective at all for menstrual cramps.

The Pill For Treating Cramps

Oral contraceptive pills (OCPs) can be quite useful in treating menstrual cramps because they decrease the amount of menstrual tissue formed and lower the pain level (amplitude) of the uterine contractions probably due to their progestin effect. When given in a continuous fashion, i.e., no week of placebo pills to allow an artificial menstrual period, they can further reduce the level of pain because most of the time menstrual periods are blocked completely. There still may be some irregular spotting with cramps but generally they are of much lower severity and less interruptive of everyday activities.

You have concerns about long term side effects or complications of continuous birth control pills. It would be helpful to know which concerns you have in mind because the television and newsprint media often exaggerate reported studies or experts comments out of proportion; otherwise they would have "ho-hum" news. You may need a personal medical educational consult to answer a specific concern.

In general, physicians do not have evidence of significant long term problems from either normal withdrawal oral contraceptive regimens or continuous oral contraceptives as used for endometriosis or severe menstrual cramps. OCPs are associated with a much lower incidence of ovarian cancer and endometrial cancer. In fact they are one of the very few medicines known to actually prevent any cancers. Cervical cancer is slightly higher on the pills and breast cancer is essentially unchanged. As far as cervical cancer goes, the pills are not thought to have a chemical effect on it but rather they allow the behavior, intercourse with multiple partners, that has been also associated with increased cervical cancer. Long term use of OCPs are not known to affect future fertility one way or the other so this treatment now should not affect her ability to have a pregnancy in the future.

The main deleterious effect of OCPs is the formation of blood clots in the veins and arterial thrombosis. The increased incidence is real but very small, on the level of two times increased over not taking the pills - 3 per 10,000 women. The risk can go higher in women who are over 35 years of age and smoke or who have hypertension but it is highly unlikely your 17 year old will have a problem with this. The small increase in risk does have to be weighed against the possible benefits, however.

All in all, I would be comfortable prescribing the continuous pill regimen for this purpose. If she does not have significantly less days of severe pain after a 3 month course of continuous pills, then I would strongly consider a diagnostic laparoscopy to look for endometriosis. Endometriosis is the one thing that if not diagnosed early, can cause impaired fertility in the long run.