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Women's Health
Choosing whether—and when—to menstruate
By Andrew M. Kaunitz, MD
Reducing the frequency of menstruation—or simply eliminating
it—is a safe and effective option for many women, argues this author. Controlling
when and whether menstruation occurs may even be beneficial to their health.
Menstrual disorders affect approximately 2.5 million American women between
18 and 50 years of age.1,2 Of these women, two thirds contact a doctor
for relief of their ailments each year.1 Nearly one third of all
the women afflicted report that their menstrual symptoms confine them to bed
an average of 9.6 days per year.1 This, in turn, costs American industries—particularly
the sectors that predominantly employ women—an estimated 8% of the total wage
bill.2
Menstruation and its associated hormonal changes are often at the heart of
these women's monthly suffering. An excessive menstrual flow, for example, can
cause anemia in otherwise healthy women or worsen the condition in those with
certain types of preexisting anemia. Also, hormonal changes can cause dysmenorrhea
and migraine headaches, and may contribute to the aggravation of porphyria,
epilepsy, and chronic pelvic pain.3,4
To alleviate menstrual symptoms, a number of interventions are available that
reduce or eliminate monthly bleeding. The safety and efficacy of these methods
may make them desirable to women who simply want to suppress menses for convenience
sake. In this article, I will discuss the advantages to reducing or eliminating
menstruation, and describe the therapeutic regimens that can contribute to a
woman's overall well-being.
The benefits of suppressing menses
The idea that menstruation must occur monthly in healthy, non-pregnant women
has been perpetuated by the use of oral contraceptives designed to mimic the
average length of a normal menstrual cycle—21 days of active hormones followed
by 7 days of placebo. The developers of the first OC—Drs. Gregory Pincus and
John Rock—understood that monthly bleeding was not a necessary phenomenon but
rather a response to the withdrawal of hormones. However, many of today's women
and clinicians continue to believe that monthly menstruation is necessary for
a woman's health.
In fact, there is evidence to suggest that frequent, regular menstruation
may actually increase a woman's health risks. For example, today's Western
woman has an estimated 450 menstrual periods until menopause (at approximately
age 51), whereas her preagricultural ancestor had about 160 ovulations in a
lifetime.5 Fewer menstrual cycles among preagricultural women is
attributed to such factors as late menarche, high parity, extended periods of
breastfeeding, and early menopause. These exposures, which are not typically
experienced by today's women, have also been found to decrease the risk of breast,
endometrial, and ovarian cancers.5,6
Certain conditions can be alleviated. A recent prospective study of
262 women—all of whom took a low-dose, combination OC containing 35 mg or less
of ethinyl estradiol plus progestin—found that the women experienced headaches,
pelvic pain or cramps, bloating or swelling, and breast tenderness more frequently
during the 7-day, hormone-free period than during the 21 days of active hormone
use.7
Drawing on these data, Sulak and colleagues conducted a prospective study
of 50 patients to determine whether extended use of active hormones, for up
to 12 weeks, would alleviate such problems as dysmenorrhea, menorrhagia, premenstrual
syndrome, and migraines. While about one quarter of the patients (13) discontinued
OCs or reverted back to the standard 21/7 regimen, nearly three quarters (37)
completed the extended OC regimen without problems such as breakthrough bleeding.
Within this group, 16 took active OC tablets for 84 days (12 weeks) followed
by 7 days of placebo; 13 used a 63/7 regimen; and 8 used a 42/7 regimen. The
investigators found that "all 37 patients reported that extending the active
OCs delayed the onset and decreased the severity of their reported [menstrual]
complaints." Ultimately, 27 of these patients continued with the regimen for
an average of 17.2 months, completing between 5 and 13 cycles.8
TABLE 1
Conditions that may be remedied with reduced menstrual frequency or
amenorrhea
|
| Anemia |
| Dysmenorrhea |
| Endometriosis/chronic pelvic pain |
| Epilepsy |
|
Menorrhagia associated with:
- acquired bleeding disorders such as chronic anticoagulation and thrombocytopenia
- inherited bleeding disorders such as von Willebrand disease, hemophilia,
and factor XI deficiency
- uterine leiomyoma/adenomyosis
|
| Migraine headaches |
| Premenstrual syndrome |
| Porphyria |
Amenorrhea or reduced menstrual frequency may also be use-ful in providing
relief to women with other medical conditions. For example, those with endometriosis
have been treated for years with medications that inhibit ovulation and menstruation.9
In addition, women who experience symptoms that are aggravated by menses may
be able to avoid cyclical exacerbations of their complaints by decreasing the
number of times they menstruate.
Women with inherited bleeding disorders may also benefit from suppressed menses
because they frequently suffer from menorrhagia, which impairs their quality
of life. One study of 99 patients with von Willebrand disease, hemophilia, and
factor XI deficiency found that, during menstruation, 47% felt that they accomplished
less, 40% thought it took more effort to perform their work, 39% reported cutting
down on the amount of time they spent on work or other activities, and 38% felt
limited as to the kind of work and activities they could do.10 The
study also found that 51% experienced moderate to very severe dysmenorrhea.10
Combination OCs in the standard 21/7 regimen have been shown to reduce menorrhagia
in women with von Willebrand disease.11 One can only imagine the
benefits that patients with von Willebrand disease and other inherited bleeding
disorders may experience through an extended OC regimen.
Infrequent menses provides convenience. A number of studies, dating
back to 1977, have shown that women favor infrequent menses. For example, a
1996 telephone survey of Dutch women found that, if women could create an OC
to change how often they menstruated, the majority—regardless of age—would
eliminate menses completely or reduce the frequency to less than once a month
(Table 2).12
TABLE 2
A Dutch woman’s view on ideal menstruation
|
| |
Age of women |
| |
15-19
(N=321) |
25-34
(N=324) |
45-49
(N=319) |
 |
Once a month |
26.2 |
33.3 |
28.8 |
| Once every 3 months |
38.3 |
25.0 |
21.3 |
| Once every 6 months |
7.8 |
6.8 |
4.4 |
| Once a year |
4.0 |
3.4 |
6.6 |
| Never |
21.8 |
25.0 |
26.3 |
| Not inclined to use OCs |
1.9 |
6.5 |
12.5 |
| |
x2 (4df)
P value |
21.1
0.001 |
13.3
0.02 |
|
| Source: Adapted from den Tonkelaar
I, Oddens BJ.12 |
The survey also found that among those who were currently using or had previously
used OCs, 69% of adolescents (ages 15 to 19) and 63% of reproductive-age women
(ages 25 to 34) had used the pills to postpone menstrual bleeding. The study
investigators noted that the preferences of these women contrast with current
medical practice in that combination OCs are designed to mimic monthly menstruation
and clinicians often change formulations of OCs to produce monthly bleeding
when amenorrhea occurs.12
In general, young teens and perimenopausal women have much to gain from reducing
menstrual frequency. For example, American teens, whose age of menarche continues
to decline, must cope with the pain and inconvenience of menstruation.13
Moreover, they often experience dysmenorrhea and iron-deficiency anemia.14
Prescribing OCs using the standard 21/7 regimen can provide relief for dysmenorrhea
and reduce menstrual flow by nearly 50%.14 However, extended use
of active OCs may improve their quality of life more dramatically.
Similarly, perimenopausal women can find relief from irregular menses and
vasomotor symptoms by taking combination OCs in the standard 21/7 regime.15,16
But because hot flashes and other vasomotor symptoms may still occur during
the hormone-free period, these women may benefit from an extended OC regimen
that reduces the number of times per year that they must endure symptoms.
Finally, women in the military and female athletes may find it useful to suppress
menstruation to improve performance. For example, according to a recent survey,
more than 60% of 158 female cadets enrolled at the United States Military Academy
at West Point reported that menstrual-related symptoms interfered with required
physical activities—not to mention the difficulties the cadets experienced
in maintaining menstrual hygiene.17 An extended OC regimen could
help these cadets function more optimally in the military setting. Moreover,
female athletes have used standard OCs to manipulate their cycle and control
premenstrual symptoms—actions that may enhance their athletic abilities.18
Again, an extended OC regimen may be a more effective way of improving performance.
Contraceptive efficacy may improve. Unintended pregnancies often result
because a woman is confused about when to start the next pill pack, does not
take the pill at the same time every day, or forgets to start the next pill
pack at the correct time.19,20 Arguably, an extended OC regimen may
help improve contraceptive efficacy by limiting the chance that a woman will
forget to start a new pill pack: For example, a woman who uses an extended OC
regimen that contains 87 days of active hormones must only start a new pack
four times—rather than 13 times—per year.
Therapeutic options to reduce or halt menstruation
Historically, hysterectomy has been the only definitive treatment to attain
amenorrhea for women with severe problems associated with menstruation. In the
1980s, endometrial ablation was developed. Although this alternative procedure
costs less, requires little if any hospitalization, and has a shorter recovery
period than hysterectomy, menorrhagia may recur within 3 years and amenorrhea
is achieved in less than 50% of patients. Still, among the successful cases,
85% are cured of menorrhagia at 3 years.21
Today there are a number of alternative therapies for women with menstrual
disorders. These alternatives, which either reduce menstrual frequency or completely
eliminate it, are well tolerated and often have the added bonus of protecting
against pregnancy (Table 3).
TABLE 3
Therapeutic options for suppressing menses
|
| |
Extended OC regimen* |
DMPA* |
Levonorgestrel IUD |
Norethisterone acetate† |
Danocrine† |
GnRH agonist |
| Dosage |
<35 µg estrogen monophasic continuous; Seasonale
(investigational drug): extended 84/7 regimen |
Depo-Provera:
150 mg IM every
3 months |
Mirena: Releases 20 µg levonorgestrel daily, effective
for 5 years |
Aygestin: 5 mg, 1–3 times daily |
Danazol: 800 mg twice a day (optional titration to lowest dose
sufficient to maintain amenorrhea) |
Leuprolide acetate (Lupron Depot ):
3.75 mg monthly or 11.25 mg every 3 months |
| Medical uses |
Menorrhagia, dysmenorrhea, endometriosis, anemia, premenstrual
syndrome, menstrual migraines |
Menorrhagia, dysmenorrhea, endometriosis, anemia, premenstrual
syndrome, menstrual migraines |
Menorrhagia |
Menorrhagia, dysmenorrhea, endometriosis, anemia, premenstrual
syndrome, menstrual migraines |
Endometriosis, menorrhagia |
Menorrhagia dysmenorrhea endometriosis anemia premenstrual
syndrome menstrual migraines |
Contraception
provided |
Yes |
Yes |
Yes |
Yes |
No |
No |
| Adverse effects |
Breakthrough bleeding or spotting |
Irregular bleeding or spotting |
Intermenstrual bleeding |
Progestin side effects such as bloating or mood changes |
Androgenic and hypoestrogenic side effects |
Hypoestrogenic side effects that can be counteracted with estrogen
supplementation |
Cost-
effectiveness |
Cost-effective if the use of sanitary products is high |
Cost-effective |
Initial high cost, but becomes cost-effective with extended
use |
More costly than extended OC regimen |
Expensive |
Very expensive |
*None of the medical
uses listed are FDA-approved indications.
† Approved for the treatment of endometriosis.
Approved for the
treatment of endometriosis and menorrhagia-induced anemia in women with
fibroids. Other GnRH agonists approved for the treatment of endometriosis
include Synarel and Zoladex.
DMPA—depot medroxyprogesterone acetate |
Extended OC regimen. Sulak argues that women who suffer from menstrual
symptoms obtain only limited relief when they use the standard 21/7 OC regimen.
She notes that these women still experience menstrual symptoms during the 7-day
hormone-free period. Extending the use of active hormones over several cycles,
based on the individual woman's tolerance level, decreases the number of times
that she must suffer during the hormone-free period.22
In addition, Sulak contends that shortening the hormone-free period from 7
to 4 or 5 days—in addition to extending the active-hormone period—provides
greater ovarian suppression. This, in turn, helps reduce the occurrence of symptoms
associated with hormone withdrawal, as well as the risk of ovulation that can
lead to pregnancy.22
A new OC formulation--known as Seasonale--was approved by the FDA in September
2003. It is a 91-day OC regimen of ethinyl estrodiol and levonorgestrel for
84 days and 7 days of placebo.
Depot medroxyprogesterone acetate (DMPA). Between 50% and 73% of women
who use DMPA (Depo-Provera) for 1 year experience amenorrhea. As the duration
of use increases, amenorrhea—and the reduction of menstrual symptoms—becomes
more common.23,24 DMPA works by inhibiting ovulation, providing highly
effective contraception as well.
Initial injections of DMPA should be administered within 5 days of the onset
of menses and every 3 months thereafter. The usual dose is 150 mg. Reinjecting
DMPA at an earlier time (8 or 10 weeks) to reduce bleeding was found to be ineffective
and to cause weight gain.25 Similarly, there is little evidence to
support the use of supplemental estrogen to accelerate the onset of amenorrhea.26
Likewise, while monthly injections of medroxyprogesterone acetate/estradiol
cypionate (Lunelle) is associated with regular withdrawal bleeding similar to
spontaneous menstruation, there is no evidence to indicate that changing the
injection interval of this monthly contraceptive will create an amenorrhic state.27
Levonorgestrel intrauterine device (IUD). A recent study of 30 patients
with refractory recurrent hypermenorrhea found that the levonorgestrel IUD (Mirena)
was as effective at reducing bleeding over 12 to 24 months as roller-ball endometrial
ablation. Investigators believe that the Mirena system, which received FDA approval
last year for contraceptive use, will replace approximately 75% of endometrial
ablation.28
Another recent study of women with idiopathic menorrhagia found that this
progestin-releasing IUD reduced menstrual blood loss by 94% after 3 months.
Nearly one third of the women who used the IUD experienced amenorrhea during
this study period. At the end of the study, investigators found that more than
three quarters of those using the IUD wanted to continue with the treatment.29
Norethisterone. The same study that examined the use of levonorgestrel
IUD in women with idiopathic menorrhagia also found that a 5-mg oral dose of
norethisterone taken three times a day reduces menstrual blood loss by 87%.
However, none of the women treated with norethisterone experienced amenorrhea
during the 3-month study, and only about one quarter elected to continue with
the treatment once the study ended.29
In my experience, a lower dose of norethisterone (5 mg, once a day) can produce
amenorrhea in patients suffering from menorrhagia, including those with uterine
fibroids. However, even at this low dose, there seem to be more side effects,
including bloating and mood swings, than with OCs, DMPA, or the levonorgestrel
IUD. Moreover, norethisterone is more costly than OCs or DMPA.
Danocrine and GnRH agonists. To induce amenorrhea, decrease menorrhagia,
and shrink uterine fibroids, danocrine (Danazol) and GnRH agonists are also
effective treatments.21 However, they are costly and may not universally
suppress ovulation; therefore, a nonhormonal contraceptive may be necessary.
Moreover, this class of medications produces hypoestrogenic side effects. For
example, leuprolide acetate, a GnRH agonist, may cause breast tenderness or
pain, vaginal dryness, and a loss of bone density.
As additional therapeutic options to suppress menses become available, many
women will choose whether and when to bleed. Clinicians are in an ideal position
to educate their patients about ways to reduce the frequency of menstruation
or to eliminate this burden altogether.
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Dr. Kaunitz is Professor and Assistant Chairman, Department of Obstetrics
and Gynecology, University of Florida Health Science Center, Jacksonville, Fla.
Choosing whether--and when--to menstruate. JAAPA March 2004;17:Web.
Copyright © 2004, Advanstar Medical Economics Healthcare Communications at Montvale, NJ 07645-1742. All rights reserved.
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