Myth: On the oral contraception pill, the placebo pill week is a ‘real, medically necessary’ period.

Currently, most combined oral contraceptive pill packs include a week of placebo (“sugar”) pills that contain no hormones and are taken after several weeks of active hormonal pills.

Currently, most combined oral contraceptive pill packs include a week of placebo (“sugar”) pills that contain no hormones and are taken after several weeks of active hormonal pills.

A common misconception about menstruation is the belief that the bleeding that occurs during the placebo week of the oral birth control pill is a classically “real” period and is medically necessary for one’s health (DeMaria et al., 2019). 

Many people believe that this monthly bleed signals that the body is functioning properly or that it is important to ‘reset’ the reproductive system (Britton et al., 2020; DeMaria et al., 2019). In reality, this belief is based on historical precedents, political agendas, and social norms, rather than medical evidence. 

When someone takes a combined oral contraceptive pill, ovulation is suppressed by hormones (estrogen and/or progestin). During the placebo (‘sugar pill’ week), the sudden drop in hormones triggers withdrawal bleeding, not menses from a classic menstrual cycle (Cooper & Patel, 2024). 

This bleeding does not occur because the uterus needs to shed built-up blood or because the body requires a ‘monthly cleanse’. Instead, this is just a physiological response to a temporary stop in hormone additions. Specifically, when hormone levels drop during the placebo week, the stabilized uterine lining is no longer hormonally supported, leading to shedding of the endometrial lining.  Medically, there is no requirement to have this bleed every month (Strandjord & Rome, 2015). *Check with your doctor, as everyone’s healthcare plan is different. 

Currently, depending on the withdrawal bleeding desired by the patient and that is clinically recommended, the pill can be prescribed as a cyclic (monthly bleeding), extended cyclic (having a withdrawal bleed every 3 months), or continuous dosing (no bleeding, however, increasing one’s risk for occasional breakthrough bleeding) (Cooper & Patel, 2024). 

Q: Why do we have this placebo week built in then? 

This week was built in by birth control companies in the 1960s in order to make hormonal contraception appear more “natural” and socially acceptable (Coutinho, 2007). At the time, patients were more comfortable with a pill that mimicked a monthly cycle (Coutinho, 2007). In reality, the frequency of these placebo weeks was chosen arbitrarily based on social norms. Skipping the placebo week (continuing into your next birth control pack), or continuous hormonal contraception is safe for most people. 

How may this impact you?

Understanding that the pill placebo week is a withdrawal bleed, and not obligatory every month, may empower people to make informed choices about their reproductive health. This may mean improving one’s quality of life, focus, energy levels, and avoiding bleeding during life activities (Szarewski & Moeller, 2013). Whether someone prefers monthly bleeding or chooses to suppress it, that decision should be guided by accurate information rather than fear. 

Menstrual health is not defined by how often someone bleeds for placebo weeks, but by whether their choices support their overall well-being.

References: 

Britton, L. E., Alspaugh, A., Greene, M. Z., & McLemore, M. R. (2020). CE: An Evidence- Based Update on Contraception. The American journal of nursing, 120(2), 22–33. https://doi.org/10.1097/01.NAJ.0000654304.29632.a7 

Cooper, D. B., & Patel, P. (2024). Oral Contraceptive Pills. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430882/ 

Coutinho E. M. (2007). To bleed or not to bleed, that is the question. Contraception, 76(4), 263–266. https://doi.org/10.1016/j.contraception.2007.06.004 

DeMaria, A. L., Sundstrom, B., Meier, S., & Wiseley, A. (2019). The myth of menstruation: how menstrual regulation and suppression impact contraceptive choice. BMC women's health, 19(1), 125. https://doi.org/10.1186/s12905-019-0827-x

Strandjord, S. E., & Rome, E. S. (2015). Monthly Periods--Are They Necessary?. Pediatric annals, 44(9), e231–e236. https://doi.org/10.3928/00904481-20150910-11

Szarewski, A., & Moeller, C. (2013). Women’s perceptions about reducing the frequency of monthly bleeding: results from a multinational survey. Open Access Journal of Contraception, 29-37.