It seems intuitive that women would be attached to their monthly menstrual cycle. They are taught from their early days in sex education that menstruation is a natural part of womanhood; something to be accepted and embraced as the monthly reminder of fertility. However, results from a recent study on attitudes toward menstruation and menstrual suppression suggest that the proverbial “Aunt Flo” is neither a beloved member of the family nor a welcome visitor. Women maintain little affection toward their period, and a majority would prefer less frequent menstrual cycles.
There is tremendous opportunity here to educate women about menstrual suppression. The release of Seasonale onto the market increased awareness of continuous regimens, especially for oral contraceptives. There is now greater interest in learning about and potentially using menstrual suppression therapies than in the past. But while they are ready and willing to accept a better way, women have serious questions about menstrual suppression. Some are based on an incomplete or incorrect understanding of the effects of hormones on their reproductive systems, while others, such as long-term effects, are a reflection of incomplete knowledge of taking hormones for a prolonged period of time.
- Few women have an emotional connection to their period. Most simply do not like having it, and would happy to be rid of it.
- Women are very familiar with hormonal contraceptives, especially the pill. A strong majority has used them at some point in their life, and one quarter is on them currently.
- Women are very receptive to innovations that would enable them to delay or even stop menstruation. Some would like to have it a few times a year, but many would prefer not to have a period at all.
- Compared with 2003, women are now more likely to have heard about menstrual suppression, and are more likely to say they are interested in it. This suggests that Seasonale has been fairly successful in raising awareness among women to the possibility of long-term suppression.
- However, there still remains a strong need for education. Women show surprisingly little knowledge about the effects that hormonal contraceptives have on their bodies. Women believe it is natural for a woman to have her period while on the pill, and most remain wedded to the notion of a 28-day menstrual cycle.
- The biggest obstacles toward greater acceptance of suppression are safety and cost. Women have very strong reservations toward the safety of suppression, but this can be mediated through greater education efforts. Insurance is problematic, as public care often will not support continuous use oral regimens. Providers must often trade off brand regimens with clear instructions and expensive co-pays with less expensive off-label generics and unclear instructions.
- Women already on birth control pills, women with severe symptoms, low-income women, and younger women all show signs of being particularly receptive to menstrual suppression and make particularly desirable targets for efforts of messaging and education. These are examples of women who will benefit greatly, women who will not have to make substantial lifestyle changes, and women who will not have to greatly alter their ways of thinking about their bodies.
Women Do Not Like Having Their Period
Women have a strong negative attitude orientation toward their period. They simply do not like it. They do not like the symptoms, they do not like that it is something they have to hide, and they do not like the fact that it puts them at a disadvantage relative to men. It is not something they would miss if it went away.
- Women have little affection for their period. Only 8 percent say that they enjoy their period in some ways, while strong majorities view it as something they simply have to put up with (77 percent agree). Worse yet, many believe it puts them at a disadvantage in today’s society. A strong majority of women feel that men have a real advantage because they do not have a period (74 percent agree).
- The issue for women is the nuisance factor. Women are not ashamed of their period – they do not feel any need to hide the fact that they get their period or have to purchase pads and tampons – they just see it as a major inconvenience. Only 9 percent of women said they were embarrassed to purchase menstrual products. Similarly, less than one-fifth (19 percent) said they preferred not to talk openly about menstruation. Rather, women are bothered by the impact it has on their lives. Nearly all women report having experienced cramps (81 percent), moodiness (84 percent), and bloating (81 percent). And an overwhelming majority mention times when their period has gotten in the way of their daily lives; (74 percent) of women say that their menstrual symptoms have caused them to miss sex, and nearly half of women say that their symptoms have gotten in the say of taking part in an athletic event (46 percent), a party (44 percent), or time with friends and family (40 percent.)
- When asked what their ideal menstrual interval would be, most would choose to have a period less frequently than once a month (78 percent). Nearly half, 40 percent, would prefer never to have it at all.
Many women have used hormonal contraceptives
Although there is some hesitancy toward taking hormones, it rarely seems to stop women from using hormonal contraceptives. We observe widespread familiarity with birth control pills. Many women have also tried other hormonal alternatives such as the shot and the patch.
- Many women have lingering doubts about hormones. Only 17 percent of women felt it was safe to take hormones. Over a third (37 percent) felt it was not safe, and nearly half (46 percent) were neutral on the subject.
- However, this level of concern does not seem to bar women from using hormonal contraceptives. Most women are very familiar with hormonal contraceptives, especially the pill, and have used them at some point. Over one-quarter (28 percent) are currently using them. Three-quarters (77 percent) of women have been on the pill, either currently or in the past.
- Many women have also tried other hormonal contraceptive alternatives. Roughly 1 in 5 women (19 percent) have had Depo-Provera, and roughly 1 in 10 women (11 percent) have tried the patch. Only 4 percent have ever used an IUD, and only 4 percent have used the ring.
Women Are Interested in Suppression
When presented with the idea of menstrual suppression, many women express interest. In fact, more women are interested than in the past: in the last two years, women were more likely to have heard about suppression from the television, which suggests that the Seasonale campaign and related news stories have been breaking through. In addition to the marketing, some providers observed that women have been asking more questions about suppression because they have friends and family who are suppressing their period.
- Interest in menstrual suppression is high. Given how much women dislike getting their period, it is not surprising that they would consider a suppression regime. Over half (55 percent) of women say they would be interested in stopping or delaying their period. Roughly half (49 percent) of women would be interested in learning more about stopping or delaying their period.
- Familiarity with menstrual suppression is up from 2003, and it is largely attributable to the paid and earned media from Seasonale. Women were much more likely to report having heard of menstrual suppression than they were just two years ago (45 percent in 2005 versus 28 percent in 2003). A third of women in 2005 said they had heard about suppression from the television, versus only 13 percent in 2003.
- The research suggests that providers, too, overwhelmingly favor menstrual suppression. They “think it’s great”. They point out that until recently it was something women health care providers did for themselves, but with the increased attention given to Seasonale and other continuous regimen methods, women are increasingly likely to want it for themselves.
From what I’ve read there’s absolutely no reason that you have to have a period every month. And the only reason women have a period every 28 days is because of the birth control pill. So we’ve all been programmed to think we have to have a period every 28 days or there’s something wrong. If the research is out there and they say it’s safe, you don’t have to have a period every month, there’s no reason to have a period every month, then I think it’s great. (Nurse practitioner)
Before Seasonale was on the market, the people that tended to suppress periods were doctors or nurse practitioners who knew that that was possible. (OB/GYN)
Women Know Very Little About Their Bodies
Women may be interested in suppression, but they require considerable education about the mechanics behind it. Many women are misinformed or unsure about the effects of hormonal contraceptives on the body.
- Women are fairly attached to what we learn in sex education class: namely that a “normal” menstrual cycle is 28 days long. A near majority (47 percent) of women agreed that every woman’s menstrual cycle should be 28 days or about every month.
- Women do not understand that menstrual suppression does not affect fertility. Only one-quarter of women correctly believed that suppression would not affect fertility.
- Most women are familiar with the regular birth control pill, and thus were extremely likely to agree (67 percent) that it is natural for women to have their period when they are on the pill. Indeed, most women (56 percent) did not believe that taking the pill continuously would affect their menstrual cycle.
- Nearly three-quarters (73 percent) of women have used birth control pills at some point in their life. However, usage does not seem to increase knowledge of the effect of hormonal contraceptives on a woman’s reproductive system. Only 16 percent of women who had used birth control pills agreed that taking the pill continuously stops women from having their period. In contrast, 76 percent of women who had used birth control pills agreed that it is natural for women to get her period, even if she is on the pill.
Obstacles: Widespread Concerns of Safety and Limited Access
Although the interest is there, as long as women remain relatively uninformed about the mechanics of menstrual suppression, they will continue to be skeptical of it. We observe in both the survey and the provider interview that, above all, women want assurance that suppression is safe. They also want to ensure they will be able to fully control when and if they do have a period. Finally, they want it to be affordable.
- The biggest concerns about suppression relate to safety. Women are overwhelmingly concerned that there might be side effects (88 percent worried) or long term health effects (89 percent).
- Providers echo this concern, and observe that overwhelmingly the first, and biggest, question women ask about menstrual suppression is “is it safe?”
The hardest sell is the question you asked a minute ago. Is it safe not to have a period? (OB/GYN)
- The research body on the long-term effects of continuous regimens is incomplete. Most providers note this, and the concern is also prevalent among patients. Most women feel this is a subject that needs to be researched more (75 percent agree).
I think we need to find a cohort of women kind of long term. I don’t think it’s going to be much different than the data that we have long term on birth control pills, but you know it’s still out there and we need to know about it. (OB/GYN)
- Cost is also an important consideration for women interested in suppressing their period. More than half (57 percent) of women worry that they would not be able to stop or delay their period because it would be too expensive. As we learned in the provider study, this concern is not unfounded. Many providers cannot or do not prescribe brand-name continuous regimen oral contraceptives for insurance reasons.
We don’t use Seasonale. We’d rather give them the same hormones in a cyclic preparation that we can tell them to don’t take the inactive pills and start a new pack because it is a heck of a lot cheaper than Seasonale. (OB/GYN)
[Seasonale is] like a $65-75 co-pay, depending on what insurance they have. So yeah we do use some of the other things here. (Physician Assistant)
- There is evidence that many providers prescribing continuous regimen oral contraceptives choose the off-label variety. This is in part to circumnavigate the co-pay problem of insurance, but also because many providers talked about break-through bleeding. Providers observe a lot of break-through bleeding on continuous oral regimens, especially at first. They note this can be problematic, since many women want to be able to know when their period is coming.
What I’ve done for patients who are not necessarily on Seasonale is to actually kind of build them up. So in other words, a patient who was on Ortho-Cyclin and she says, okay I want to do long term. I say, it will take 6-8 weeks first. Have a period and then keep going up each cycle length, add a week or so to try and minimize the break-through bleeding. As their body adjusts to have the long-term. So far, I’ve had good responses. (Physician Assistant)
Because women need a great deal of talking to and persuasion, many providers will not initiate the suppression conversation with women. The education burden is high among providers, and the little amount of time they have with a patient impacts their ability to effectively educate. They also may find that a daily regimen may be hard for all but the most motivated women to adhere to. Consequently, providers often employ short-cut heuristics like profiling and will offer the suppression option only to women who experience severe symptoms like heavy bleeding or those who ask about it first.
- Roughly half of providers we interviewed offer continuous regimen contraceptives to all their patients. Others indicate they wait for patients to approach them about menstrual suppression. Providers voice concern that a patient must be motivated in order to adhere to the regimen. Instead, many will profile patients depending on their insurance status and stage of life. For example, providers are far more likely to offer Depo-Provera to teenagers and younger patients than to women in their late 20s.
For some people (menstrual suppression contraceptives) would be too complicated. Too hard to keep track of. (Family practice physician)
- Providers note that women require a great deal of education about their bodies, which may be an obstacle to providers initiating the conversation of menstrual suppression with all their patients. Some opt toward Seasonale for this reason alone. It may be expensive, but providers like the packaging and the clear explanations that help with the education burden.
The misinformation about reproductive choices is amazing. I’ve heard it’s going to cause cancer, breast disease, cause this and that. And it’s still there. I’ve been in practice for 21 years and I’ve heard this all through the 21 years. There’s a lot of misinformation out there and I don’t know where they’re getting it from. (OB/GYN)
Before Seasonale was out, I used to tell women not to take the fourth week of pills, just start right away on the next pack. But once Seasonale came out, it was so much more convenient, the packaging, the instructions, the patient education. (Nurse practitioner)
- There is also the added obstacle that many women do not approach their providers with questions about suppression. Providers note that patients may ask about suppression if they have heard something about it, either from an advertisement or from a friend who has been suppressing. However, as we observe in the survey, this still remains a relatively small fraction of women. Only 26 percent have heard about suppression from friends, and only 37 percent have seen advertisements on television. Although the numbers have increased from 2003, most women (55 percent) still have never heard of suppression. They simply do not know that they can ask the question.
- As discussed earlier, many women must deal with added costs from insurance that does not cover birth control. However, providers also observe that insurance programs and pharmacies have trouble filling the prescriptions. Providers who hoose to put patients on off-label cyclics, not necessarily tailored for continuous regimen, note that some insurance programs will not allow pharmacies to give women all the packs they need for a continuous regimen.
You need more than 12 packs, it takes 15 packs to get it for continuous. You end up with their insurance will only give them one pack a month, and they end up not being able to achieve that. So if I have samples, I’ll do that and that will determine what product I’ll give them because I’ve got samples in the office. And even if you write continuous on the prescription, sometimes the patient will say they still have a problem trying to get it. (OB/GYN)
While many women are receptive to suppression, there are certain subgroups that are more receptive than others. In particular, those who will benefit greatly, will not have to make substantial lifestyle changes, or greatly alter their way of thinking make desirable targets. Consistent with provider interviews, the survey data suggests that there is in fact a “suppression profile” of women who suffer greatly from their periods and would benefit from fewer of them. Interestingly, educated women and higher income women make less good targets than their less privileged counterparts, who carry fewer assumptions of a way a woman’s body is supposed to be. It is appealing to women already following a daily regimen to have the added bonus of no period by doing nothing different.
- Women with severe menstrual symptoms. The women most interested in suppression tend to fit an attitudinal profile, characterized by extremely negative attitudes toward their period. They are more likely mention more serious symptoms, and more likely to complain that it interferes with their daily life.
- Women most interested in suppression do not enjoy their periods. Nearly two-thirds (63 percent) strongly disagree with the statement “In some ways I enjoy my periods, versus 31 percent of women not interested in suppression.
- Women most interested in suppression feel they have to make adjustments when they are having a period (60 percent, versus 37 percent of women not interested in suppression).
- Women most interested in suppression are much more likely to say they often suffer from severe menstrual symptoms such as heavy bleeding (47 percent, versus 26 percent of women not interested in suppression) and really bad cramps (46 percent, versus 26 percent of women not interested in suppression).
- Low income women. Low income women are more likely than their well-to-do counterparts to voice interest in delaying their period. Unfortunately, these women are also those least likely to have access to private health care insurance.
- Nearly one-third (31 percent) of women with incomes less than $20,000 are very interested in delaying their period, versus only 18 percent with incomes greater than $60,000.
- However, low-income women are less likely to have access to health insurance that will support continuous regimens. Only 28 percent of women with incomes less than $20,000 have private insurance, versus 97 percent of women with incomes $100,000 or more.
- Among women who had used birth control pills for some reason other than contraception, only 4 percent of women with less than $20,000 had used them to stop their period, versus 27 percent of women with more than $100,000.
- Younger women. Still in “learning mode,” women 18-24 are more interested in ways to make their life more convenient. They look forward to the day when they can get through it quickly and painlessly, and are more open to innovations that can help them achieve that end.
- Younger women find it appealing to be able to decide when or if to have a period (51 percent, versus 42 percent of women 35-40).
- Younger women are more likely to say they hope for a day when they will be able to get through their period in a few minutes (55 percent, versus 41 percent of women 35-40).
- Younger women are much less averse to taking hormones than their older counterparts (30 percent felt it was unsafe to take hormones, versus 46 percent of women 35-40).
- Women already on birth control pills. Promisingly, women who are most primed for success on a continuous regimen, those who already adhere to a daily regimen, are also more likely to show interest in suppression. Moreover, women already on birth control pills were far more likely than others to understand the impact of the hormones on their reproductive system.
- Two-thirds (66 percent) of women who use oral contraceptives as their primary method of birth control were interested in delaying or stopping their period (versus 49 percent of women who had never used oralcontraceptives
- Women on who use oral contraceptives as their primary method of birth control were less likely than women who had never been on the pill to believe the myths about women’s health and contraception (40 percent versus 62 percent, respectively, had 4 or more incorrect responses to facts about menstruation).
The above summary is based on two rounds of research. We conducted a web survey of 1,021 women 18-40 who had not had hysterectomies and were not trying to get pregnant. Respondents were selected randomly from a panel of Knowledge Networks research participants. The Knowledge Networks panel is based on random-digit-dial sampling of the full United States population and represents people with and without their own Internet access. The survey was conducted July 8-13, 2005 and has a margin of error of +/- 3.1 percentage points. We also conducted in-depth interviews of 25 OB/GYNs, primary care physicians, nurse practitioners, and physician assistants who have patient contact and prescribe contraceptives.