8/18/2019 toag.5.1.34

1/4

REVIEW

The Obstetrician

Gynaecologist

2003; 134 7

Keywords

benefits,

elimination,

menstruation,

regulation,

symptoms.

Author details

Kelly

Blanchard

MSC,

Program

Associate, P opulation Council,Po

Box 411744, Craighall 2024,

Johannesburg, South Africa. ernail:

kblanchardOpcjoburg.org.za

34

L i fe without menstruation

Kelly Blanchard

Eliminating menstruation could improve the quality of life for many

women. Menstruation may be accompanied by debilitating pain and

is costly to women and society. Contraceptives, including the

combined oral contraceptive pil l (COC), can be used to avoid

menstruation if a woman so wishes. Research on extended COC

regimens resulting in only three periods annually is underway and the

US

FDA

is reviewing

a

dedicated extended regimen product.

Eliminating menstruation may have important health benefits and

health care providers should give their female patients information

about the potentia l for eliminating menstruation. Monthly periods

should be a woman s choice, not her curse .

introduction

For many women, el iminat ing menstruat ion

would lead

to

an improvement in their quality

of life. Menstruation is often accompanied by

both physical pain and m ood swings that can be

disruptive

or

debilitating,

to

say nothing of the

i n co n v en i en ce an d co s t o f man ag i n g t h e

month ly b leed wi th san i t a ry supp l i es . In

addition menstruation is associated with the

worsening of a num ber of condi t ions including

migraines, porphyria, epilepsy and pelvic pain

(mainly due to endometriosis) Menstrual

disorders affect nearly 2.5 million American

women annual ly and are the most commonly

reported gynaecological complaints. ' Thirty-

one percent o f wom en repor t spend ing a mean

of 9.6 days in bed each year

as

a result of their

tnonthly period. ' In a UK-based study 37% of

women had consul ted a doctor about menstrual

sym pto ms in th e last year.' Clearly,

mens t rua t ion i s no t on ly cos t ly and

inconvenient

for

many w om en, but is also the

cause of a significant cost to so ciety.The cost

to

American industry has been estimated at 8% of

its total wage bill; in Britain this figure is

approximately 3%.'

Eliminating or reducing the

frequency of menstruation

The technology

to

make menses a thing of

choice and not the 'curse' it is for many women

has existed for decades. Currently available

combined oral contraceptive pills

(COCs)

can

be used continuously, by skipping the placebo

tablets in 28-pill packs

or

skipping the pill-free

week with 21-pill packs. As early as 1977

researchers evaluated a three-month COC

regimen : 84 consecutive days of active pills with

a pill-free period and withdrawal bleed every

tnree montns." i n e vast majority

ot

women

found this regimen acceptable and 91% refused

to return to a monthly schedule once the study

was complete. Study results showed that this

regimen was associated with infrequent

breakthrough bleeding (8.5%); 24% of wom en

reported spot t ing. T h e frequency of these

complaints went down with continued use of

the regimen." M ore than 20 years later a similar

regimen, using a much lower-dose

COC

formulat ion, may soon be commercial ly

available. Seasonale" (Barr Laboratories Inc.,

Pomona, NY,USA) will be marketed in the

USA for continuous use for three m onths. ' This

combined ethinyloestradiol and levonorgestrel

regimen is currently under review by the US

Food and Dr ug Administration (FDA)." Oth er

studies have confirmed that these regimens are

acceptable and have shown that continuous

regimens can also lead

to

significant redu ctions

in menses-related comp laints like migraines

among

COC

users.'

In addi t ion

to

modified use of CO C s, a number

of other contraceptive products can lead to

am enorrho ea. After on e year approximately 50%

of women using depot medroxyprogesterone

acetate (Depo-Provera", Pharm acia Ltd, M ilton

Keynes, UK ), a th ree-m onthly progestogen-only

injectable contraceptive, will be amenorrhoeic.

This percentage may increase with longer

dur ation o f use."' Early follow-up injections and

supplemental oestrogen may accelerate the

onset

of

am eno rrho ea, but research has not yet

identified effective ways to augment this effect.'

Monthly combined oestrogen and progestogen

injectable contraceptives are also available in

many countries and theoret ical ly the t ime

between injections could be reduced

to

provide

continuous levels of hormones adequate to

el iminate menstruat ion. This metho d may be

2003

Royal ollege of Obstetricians and Gynaecologists

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rather cumbersome for women because i t

would mean quite frequent injections (more

than one inject ion per m onth).

T h e

levonorgestrel releasing

intrauterine system

(IUS) Mirena* (Schering Heal th Care Ltd,

Burgess Hill, UK) is an extremely effective

contracept ive. Studies indicate that

approximately one-third of wo me n using this

IUS will not have periods at

all

and women who

do will have significantly lighter periods. After

three months, blood loss am ong wom en with

menorrhagia is reduced by an average of 85 ,

and after 12 months

97%.

Mirena is now

licensed in the UK for treatment of heavy

periods." As for other hormonal contraceptive

meth ods, wom en choosing any of the above

methods should be told that these highly

effective contraceptive methods do not protect

against sexually transmitted diseases, includ ing

HIV.

H e a l t h b e n e f it s

Regula t ing or stopping menstruat ion can

el iminate some heal th problems and has

potent ial heal th benefi ts . Combined oral

contraceptives are routinely prescribed to address

menstrual symptoms regardless of need for

contraception.'," Eliminating menstruation and

the associated changes in hormone levels can

alleviate mood swings, personality changes and

other complaints associated with premenstrual

syndrome (also sometimes referred

to as

premenstrual tension).'. '." Continuous

COC use

can also reduce menstruation-associated

symptoms among women using COCs in the

traditional 21/7 fashion."." In addition,

el iminat ing menstruat ion can prevent the

recurrence of catamenial conditions (such

as

epilepsy and arthritis) that often worsen

cyclically, with the changes in ho rm on e levels

associated with menstruation. ' For example,

endometriosis symptoms are aggravated by

me nstru ation . Endom etriosis is associated with

severe abdominal pain, pain during intercourse

and infertil i ty. Clinicians have prescribed

con t inuous

COC

use as a treatment for

endom etriosis for years."

Reducing nienses-associated blood loss can also

reduce anaemia. An estimated

30

of the

world's population are anaemic, including 20

of regularly menstruat ing women in

industr ial ised countries . ' For malnourished

women in developing countries in particular,

monthly menstruation can cause

a

dangerous

increase in anaemia. Finally, menstruation and

repeated ovulation are thought to be associated

with

a

num ber o f reproductive cancers. '

N a t u r a l or o p t i o n a l ?

Given this large body of evidence that

menstruation may be bad for women, as well as

inconvenient, why aren't more women choosing

not to menstruate? From the earliest days of

medicine menstruat ion has been seen as

'natural'- nature's treatmen t for the variety of ills

that affected wo m en (includ ing abdom inal

cramps, depression and mood swings), which

today we understand are actually caused by the

hormonal changes leading up

to

menstruat ion.

T he beneficial effects attributed

to

menstruation

were a large part of the rationalisation for the

harmful practice of bloodletting, performed on

patients for a wide range of ailments.' Even the

development of the oral contraceptive pill was

influenced by the idea that menstruation is

n a tu r al . J o h n Ro c k , o n e o f t h e o r ig i n al

developers of

COG,

was

a

devout Catholic and

wanted a m etho d that worke d by natural means.

He believed that the hormone progesterone

prevented ovulation and established the 'safe

period' and, therefore, hoped that taking this

hormone regularly would be accepted by the

Cathol ic Church as

a

natural contraceptive

meth od." If menses were eliminated it would be

clear that this method was not natural so he

designed the regimen with a pill-free week to

induce withdrawal bleeding to mimic menses.

There is no known medical indication for the

withdrawal bleed and, in fact, it is not a

menstrual period in the medical sense.

But what is natural? Co utin ho and Segal explain

that women today have many more menstrual

periods than wo me n did in the past, due to fewer

pregnancies, shorter duration of breastfeeding

and changes in age at menarche and

menopause.'.'. 's They estimate that women today

have approximately 400 menstrual periods in

the i r l ife t ime, compared wi th 150 among

hunter-gatherer women.They argue that current

patterns of menstruation are not natural

a t all.

But does it matter if menstruation is natural

or

not ? Me nopause occurs naturally and clinicians

prescr ibe hormone rep lacement therapy to

manage the symptoms .

I t

could be that

debunking the myth that menstruation is natural

may help support the notion that i t is no

different

to

oth er 'natural' medical cond itions,

l ike headache, that are managed pharma-

ceutically."'

Research has shown that women would prefer

to

men struate less fiequently. In a D utc h study,

most w om en o f reproductive age preferred

to

menstruate once every three months

or

less

frequently; age 15-19 years

70 ,

age

25-34

years 6596, age 45-49 years

70 .

In each age

REVIEW

The Obs te t r i cian

Gynaeco log is t

2003;5:34 7

35

8/18/2019 toag.5.1.34

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REVIEW

The Obstetrician

8 G y n a e c o ’o g i s t

category more than

25

reported they would

prefer to never menstruate.” Re po rts from trials

of extended COC use have confirmed that

wom en like the method.‘’.g

2003;5:34-7

Barriers to

choosing

not t o

m e n s t ru a t e

There are a number of barriers

to

mo re

widespread adoption of active regulation

or

elimination of menstruation. Studies on the

introduction of other reproductive health

technologies, like emergen cy contraception, have

found providers slow or actively averse

to

sharing

necessary inform ation with their patients.’“.’’ If

providers are wedded to the idea that regular

menstruation is natural, convincing the m to share

information on actively regulating menstruation

with women is likely

to

be difficult. Providing

information directly

to

women would help to

overcom e this hurdle.Women could easily modify

how they take their

COCs or

choose another

hormonal method, l ike depot medroxypro-

gesterone acetate

or

the

levonorgestrel-releasing

IUS, that whe n used as labelled

or

recommended

induces amenorrhoea . But, again d rawing h m

the em ergency contracept ion experience, a

dedicated product like Seasonale will make

provider prescribing and patient access easier.”

Curren t

COCs

were developed with little input

from women. However, reproductive health

product development has shifted to include user-

perspectives earlier in the product development

process.” Additiona l research on wom en’s attitudes

towards menstruation and preferred frequency

(and thus potential markets for dedicated

products) could help stimulate increased

pharmaceutical interest in products expressly

labelled for reducing menstrual fiequency

or

eliminating m enstruation altogether.

Moving

COCs

from solely a contraceptive

method

to

m ore of a ‘lifestyle drug’, in response

to research on what women themselves prefer,

could potentially spur additional research on

other aspects of pill use; including common

adverse effects like weight gain o r loss o f libido.

A potential increase in market share could

encourage

COC

manufacturers

to

label their

products for regulat ing menstruat ion, thus

making it easier for providers

to

offer

COCs

for

this indication. I t is likely that the contraceptive

label, and therefore the association with sex, has

partly caused the paucity of research on ma king

oral contraceptives available over the counter,

or

otherwise more under the control of women.

The lack of research along these lines is

surprising given the overwhelming body of

information available on

COC

safety and long-

term experience with their use. Increasing

attention

to

health benefits and other uses of

COCs

could help stimulate efforts

to

increase

access and reduce barriers to

COC

use.

An additional barrier

to

more widespread use of

hormonal methods to eliminate or reduce the

frequency of menstrual periods is nlisinfor-

mation a bou t the risks of long-term use.There is

a significant body of data on the long-term safety

of horm onal methods of contraception.”’ Yet

studies have shown that many w om en believe that

use of these methods is not safe and in some cases

believe it might even be dangerous.’’ Providers

need

to

give wom en the m ost up-to-date and

accurate information

so

that they can make

inform ed choices, wheth er it

is

about what type

of contraceptive to use or whether

to

menstruate.

Providers themselves need accurate and clear

information to be able

to

advise wome n.

Ma ny o f the beliefs a nd practices around

menstruation are rooted in cultural constructs of

women’s place in society. I t

is likely that taboos

regulating me nstruating women’s behaviour and

cul tural constructs of the meaning of

menstruat ion wil l be s low

to

change.

For

example, in some cultures menstrual blood is

seen as

a

‘pollutant’ and menstruating wom en

avoid sex and may not cook meals for the

household.” O n the o ne hand, el iminating

menstruat ion might f iee women from such

proscriptions bu t it m ight also raise suspicion,

or

wo me n migh t find such proscriptions useful and

appealing and

might not want

to

eliminate

men struation. Most research on the acceptability

of eliminating or regulating the frequency of

menstruat ion has been conducted in

developed/western countries and addi t ional

research in

a

variety of contexts is needed.

T he idea that me nstruation ‘treated’ women’s

complaints or represented the elimination of

harmful toxins took hundreds of years

to

be

challeng ed.’ Bu t, like any n ew technology,

information will provide the key

to

more

widespread acceptance and adoption . Again,

further research into women’s attitudes and

preferences in different settings as well as wider

dissemination of information on the medical

benefits and harms of menstruation is needed.

Possible medical benefits from eliminating or

reducing frequency o f m enstruat ion, l ike

reduction of anaemia,are likely

to

be sign ificant in

developing countries. However, resource-poor

settings may present different challenges. For

example, although it is true that in industrialised

countries a woman using

COCs

continually can

use hom e pregnancy tests if she is wor ried that she

may be pregnant, in many places these might not

be physically

or

financially acce ssible.

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Treat ing menstruat ion

as

a 'pathology' or

inedicalising it may raise issues of potential

discriniination against wom en. It raises the dang er

that regular menstruation will be seen

as

a

debilitating condition and used as a reason to bar

wom en f rom demanding jobs tha t requ i re

continuous performance."' Menstruation should

be recognised

as a n

individual expe rience for

some women i t niay be th e cause ofserio us health

problems

or

discomfort that leads to the need for

days off work, while for others

it

is nierely an

inconvenience. However,

a

woman's choice to

nienstruate or not should be respected. Fear of

potential discriniination should not prevent the

disseniination of information o n this op tion b ut

rather the choice to menstruate, like decisions

to

use contraception

or

hormone rep lacement

therapy for example, should be accommodated.

Conclusions

Many w omen, armed w ith complete informat ion

on their options, will no t choose to eliminate

their mon thly periods.Taking

a

pill every day m ay

be inconvenient or a woman niight experience

horm one-rela ted adverse effects. How ever,

wonien should be given the option of making a

person al cost-benefit calcu lation. Individ ual

women should be given complete and accurate

infornlation

so

they can decide whethe r taking a

pill each day is preferable to their monthly

experience of menstruation. Clearly, for niany

women who expe rience significant discomfort, o r

even serious health problems, related to

me nstruatio n the calculation niay be easily made.

For others, information abo ut the potential health

benefits of not menstruating niay influence their

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