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REVIEW

The Obstetrician
& Gynaecologist

2003;5 134-7

Keywords
benefits,
elimination,
menstruation,
regulation,
symptoms.

Life 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 t o women and society. Contraceptives, including the
combined oral contraceptive pill (COC), can be used t o 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 potential for eliminating menstruation. Monthly periods
should be a woman's choice, not her 'curse'.
introduction
For many women, eliminating menstruation
would lead to an improvement in their quality
of life. Menstruation is often accompanied by
both physical pain and mood swings that can be
disruptive or debilitating, to say nothing of the
inconvenience and cost of managing the
monthly bleed with sanitary supplies. In
addition menstruation is associated with the
worsening of a number of conditions including
migraines, porphyria, epilepsy and pelvic pain
(mainly due to endometriosis)
Menstrual
disorders affect nearly 2.5 million American
women annually and are the most commonly
reported gynaecological complaints.' Thirtyone percent of women report spending 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 consulted a doctor about menstrual
symptoms in the last year.' Clearly,
menstruation is not only costly and
inconvenient for many women, but is also the
cause of a significant cost to society.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

Author details
Kelly Blanchard MSC, Program
Associate, Population Council, Po
Box 411744, Craighall 2024,
Johannesburg, South Africa. ernail:
kblanchardOpcjoburg.org.za

34

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 women
reported spotting. T h e frequency of these
complaints went down with continued use of
the regimen." More than 20 years later a similar
regimen, using a much lower-dose COC
formulation, may soon be commercially
available. Seasonale" (Barr Laboratories Inc.,
Pomona, NY, USA) will be marketed in the
USA for continuous use for three months.' This
combined ethinyloestradiol and levonorgestrel
regimen is currently under review by the US
Food and Drug Administration (FDA)." Other
studies have confirmed that these regimens are
acceptable and have shown that continuous
regimens can also lead to significant reductions
in menses-related complaints like migraines
among COC users.'
In addition to modified use of COCs, a number
of other contraceptive products can lead to
amenorrhoea. After one year approximately 50%
of women using depot medroxyprogesterone
acetate (Depo-Provera", Pharmacia Ltd, Milton
Keynes, UK), a three-monthly progestogen-only
injectable contraceptive, will be amenorrhoeic.
This percentage may increase with longer
duration of use."' Early follow-up injections and
supplemental oestrogen may accelerate the
onset of amenorrhoea, 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 theoretically the time
between injections could be reduced to provide
continuous levels of hormones adequate to
eliminate menstruation. This method may be

0 2003 Royal College of Obstetricians and Gynaecologists

rather cumbersome for women because it


would mean quite frequent injections (more
than one injection per month).
The levonorgestrel-releasing intrauterine system
(IUS) Mirena* (Schering Health Care Ltd,
Burgess Hill, UK) is an extremely effective
contraceptive.
Studies
indicate
that
approximately one-third of women using this
IUS will not have periods at all and women who
do will have significantly lighter periods. After
three months, blood loss among women 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
methods, women choosing any of the above
methods should be told that these highly
effective contraceptive methods do not protect
against sexually transmitted diseases, including
HIV.

Health benefits
Regulating or stopping menstruation can
eliminate some health problems and has
potential health benefits. 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,
eliminating menstruation can prevent the
recurrence of catamenial conditions (such as
epilepsy and arthritis) that often worsen
cyclically, with the changes in hormone levels
associated with menstruation.' For example,
endometriosis symptoms are aggravated by
menstruation. Endometriosis is associated with
severe abdominal pain, pain during intercourse
and infertility. Clinicians have prescribed
continuous COC use as a treatment for
endometriosis 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 menstruating women in
industrialised 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 number of reproductive cancers.'

Natural or optional?
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 menstruation has been seen as
'natural'- nature's treatment for the variety of ills
that affected women (including abdominal
cramps, depression and mood swings), which
today we understand are actually caused by the
hormonal changes leading up to menstruation.
The 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
natural. John Rock, one of the original
developers of COG, was a devout Catholic and
wanted a method that worked 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
Catholic Church as a natural contraceptive
method." 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.

REVIEW
The Obstetrician
& Gynaecologist
2003;5:34-7

But what is natural? Coutinho and Segal explain


that women today have many more menstrual
periods than women 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
their lifetime, compared with 150 among
hunter-gatherer women.They argue that current
patterns of menstruation are not natural at all.
But does it matter if menstruation is natural or
not? Menopause occurs naturally and clinicians
prescribe hormone replacement therapy to
manage the symptoms. I t could be that
debunking the myth that menstruation is natural
may help support the notion that it is no
different to other 'natural' medical conditions,
like headache, that are managed pharmaceutically."'
Research has shown that women would prefer
to menstruate less fiequently. In a Dutch study,
most women of 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

35

REVIEW

The Obstetrician

8!Gynaecoogist
2003;5:34-7

category more than 25% reported they would


prefer to never menstruate. Reports from trials
of extended COC use have confirmed that
women like the method..g

Barriers t o choosing not t o


menstruate
There are a number of barriers to more
widespread adoption of active regulation or
elimination of menstruation. Studies on the
introduction of other reproductive health
technologies, like emergency contraception, have
found providers slow or actively averse to sharing
necessary information with their patients.. If
providers are wedded to the idea that regular
menstruation is natural, convincing them to share
information on actively regulating menstruation
with women is likely to be difficult. Providing
information directly to women would help to
overcome this hurdle.Women could easily modify
how they take their COCs or choose another
hormonal method, like depot medroxyprogesterone acetate or the levonorgestrel-releasing
IUS, that when used as labelled or recommended
induces amenorrhoea. But, again drawing h m
the emergency contraception experience, a
dedicated product like Seasonale will make
provider prescribing and patient access easier.
Current COCs were developed with little input
from women. However, reproductive health
product development has shifted to include userperspectives earlier in the product development
process. Additional research on womens 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 menstruation altogether.
Moving COCs from solely a contraceptive
method to more 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 or loss of libido.
A potential increase in market share could
encourage COC manufacturers to label their
products for regulating menstruation, 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 making
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 longterm experience with their use. Increasing

36

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 nlisinformation about the risks of long-term use.There is
a significant body of data on the long-term safety
of hormonal methods of contraception. Yet
studies have shown that many women believe that
use of these methods is not safe and in some cases
believe it might even be dangerous. Providers
need to give women the most up-to-date and
accurate information so that they can make
informed choices, whether 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 women.
Many of the beliefs and practices around
menstruation are rooted in cultural constructs of
womens place in society. I t is likely that taboos
regulating menstruating womens behaviour and
cultural constructs of the meaning of
menstruation will be slow to change. For
example, in some cultures menstrual blood is
seen as a pollutant and menstruating women
avoid sex and may not cook meals for the
household. O n the one hand, eliminating
menstruation might fiee women from such
proscriptions but it might also raise suspicion, or
women might find such proscriptions useful and
appealing and might not want to eliminate
menstruation. Most research on the acceptability
of eliminating or regulating the frequency of
menstruation has been conducted in
developed/western countries and additional
research in a variety of contexts is needed.
The idea that menstruation treated womens
complaints or represented the elimination of
harmful toxins took hundreds of years to be
challenged. But, like any new technology,
information will provide the key to more
widespread acceptance and adoption. Again,
further research into womens 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 of menstruation, like
reduction of anaemia,are likely to be significant 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 home pregnancy tests if she is worried that she
may be pregnant, in many places these might not
be physically or financially accessible.

Treating menstruation as a 'pathology' o r


inedicalising it may raise issues of potential
discriniination against women. It raises the danger
that regular menstruation will be seen as a
debilitating condition and used as a reason to bar
women from demanding jobs that require
continuous performance."' Menstruation should
be recognised as an individual experience - for
some women it niay be the cause ofserious 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 on this option but
rather the choice to menstruate, like decisions to
use contraception or hormone replacement
therapy for example, should be accommodated.

Conclusions

decision. T h e technology exists for a woman to


eliminate menstruation and perhaps significantly
improve her quality of 1ife.Whatever an individual
woman's circumstances menstruation should be a
woman's choice not her 'curse'.

The Obstetrician
& Gynaecologist

2003;5:34-7

Clark TJ, Gupta JK. Outpatient hysteroscopy. The


Gynaecologist
i
2002;4:217-21.
Obstetrician &
The above article published in Volume 4 Number

4 (October 2002) contained an error, for which

we apologise. In Figure 1 the continuous line


should represent endometrial cancer and the
broken line should represent endometrial
disease, as represented here.

, 99

1 --

Many women, armed with complete information


on their options, will not choose to eliminate
their monthly periods.Taking a pill every day may
be inconvenient or a woman niight experience
hormone-related adverse effects. However,
wonien should be given the option of making a
personal cost-benefit calculation. Individual
women should be given complete and accurate
infornlation so they can decide whether taking a
pill each day is preferable to their monthly
experience of menstruation. Clearly, for niany
women who experience significant discomfort, o r
even serious health problems, related to
menstruation the calculation niay be easily made.
For others, information about the potential health
benefits of not menstruating niay influence their

REVIEW

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Pretest
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Post-test
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Endometrial cancer

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