(Published September 2004)

Consumer and Clinician Acceptance

According to recent surveys, many women—regardless of age and in a variety of populations—would prefer to eliminate menses completely or to reduce its frequency to less than once a month if they had the choice. These surveys suggest that attitudes about extended regimen contraception have changed, as they are in stark contrast to a study performed by the World Health Organization in 1981, which found that most women would prefer to bleed on a monthly basis and were not willing to use a contraceptive method that would induce amenorrhea.¹ Following are summaries of some of the most recent surveys conducted about patient and clinician attitudes toward menstruation and menstrual suppression.

Amenorrhea Acceptability Survey

An acceptability survey of 1,001 women attending family planning clinics in China, South Africa, Nigeria, and Scotland was conducted by Glasier et al. from December 2000 to June 2001.2 Many of the women surveyed said that they did not like having periods, terming them “inconvenient” and associated with menstrual problems (74 percent in Edinburgh, 25–65 percent in Cape Town, 51 percent in Hong Kong, and 63 percent in Shanghai). Given the choice, many of the women said they would opt to have a menstrual bleed every 3 months or not at all (57 percent in Edinburgh, 36–55 percent in Cape Town, 45 percent in Hong Kong, and 45 percent in Shanghai). The exception was Nigerian women, 81 percent of whom said they liked having periods and 71 percent of whom said they would prefer to bleed monthly “to get rid of bad blood.” A substantial proportion of women said that they would consider using a contraceptive method that induced temporary amenorrhea (65 percent in Edinburgh, 52–64 percent in Cape Town, 37 percent in Hong Kong, 48 percent in Shanghai, and 73 percent in Nigeria).

ARHP Menstrual Suppression Survey

In a 2003 survey from the Association of Reproductive Health Professionals (ARHP), led by Linda Andrist, PhD, RNC, WHNP, associate professor at the MGH Institute of Health Professions, 1,470 women aged 18–40 years at six sites across the United States responded to questions about menstrual suppression.3 Seventy-three percent of these women had never heard of suppressing menstruation with use of oral contraceptives (OCs). Fifty-nine percent said they would be interested in not menstruating on a monthly basis, and one-third said they would choose never to have a period. The survey participants felt that more research should be conducted on menstrual suppression and said that factors such as long-term health effects, side effects, future fertility, and cost would influence their decision about whether to use extended regimen contraception. The majority of the women said they would use hormonal contraception to reduce menstrual frequency if they believed the practice was safe.

Survey of US Military Women

An anonymous, volunteer survey of 154 women in Army Active Duty or Reserve and the National Guard published in 2003 found that 86 percent of military women would desire menstrual suppression during field training and 83 percent would desire it during deployments.4 Despite the interest in temporary amenorrhea, 54 percent of the respondents were unaware that OCs could be used to suppress menstruation. and only 7 percent had used OCs for this purpose. However, 49 percent said they would take advantage of this feature of OCs if it were available.

European Surveys

In 2000, German investigators Wiegratz et al. conducted a survey of 1,195 women between 15 and 49 years of age.⁵ The survey revealed the following.

Desired bleeding patterns. Only 26–35 percent of the German women surveyed desired monthly menstrual bleeding; 37–46 percent preferred no menstrual bleeding. The latter group of women cited less menstrual discomfort, better hygiene, better quality of life, and less blood loss as reasons for desiring amenorrhea. Most of the women (65–78 percent), however, had never used OCs to suppress menstruation. Reasons cited among women using OCs who preferred monthly menstrual bleeding were fear of pregnancy, infertility, adverse effects, and a belief that menstruation was natural.

Interest in menstrual suppression. Of the women surveyed, 32–54 percent said that they would suppress menstruation occasionally, and 11–14 percent said they would suppress it for a longer period of time.

Conventional versus continuous OC regimen. As part of the same German study, 30 women received a 30-mg ethinyl estradiol monophasic combination OC for 6 months after actively requesting extended use for personal reasons, such as to avoid bleeding during holidays, sporting events, or examinations. After a 7-day pill-free interval, they were treated for three cycles with a conventional OC regimen. Sixty percent chose to take their OCs on a continuous regimen after completion of the study, despite a higher rate of irregular bleeding. The investigators found that bleeding occurred more commonly among new OC users and particularly during administration of the second pill pack. This finding led them to suggest that extended regimens should be recommended for women who have been taking OCs for a number of cycles, rather than for new starts, because it appears that unscheduled bleeding and spotting is less frequent with this approach.

In a comparable survey conducted with 325 Dutch women in 1996, 71.5 percent of menstruating women desired changes in their bleeding patterns, such as less painful, shorter, and lighter periods, and 9 percent preferred a total absence of menstrual bleeding.6 Many women expressed a desire for bleeding once every 3 months or never. The desire to stop menstruation altogether increased with age.

2002 ARHP Harris Poll of US Women

In 2002, ARHP commissioned Harris Interactive, Inc., to conduct telephone interviews of 491 women aged 18–49 years about their preferences on the frequency and characteristics of menstrual bleeding.7

• Only 25 percent relied on the occurrence of their menstrual period to indicate whether they were healthy, 24 percent to tell them whether they were able to have children, and 31 percent to tell them whether they were pregnant.
• Overall, 44 percent preferred never to menstruate; this increased to 59 percent for women aged 40–49 years. Twenty-nine percent preferred to menstruate once a month.
• More than one in four women said they had missed professional, social, athletic, or family-oriented events because of their period, menstrual cramps, or other menstrual effects.
• Of the 70 percent of respondents who were using or had used OCs, 15 percent had used pills to delay or stop their periods.

Need to Bleed Study

In 2002, Linda Andrist and colleagues conducted a pilot study to explore women’s attitudes and beliefs about menstruation and menstrual suppression.8 Self-administered questionnaires were given to a convenience sample of 221 females aged 18–30 years who were highly educated; most of the respondents were Caucasian. Forty-eight percent were not using a hormonal birth control method, and 50 percent were using OCs. The following is a summary of the survey results.

Sixty-three percent of respondents were interested in reducing menstrual pain and 69 percent were interested in reducing the amount of bleeding. These responses were particularly noted among those who were not using OCs.

When asked whether it was necessary to have a period every month, 44 percent said yes, 39 percent said no, and 16 percent were not sure.

Fifty-six percent strongly agreed or agreed that they were interested in menstrual suppression, 12 percent neither agreed nor disagreed, and 30 percent disagreed or strongly disagreed. Women not currently using OCs were more interested in using a contraceptive for menstrual suppression than women who were using OCs. Women who were not interested in changing their menstrual pattern said they would be anxious about not bleeding and that not experiencing menstruation would be abnormal.

Provider Acceptability

In the international study of women, Anna Glasier and colleagues also surveyed clinicians and found that health practitioners tend to overestimate the importance of monthly menstruation to their clients.² Most clinicians reported that they thought it was important for women to menstruate while using contraceptives, and 75 percent thought their patients felt the same way. More than half of the providers surveyed (except those in Shanghai), however, said that they would recommend a contraceptive method that would stop menstrual bleeding.

The ARHP Menstrual Suppression Survey included a sample of 512 providers to determine clinicians’ attitudes toward menstrual suppression.³ This survey found that only 7 percent of providers believed it was physically necessary for women to have a menstrual period every month; in fact, 44 percent of the sample felt that menstrual suppression was a good idea. Fifty-seven percent of the providers said that their patients do not ask them about extended use of OCs. Fifty-two percent said that they prescribe them. These latter respondents cited dysmenorrhea, menorrhagia, and endometriosis as medical indications for prescription; extended OCs were also prescribed upon patient request. Like patients, providers said that more research should be conducted, particularly in regard to long-term health effects, side effects, future fertility, and the cost of extended regimen contraception.

A Gallup telephone survey of female obstetrician/gynecologists conducted for the American College of Obstetricians and Gynecologists (ACOG) in September 2003 revealed that 99 percent of these clinicians believe that menstrual suppression is a safe practice for their patients, 69 percent believe that long-term suppression with OCs is safe, and 30 percent believe that it is safe if used occasionally.⁹ Fifty-three percent of the female obstetrician/gynecologists had tried menstrual suppression themselves, with a higher percentage of practitioners under the age of 40 reporting personal experience.

In the German study conducted by Wiegratz el al., gynecologists were sent surveys to evaluate their professional attitudes and experiences with suppression of menstruation and extended use of OCs.⁵ Of the 1,152 questionnaires that were evaluable, 99.5 percent of gynecologists had prescribed OCs for the postponement of menstrual bleeding; 97 percent had prescribed extended-cycle OCs for at least a limited time to suppress bleeding for medical reasons (menstruation-related disorders or complaints, endometriosis, polycystic ovary syndrome) or at the request of their patients. These clinicians rated the experience of suppressing menstruation as good (60 percent) or very good (28 percent). Sixty-one percent prescribed a regimen consisting of three packs (63 pills) of OCs followed by a hormone-free week.

ARHP and the National Association of Nurse Practitioners in Women’s Health (NPWH) surveyed 117 annual meeting registrants in August-September 2002 (before US Food and Drug Administration approval of a dedicated extended regimen OC) to determine their practices concerning prescription of extended OCs.¹⁰ Seventy-eight percent of the respondents specialized in obstetrics/gynecology. Forty-eight percent of the respondents were nurse practitioners, 16 percent were physicians, and 33 percent were in private practice.

Seventy-seven percent of the survey participants prescribed extended regimen OCs. The prescription patterns included more than 21 active pills per cycle and a shortened pill-free interval (15 percent); 42 active pills followed by a 7-day pill-free interval (29 percent); 63 active pills followed by a 7-day pill-free interval (72 percent); continuous active pills with instructions for the patient to take a 7-day pill-free interval if spotting occurred with uninterrupted use (35 percent); or other regimens (12 percent).

References

1. World Health Organization Task Force on Psychosocial Research in Family Planning, Special Programme of Research, Development and Research Training in Human Reproduction. A cross-cultural study of menstruation: implications for contraceptive development and use. Stud Fam Plann 1981;12:3-16.
2. Glasier AF, Smith KB, van der Spuy AM, et al. Amenorrhea associated with contraception—an international study on acceptability. Contraception 2003;67:1-8.
3. Andrist LC, Arias RD, Nucatola D, et al. Women’s and providers’ attitudes toward menstrual suppression. Contraception; in press.
4. Powell-Dunford NC, Deuster PA, Claybaugh JR, Chapin MG. Attitudes and knowledge about continuous oral contraceptive pill use in military women. Mil Med 2003;168:922-928.
5. Wiegratz I, Hommel HH, Zimmermann T, Kuhl H. Attitude of German women and gynecologists towards long-cycle treatment with oral contraceptives. Contraception 2004;69:37-42.
6. den Tonkelaar I, Oddens BJ. Preferred frequency and characteristics of menstrual bleeding in relation to reproductive status, oral contraceptive use, and hormone replacement therapy. Contraception 1999;59:357-362.
7. Association of Reproductive Health Professionals. Extended regimen oral contraceptives. Harris Poll, June 14-17, 2002.
8. Andrist LC, Hoyt A, Weinstein D, McGibbon C. The need to bleed: women’s attitudes and beliefs about menstrual suppression. J Am Acad Nurse Pract 2004;16:31-37.
9. American College of Obstetricians and Gynecologists. Gallup survey reveals women ob-gyns benefit from “insider knowledge.” ACOG news release, December 9, 2003. Available at: www.acog.org/from_home/publications/press_releases/nr12-09-03-2.cfm. Retrieved August 15, 2004.
10. Association of Reproductive Health Professionals and National Association of Nurse Practitioners in Women’s Health. Annual meeting registrant survey. August-September 2002.