And if not... where does the blood go?

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Is it just me, or is it a little freaky to use birth control to skip your period? Isn’t it natural to bleed? And where does that blood go if it doesn’t come out?

Here’s one thing I absolutely know is not just me: People who menstruate often wish they could reschedule their period. For me, that was true in the days leading up to my first triathlon, and also the week I was spending with my then-long-distance boyfriend in the Dominican Republic. Please, whatever Uterine Goddesses may be listening, don’t let it come now.

It’s a plea I imagine is as old as menstruation itself—and one that’s all too familiar to Maria Sophocles, MD, medical director of Women’s Healthcare of Princeton in New Jersey. “It’s not always fun to have a period and be traveling, or having an 80-hour workweek, or being a professional athlete, or even being regularly sexually active,” she says. Seriously, who has time to add “bleed” to their monthly to-do list?

Wishing and hoping and thinking and praying for your flow to show up any other time has inspired plenty of monthly bleeders to hack their packs by skipping the seven days of placebo pills. That's the appeal of a birth control pill like Seasonale, which postpones menstruation so it only happens every three months. It’s also why birth control manufacturers continue to #innovate: Now there’s a pill called Amethyst (among other generic names) that delivers active hormones every damn day, stopping periods for an entire blissful, cramp-free year.

But as dreamy as that sounds, is it safe to use these so-called extended or continuous oral contraceptives? Nature gave us periods for a reason, I have to believe—otherwise what is this cruel torture? And if you don’t have a period for a year, are you just a bloated belly of brownish blood?

It turns out there was never a health-related reason for women on the pill to even have a monthly bleed. Birth control researcher Elizabeth Micks, MD, MPH, an assistant professor at UW Medicine and the director of research in the division of family planning, explains that there’s absolutely no safety or medical difference between taking a birth control break every 21 days to get your period or sticking with it every day so you skip shark week entirely.

Back when the pill was first invented, “the belief at the time was that women needed to be able to have a regular cycle to feel healthy,” Dr. Micks says. “It is my understanding that the pill was never developed [cyclically] for health reasons, but because it would be more acceptable to women and their partners, which is, I think, something people don’t realize.” In fact, the pill could have been created right off the bat to make you bleed “once a week, once a year, or anything in between,” she adds.

When you take that traditional seven-day break from hormones on the pill, you’re not really getting your period because you’re not ovulating. Instead, you’re having what’s called a "withdrawal bleed" triggered by that brief hormone-free pause. Sure, birth control manufacturers may have thought this bleed would make the pill feel more natural. But it’s not actually a natural (or necessary) thing, Dr. Sophocles points out.

Anyone else feeling royally duped right about now? Pill-regulated periods could have been choose-your-own-adventure this whole time? It’s particularly frustrating when you take into consideration that “unfavorable or unsatisfactory” bleeding patterns are major reasons women ditch their birth control, according to Dr. Sophocles.

Finally, however, birth control is moving in this direction, she says. Doctors are increasingly focusing on what their patients really want out of their oral contraception, whether it’s fewer periods, more flexible bleeding patterns, or just solid pregnancy prevention. That last one is a biggie. Since no hormonal method is 100% effective, getting your period once a month is the reassurance many women are glad to have—so they know they didn't accidentally conceive.

By continuing your pill pack and skipping that monthly bleed, “you may not be sure if you’re pregnant or not, which is kind of an anxiety-provoking way to exist,” Dr. Sophocles says. If you’re the kind of person who likes that phew! feeling when the crimson tide rolls in once again, a continuous or extended-use birth control may not be for you, she says.

OK, so what about the blood you might imagine is pooling up inside you? Dr. Micks says that's actually not happening. The synthetic hormone progestin in the birth control pill prevents the buildup of blood. “This keeps the uterine lining very thin,” she says. When the placebo pills roll around, “there’s really nothing that needs to be shed because you’ve been on progestin the whole cycle.” (You can thank progestin for lighter periods on hormonal birth control in general!)

Even more baffling: Skipping this manmade (and yep, the Pill was created by a man) withdrawal bleed might be good for some women. Extended and continuous birth control methods have long been used to treat issues like heavy periods, menstrual migraines (you can’t have one if you don’t menstruate, after all), and endometriosis.

If reading this has convinced you to set your own period schedule, talk to your ob-gyn about the best hormonal birth control method for you and which ones might give you your ideal bleeding pattern. If you do decide to try an extended or continuous method, know you might experience some spotting (aka breakthrough bleeding) until your body settles into this new routine.

Of course, if a cyclic method with a regular bleed still sounds best to you, that's totally OK too. “It’s really nice to have options,” Dr. Micks says. As for me, I'm just glad to know one of those options is not a uterus chock-full of stale blood.

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