Menstrual Suppression

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What woman hasn't at least occasionally wished she could avoid having her period? For decades some women have taken their traditional pills on a non-traditional schedule in order to manipulate the timing of their periods - for example, to avoid menstruating during a vacation, athletic competition or another important personal event. There are now products on the market that offer this option with an extended schedule for taking oral contraceptive pills to suppress menstruation. These pills are intended to change a woman's bleeding pattern to produce either no periods (Lybrel) or just four periods a year (Seasonale and Seasonique), instead of a dozen.

Menstrual suppression products are chemically identical to traditional oral contraceptive pills. The active tablets contain a combination of levonorgestrel and ethinyl estradiol. The difference lies in the way a woman takes the pills. The traditional OC is taken for 21 days, followed by 7 days of placebo pills. Seasonale and Seasonique are taken for 84 days consecutively, followed by 7 days of placebo pills. In both cases, while the woman is taking the placebo pills, she gets her period.* Lybrel uses the same hormones, in a slightly lower dose, with no change in hormone dose throughout the year. Lybrel is designed to produce no periods at all.

Women's individual experiences of, and attitudes about, menstruation play an important role in determining their interest in menstrual suppression and may also affect the level of satisfaction with the method among women who use it. For women who have pain or other discomfort with their periods, the option of menstrual suppression offers a health benefit by reducing the frequency of that pain and discomfort. Some women find the thought of fewer periods, or no periods, appealing for its convenience. But others express a preference for monthly menstruation because they rely on the monthly period as a signal that they are not pregnant or because they view it as a sign that their bodies are in a healthy rhythm. They will be less likely to choose or be satisfied with a method that reduces the frequency of their periods.

Effectiveness, health risks and benefits

From a safety perspective, menstrual suppression is probably a reasonable option for most women. If you can take birth control pills safely, you can probably take these. Although a woman taking a menstrual suppression pill will take a few dozen more active hormone pills over the course of a year than a woman taking the 21-day version of the pill, there's probably no meaningful increased health risk. The small risks of stroke and blood clots associated with traditional oral contraceptives - increased in women who smoke - are also associated with extended use pills. But even though there are many years of accumulated experience with these drugs, this is a new product so there could be unanticipated effects over the long-term. The drop out rate in the trials has been high, and in the trials of Seasonale, for example, fewer than 300 women were observed for a full year.

The effectiveness of menstrual suppression products for preventing pregnancy is also very similar to regular oral contraceptive pills. But their effectiveness for menstrual suppression is not so straightforward because during the first year of use many women in the studies have experienced break-through bleeding - instead of ending or reducing their periods, they were bleeding on an irregular, unpredictable schedule. During the first year, women using Seasonale or Seasonique had as many days of bleeding as women using traditional oral contraceptives. This probably contributed to the high drop-out rate in the trials. Most women who experienced break-through bleeding and didn't drop out of the trials found that it did eventually go away, but might take many months.

The need for a balanced, accurate discussion of what's normal and what's healthy

The National Women's Health Network supports the availability of menstrual suppression products as an option. Our concerns about this method have to do with the way that it is being marketed and presented to women by manufacturers and health care providers.

  • One doctor brought to a media briefing by the makers of Seasonale asserted that using Seasonale could improve high school girls' test scores because, she said, girls score lower on the SATs when they are menstruating although she provided no evidence for this claim.1
  • Several physicians have referred to the experience of women in earlier eras who had more frequent pregnancies and longer periods of amenorrhea associated with breast feeding to support the claim that women weren't intended to menstruate as much as they do today. One gynecologist who conducted research on menstrual suppression said "It's having seven or 10 kids that is natural," explaining that menstrual suppression "gets women to a more natural state."2 Another said, "Menstruation is not a normal, healthy thing to happen."3 While it is accurate to say that women menstruate more today than they have at other times, the assertion that monthly menstruation is unnatural is unfounded.
  • Some scientists have speculated that reducing the frequency of menstruation and ovulation might reduce the risk of breast, endometrial and ovarian cancers and even extend fertility, but these ideas have not been proven by scientific study.4,5 The association that has been identified in epidemiological studies between frequency of menstruation/ovulation and some reproductive cancers does not indicate that one causes the other.
  • One manufacturer presented a distorted picture of women's feelings about menstruation by misrepresenting data from a survey that the company commissioned. In a news release about the survey the company wrote that more than half of women feel "messy, fat and unattractive" during their periods; but in fact, only a third of women reported feeling unattractive during their period, and 68 percent of women said they feel healthy.6

These misrepresentations and unsupported claims are particularly a concern with respect to young teens or girls who are just beginning to learn about menstruation and are forming a new understanding about the way their bodies work. Telling them that it's unnatural or unhealthy to get a monthly period, or that they'll perform better in school, in sports or socially if they suppress their periods is doing them a real disservice. Introducing menstruation to pre-adolescents and newly menstruating girls as a negative experience to be avoided may affect the girls' body image and relationship to their bodies in negative and lasting ways.

Women need truthful and complete information about these products to make good decisions about them. As more products get approved, the marketing competition is likely to increase. Drug companies and clinicians promoting menstrual suppression must not tell women that it's healthier to have fewer periods because this is not supported by evidence. Making menstrual suppression products available will expand women's contraceptive options and increase convenience for some. This advance should not be undermined, however, by over-promising and over-promotion or by stigmatizing menstruation.

* The menstrual period of a woman using hormonal contraception is sometimes called withdrawal bleeding. Instead of a natural menstrual cycle controlled by the body's own hormonal fluctuations, withdrawal bleeding is the body's reaction to the cessation of the hormone dose that the contraceptive has been providing. Whether she bleeds monthly or quarterly, a woman who takes either traditional or extended cycle oral contraceptive pills is not having a natural period.

Updated May 2007

REFERENCES
1. Rabin R, "the New Pill in Town: Controversial form of birth control delays monthly cycle," Newsday, January 25, 2004.

2. Parker-Pope T, "Eliminating women's periods - Gynecologists say stopping ovulation with drugs or surgery can be healthy," The Wall Street Journal Europe, June 26, 2002.

3. Rabin R, "The New Pill in Town: Controversial form of birth control delays monthly cycle," Newsday, January 25, 2004.

4. Eaton SB, Pike MC, Short RV, et al. Women's reproductive cancers in evolutionary context. Q Rev Biol. 1994; 69: 353-367.

5. Arthur C, "New Pill will allow women to have just three periods a year," The Independent, March 14, 2002.

6. Rabin R, "The New Pill in Town: Controversial form of birth control delays monthly cycle," Newsday, January 25, 2004.