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Menstrual Suppression

(Updated April 2008 )

The adjustment of the menstrual cycle, or menstrual suppression, via hormonal contraception allows women to have less frequent periods and avoid bleeding at inconvenient times in their lives. Menstrual adjustment also helps to suppress medical conditions that are exacerbated by menstruation and the cyclical variations in female hormones. Menstrual suppression has been practiced for many years worldwide, and a number of surveys indicate that women are interested in eliminating menses completely or reducing its frequency to less than once a month.1,2

There is an absence of evidence to support regular menstruation as medically necessary, as well as an absence of evidence to suggest that suppressing menstruation is deleterious to a woman’s health.

Benefits of Menstrual Suppression

Menstrual benefits of suppressing periods include a reduction in dysmenorrhea, menorrhagia, premenstrual syndrome, and perimenopausal symptoms (e.g., hot flashes, night sweats, and irregular monthly periods).3

Nonmenstrual benefits include a reduction in menstrual migraines, endometriosis, and acne and an improved sense of well-being.3

Disadvantages of Menstrual Suppression

The major disadvantage of menstrual suppression is an increase in breakthrough bleeding during the first few cycles using a hormonal method as the body adjusts to the new hormone balance. Some women may be uncomfortable suppressing menstruation and may have difficulty determining if they are pregnant, should pregnancy occur.

Methods of Menstrual Suppression

Use of Combined Oral Contraceptives

The most common way to reduce or suppress menstruation is to change the manner in which a monophasic combined oral contraceptive (COC) is taken. With this method, the placebo week from the standard 21/7-day cycle (i.e., 21 days of active pills followed by 7 days of placebo) is eliminated and a new pack of pills is started immediately thereafter.

Extended use refers to a variety of patterns. For instance, Seasonale® is a dedicated extended-regimen COC product indicated for 84 days of active pills followed by a 7-day pill-free interval to induce withdrawal bleeding.5 When conventional COCs are used, three pill packs (63 active pills followed by a 7-day pill-free interval) are often prescribed.5 Researchers have studied extending the use of COCs to reduce menstrual bleeding since the late 1970s. The majority of studies show that the practice is well accepted by patients and confirm that menstrual suppression offers a number of desirable benefits. The largest trial to date of an extended-regimen COC was conducted with Seasonale (30 mg of ethinyl estradiol [EE] and 150 mg of levonorgestrel [LNG]) compared with a conventional-cycle regimen of Nordette® (30 mg of EE/150 mg of LNG).4 The 1-year, multicenter, randomized, parallel, open-label study enrolled 682 healthy women aged 18–40 years who desired oral contraception. The duration of withdrawal bleeding was comparable on both regimens, but the frequency of scheduled bleeding was less with the extended regimen. The frequency of unscheduled bleeding episodes was initially higher with Seasonale than with Nordette but declined with each successive cycle.

Continuous use refers to the administration of COCs for an unlimited time without interruption to eliminate menstrual periods. A number of studies have demonstrated that continuous OC use is safe and eliminates menstrual periods in 53% of women by 12 months of use.6,7 Lybrel TM is an FDA-approved continuous COC packaged as an entire year of active pills.

Use of COCs for Nonmenstrual Benefits

Several studies show that COCs can be prescribed to relieve menstruation-related complaints, such as breast tenderness, bloating, menstrual migraine, and premenstrual syndrome or premenstrual dysphoric disorder, as well as medical conditions such as endometriosis and acne.3,8,9

Other Hormonal Methods

In addition to COCs, other contraceptive methods can be used on a similar schedule to suppress menstrual bleeding.10 These methods are described in the table below.

Method

Use

Combined oral contraceptives (including dedicated product Seasonale® and LybrelTM)

Extended or continuous cycles suppress menstruation

Contraceptive vaginal ring (NuvaRing®)

Studies not published, but regimens similar to COCs suppress menstruation

Transdermal contraceptive patch (Ortho Evra®)

Studies not published about safety or efficacy, but regimens similar to COCs suppress menstruation

Depot-medroxyprogesterone actetate injections (Depo-Provera®)

Amenorrhea common with long-term use—50% after 1 year, 90% after 2 years

Levonorgestrel intrauterine system (Mirena®)

Significant (80%–90%) decrease in blood loss; approximately 20% of users amenorrheic by 1 year

Etonogestrel implantable contraceptive (ImplanonTM)

21% of users are amenorrheic in any 90-day reference period

Counseling Women

Many women are still unfamiliar with the concept of menstrual suppression.2 Providers and patients often use different language when discussing this topic. Clinicians may employ the medical term, menstrual suppression, while patients might better understand ‘not having a period.’ Clear dialogue on this topic is important.11 Below are some strategies for introducing the concept of extended or continuous hormonal use to patients and counseling patients who have elected to use such a method.

Introducing the Concept

  • Standard oral contraceptives (OCs) include placebo pills to mimic a woman’s natural menses, but when a woman is on OCs, she does not have a natural bleeding episode.12
  • There is no medical or health reason to bleed while on hormonal contraceptives.
  • Menstrual blood does not build up when women are using hormonal birth control.

Safety

  • Safety appears comparable to that of conventional COC regimens.
  • Return to fertility after discontinuation is expected to be the same as for conventional COC use.

Advantages

  • Menstrual suppression can help alleviate menstruation-related conditions.
  • Such regimens are more convenient in general and during particular occasions, such as vacations and athletic activities.
  • Menstrual suppression eliminates the need to purchase and carry as many hygiene products.
  • Some regimens (e.g., the vaginal ring) may be less costly.

Disadvantages

  • Unpredictable breakthrough bleeding is initially more common than with conventional COCs. Bleeding will lessen as the body adjusts to the new hormone balance.
  • It often takes a few months before the desired effect of reduced bleeding is achieved. If the method is being used to eliminate menstruation for a specific event, it should be initiated well in advance of the event.
  • It may be more difficult to detect pregnancy with a suppressive regiment. Patients should be advised to look for other signs of pregnancy besides a skipped menstrual period, such as breast tenderness, nausea, fatigue, and other signs, and to obtain a pregnancy test if unsure.
  • In some cases the regimens (e.g., pills, patches) may be more costly.

How to Follow an Extended-Use Regimen

  • Discuss when to have hormone-free days, if any.
  • Discuss the schedule of the method, such as taking COCs at the same time every day.

What to Expect

  • Spotting.
  • Blood may be dark brown (oxidized due to remaining in vagina longer) rather than red (blood noted with active bleeding). Blood may have a different texture.

When to Call a Provider

  • Contact a clinician if side effects such as ACHES—Abdominal pain, Chest pain, Heavy bleeding, Eyesight or vision changes, or Severe leg pain—occur.13

References

  1. Glasier AF, Smith KB, van der Spuy AM, et al. Amenorrhea associated with contraception—an international study on acceptability. Contraception 2003;67:1-8.
  2. Andrist LC, Arias RD, Nucatola D, et al. Women’s and providers’ attitudes toward menstrual suppression. Contraception 2004;70:359-363.
  3. Sulak PJ, Kuehl TJ, Ortiz M, Shull BL. Acceptance of altering the standard 21-day/7-day oral contraceptive regimen to delay menses and reduce hormone withdrawal symptoms. Am J Obstet Gynecol 2002;186:1142-1149.
  4. Anderson FD, Hait H, Seasonale-301 Study Group. A multicenter, randomized study of an extended cycle oral contraceptive. Contraception 2003;68:89-96.
  5. Association of Reproductive Health Professionals and National Association of Nurse Practitioners in Women’s Health. Annual meeting registrant survey. August-September 2002.
  6. Archer, D. Menstrual-cycle-related symptoms: a review of the rationale for continuous use of oral contraceptives. Contraception 2006;74:359-366.
  7. Turok, D. The Quest for Better Contraception: Future Methods. Obstet Gynecol Clin N Am 2007;34:137-166.
  8. Sillem M, Schneidereit R, Heithecker R, Mueck AO. Use of an oral contraceptive containing drospirenone in an extended regimen. Eur J Contracept Reprod Health Care 2003;8:162-169.
  9. Vercellini P, Frontino G, DeGiorgi O, et al. Continuous use of an oral contraceptive for endometriosis-associated recurrent dysmenorrhea that does not respond to a cyclic pill regimen. Fertil Steril 2003;80:560-563.
  10. Kaunitz AM. Menstruation: choosing whether…and when. Contraception 2002;62:277-284.
  11. Barnhart, K. Remarks made at the Reproductive Health 2007 conference. Quoted in Differing attitudes found between women and doctors concerning menstrual suppression [press release]. Philadelphia, Pennsylvania: University of Pennsylvania School of Medicine; October 3, 2007. Available at http://www.eurekalert.org/pub_releases/2007-10/uops-daf100307.php. Accessed on April 2, 2008.
  12. Gladwell M. John Rock’s error: what the co-inventor of the Pill didn’t know: menstruation can endanger women’s health. The New Yorker 2000;March 13:52-63.
  13. Association of Reproductive Health Professionals and the National Association of Nurse Practitioners in Women’s Health. Extended and continuous use of contraceptives to reduce menstruation. ARHP/NPWH Clinical Proceedings 2004. Accessed April 2, 2008 at http://www.arhp.org/Publications-and-Resources/Clinical-Proceedings/Reduce-Menses