Advances & Insights: Women’s Health
November 15, 2006
What the news means for you
Pamela R. Midboe-Penn, MD
Suppressing menstruation gains acceptance
Suppressing menstruation is gaining greater acceptance in the patient population. I think this is another sign that women want to gain more control over their lives. Physicians have been using this practice for years, primarily for women who have problems with their periods, such as severe menstrual migraines or endometriosis that is debilitating and cannot be controlled with nonsteroidal medication. We’ve also manipulated periods around vacations, honeymoons and athletic competitions.
“Physicians have been [suppressing menstruation] for years, primarily for women who have problems with their periods. . . .”
At the time I was in training, a lot of female gynecologists did that for themselves, but we weren’t necessarily promoting it to the general patient population. And I’ve even found that, when I suggest it to patients, some are concerned because they’re accustomed to having a period.
The pills were originally designed with 21 days of active ingredients and seven without as a means of mimicking the natural cycle. There really wasn’t any data or science behind it. Researchers just thought women would prefer having a period, which I think is kind of a paternalistic viewpoint.
New options in the spotlight
With the marketing around Seasonale, I think women are beginning to realize they have the option of stopping their periods. I still don’t routinely discuss or recommend it to a patient who just wants birth control. One reason is the expense. Until the pharmaceutical and insurance industries catch up to this new trend, patients are going to have to pay for extra pill packs. Some companies won’t let them refill it earlier. For other women, their plan will cover 12 months a year, but they’ll need to pay for an extra four packs.
Seasonale and Seasonique are being marketed specifically to suppress menstruation. Lybrel, which is still under review, is designed to eliminate a woman’s period for a year. But the question remains, is the intent to stop having periods for a year or eliminate them altogether?
Not for everyone
We don’t have any long-term data yet about suppressing the cycle continuously. There’s plenty of data showing the risks and advantages in general of the birth control pill. For some women, the pill in general has risks, just as any hormone preparation does. But the risks of pregnancy, where the hormone levels are much higher, are weighed against it.
It’s idealistic to think that anything we take, things we eat, different diets might not at one point be found to be problematic, so we have to go with the best data we have at the time and be open-minded about it.
I wouldn’t go out and recommend this to every woman. Certainly, I would be less inclined to offer the option to teens unless the patient was on a swim or diving team or had menstrual migraines or periods that were so disabling she missed school.
“I still feel most comfortable with my patients having three or four periods a year.”
I still feel most comfortable with my patients having three or four periods a year. In fact, when women aren’t on any kind of hormonal birth control, we don’t like for them to go more than six to 10 weeks without a period. We give them medication to bring about a period because the endometrial lining can get quite heavy and thick, possibly resulting in heavy, painful periods. There is also more risk of abnormal cells forming.
When we use hormonal birth control, the endometrial lining stays the same because the hormones are at the right level. The actual bleeding a woman has isn’t a real "period." It’s more withdrawal bleeding.
I don’t think we’re going to get to the point where the majority of women will want to suppress their period altogether. But patients are getting more interested in their health. The era of the doctor saying, "Here, take this pill. It will be good for you," is over. Patients are reading, thinking and asking questions.
Pamela R. Midboe-Penn is an obstetrician/gynecologist at UK HealthCare and an assistant professor of obstetrics and gynecology at the UK College of Medicine.
New medications foil “the curse”
The Food and Drug Administration recently granted approval for several new medications that give women a choice about whether to shorten or eliminate their menstrual period, and two more period-suppressing contraceptives are under review. While there is no long-term data on the effects of the new methods, many doctors appear to consider them as safe-if not safer-than earlier generations of the birth control pill.
“Several new medications give women a choice about whether to shorten or eliminate their menstrual period.”
Two of the products-Seasonale and its more recent version, Seasonique-are contraceptives designed specifically to reduce the frequency of a woman’s period. Another medication, Loestrin 24 Fe, shortens the average period from more than five days to less than three, according to its manufacturer, Warner Chilcott. Lybrel, currently under review by the FDA, is the first year-long oral contraceptive.
Best kept secret
Many women have never heard of manipulating birth control pills to suppress their period, according to a survey conducted by the Association of Reproductive Health Professionals. Yet doctors have been using the technique for years with patients who have problems during menstruation and others who want to schedule menstruation around special events like a honeymoon or vacation. Female doctors and nurses have also reportedly blocked their periods for years to accommodate their schedules.
High-profile marketing of the new birth control pills, along with the advent of Web sites like NoPeriod.com, has put the practice in the spotlight. Now, some women may be wondering, why have a period at all?
Apparently, women did not always have as many monthly periods. Writing on the site NoPeriod.com, Dr. Leslie Miller, MD, an associate professor of obstetrics and gynecology at the University of Washington School of Medicine, stated "100 years ago, the average woman had fewer than 150 periods in her lifetime. Now the modern woman could have 450 lifetime cycles and spend half her life with monthly periods."
How they work
With use of the standard birth-control pills, a woman takes the pill for 21 days and a placebo for seven days to have her period. To decrease period frequency. she can simply skip the placebo week and take the next three-week supply.
Seasonale, which was introduced in 2003, is taken for 12 weeks with one break for a period every three months. Lybrel, which can be taken indefinitely, and a new implanted contraceptive, Implanon, stop menstruation for most women for 12 months.
The NuvaRing, a vaginal ring, or the birth control patch Ortho Evra can be manipulated to suppress menstruation if a woman replaces them every three weeks instead of following the usual practice of removing them a week to allow for a period.
“No long-term research has been conducted on the effects of long-term suppression of menstruation.”
Risk and benefits
Hormone-based birth control isn’t recommended for women over the age of 35 who smoke because it increases their risk of stroke. Women who have had breast cancer, liver disease or a stroke should also avoid this method of birth control.
So far, no long-term research has been conducted on the effects of long-term suppression of menstruation. However, the birth control pill, which was introduced in 1960, has a proven track record of safety for the majority of women who use it. There are, however, a few known drawbacks of period suppression:
• Some women experience the inconvenience of spotting or unpredictable bleeding.
• Unplanned pregnancies may initially go unnoticed.
• Taking the pill for four rather than three weeks is likely to increase a woman’s risk of stroke, heart attack or pulmonary embolus by one-third.
• And there are several advantages:
• Less inconvenience.
• A lower chance of developing anemia.
• Fewer migraines and menstrual cramps and less bloating.
• A lower risk of ovarian cancer.
UK HealthCare Women’s Health Services
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