ESSAY
Essay
Nuisance or natural and healthy: should monthly menstruation be
optional for women?
Sarah L Thomas, Charlotte Ellertson
It is simplicity itself to eliminate menstruation with safe,
inexpensive, and widely available oral contraceptive
tablets. Yet monthly menses continue to be the standard
for women. Why? Any woman can tell you that
menstruating is a pain, literally and metaphorically. At a
minimum, it is a nuisance that requires planning and
expensive sanitary supplies and paracetamol to avoid
messy discomfort for about 1 week each month. In many
cases, however, menstruation has a far greater impact on
the female half of the population. It can debilitate, and it
constitutes a significant and largely unacknowledged cost
to society, according to a lively and provocative new book
by Elsimar Coutinho and Sheldon Segal.1 Menstrual
disorders are by far the leading cause of gynaecological
morbidity reported in the USA, outnumbering their
nearest competitor (adnexal masses) by a factor of three,
and affecting nearly 25 million American women
anually.2 The effects extend beyond individual women to
society more generally, including through the workplace.3
Menstrual disorders cost US industry about 8% of its
total wage bill. Expenses are particularly concentrated in
sectors that employ predominantly women. For example,
Texas Instruments found a 25% reduction in the
productivity of female workers during the paramen-
struum. Most treatments for conditions caused or
exacerbated by menstruation are symptomatic, with little
attention paid to the underlying causeie, the menstrual
cycle itself and its hormonal fluctuations. Women are
expected to function as usual, with minimal attention paid
to managing the physical and mental pain and discomfort.
This is surely an anomaly in modern medicine. There can
be no other disease or condition that affects so many
people on such a regular basis with consequences, at both
the individual and societal level, which is not prioritised in
some way by health professionals or policy makers.
Monthly menstruation has been socialised and
mythologised into being the unquestioned natural,
normal, and beneficial state for women. Perhaps early
observations that the week of menstrual bleeding itself
accompanied relief of many premenstrual or catamenial
discomforts in women led to the false conclusion, in an
age where few therapeutic options were available, that
induced bleeding generally must be healthful. Indeed,
The Lancets name reflects the prominence of this almost
universally harmful medical practice in previous centuries.
This historical mindset of bleeding being good may
explain why the consequences and discomforts associated
Lancet 2000; 355: 92224
Population Council, Latin America and the Caribbean, Regional
Office, Escondrida 110, Col. Villa Coyoacn, Mexico 04000,
DF, Mexico (S L Thomas BA, Charlotte Ellertson PhD)
Correspondence to: Charlotte Ellertson
(e-mail: cellertson@popcouncil.org.mx)
922
with monthly bleeding in women have not to date
afforded the same investment and scrutiny as conditions
that are considered unnatural.
Health professionals and women ought to view
menstruation as they would any other naturally occurring
but frequently undesirable condition. This means
providing those women who want it with safe and effective
means to eliminate their menstrual cycles, contributing to
happier, less encumbered lives and helping women
individually and society as a whole. The required
technology is simple: ordinary oral contraceptives that we
have had for 40 years, which have been studied extensively
in huge cohorts of women and over long periods of time,4
and that now contain such low doses of oestrogen that
there are scarcely any women for whom they are con-
traindicated.5 Continuous use of ordinary contraceptives
ie, discarding the seven placebo tablets typically packaged
with every 21 active pills and taking the active tablets daily
for months on end rather than in the usual schedule of 3
weeks on, 1 week off (or 21/7), regulates hormonal
fluctuation and eliminates bleeding (except some
occasional break-through spotting). Using oral
contraceptives in this way safely lets women control their
hormonal profiles as well as whether and when they choose
to bleed. Suppression of bleeding by this mean is in fact
already practised in special circumstances where the
inconvenience and disruption of menstruation is especially
consequential, such as for healthy women competing in
athletic competitions or going on their honeymoons, as
well as for women for whom bleeding poses a severe
sanitary problem, such as for individuals with severe
mental disabilities. Unfortunately however, for most
women, the fact that they can suppress their periods on an
ongoing basis remains one of medicines best-kept secrets.
Is menstruation really natural?
Monthly menstruation for decades on end is not the
historical norm. Women in prehistoric times, as estimated by
research among contemporary hunter-gathered populations,6
probably had far fewer periods (about 160 ovulations over
their lifetime) than modern women. Our foremothers
most likely experienced later menarche (around 16 years
of age), earlier first births (195 years), frequent
pregnancies (on average six livebirths), and long periods
of breastfeeding between pregnancies, with births at
intervals of 3 years. By contrast, the modern woman living
in an industrialised country begins menstruating earlier
(on average 125 years of age for American girls), first
gives birth later (24 years), has fewer pregnancies (two or
three), scarcely breastfeeds (3 months per birth, with half
of American infants never breastfed at all), and undergoes
menopause later. She can expect about 450 periods in her
life. Current menstrual patterns are in this sense new and
unproven as to their health effects.
THE LANCET Vol 355 March 11, 2000

Furthermore, there is plenty of modern evidence that
amenorrhoea is often healthier than the alternative.7 If a
woman is not menstruating, she is probably also avoiding
the sharp changes in hormone levels that regulate this
bleeding. Measures to eliminate these fluctuations may
help some women to avoid those mood and personality
changes of premenstrual syndrome (PMS) that do not stem
from problems with the receptors for these hormones. In
addition, diseases directly caused by menstruation such as
endometriosis would improve; and catamenial conditions
(such as epilepsy and arthritis) would not worsen cyclically.
Frequent ovulation and menses also contribute to anaemia,
some reproductive cancers and heart disease, as well as
other health threats. Anaemia in turn has been shown to
hinder learning; similarly endometriosis causes great
discomfort, contributing to painful intercourse and
infertility among other conditions.
Obviously, our ancestors did not accomplish their long
menstruation-free intervals by the artificial use of
hormones. But by re-examining the credo that frequent
and prolonged menstruation is the natural state, it is
easier to see menstrual management using oral contra-
ceptives as just another medical therapy, akin to daily and
continuous pharmaceutical management of hypertension
or benign prostatic hypertrophy for men. The latter is
an extremely common condition among older men that
was traditionally managed surgically, but is increasingly
handled by ongoing medication. Modern medicine is all
about the artificial control of conditions that range from
the life threatening, debilitating, and uncomfortable to
matters of mere taste. Eye glasses, insulin, fluoridated
water, and now perhaps Viagra, are just a few examples.
The use of hormone replacement therapy (HRT) is a
closely related example. HRT has been widely accepted
by women and health professionals and provides undis-
puted protection against certain conditions. Suppression
of menstruation is no different, and in some ways more
beneficial. It not only gives relief from menstrual-related
disorders to individual women, but it also confers
additional health benefits and gains to society.
Cultural biases against medicalising
menstruation
There is still, however, some way to go before widespread
acceptance of the idea that menses should be optional
and convenient. Women and health professionals are
conditioned to think of monthly menstruation as the holy
grail of womanhood. Birth control pills themselves, for
contraceptive purposes, have now been accepted for many
years, but there was a sensitivity among their earliest
marketing executives to the psychological importance to
women of the monthly bleed. The classic 21/7 schedule
of oral contraceptive use was designed to mimic the
normal menstrual cycle, even though it was unnecessary
(other than perhaps to reassure women pioneering this
new technology each month that they were not
pregnantsomething easily handled today with home
pregnancy urine dipsticks which can be used as needed).
Users of oral contraceptives experience a withdrawal
bleeding or pseudo period for 1 week out of each 28
days, substituting in the minds of many women for
menses. This schedule is supposedly easier for doctors to
explain and for women to understand.
Actually, the bleeding that oral-contraceptive users
experience each month bears little biological resemblance
THE LANCET Vol 355 March 11, 2000
ESSAY
to a menstrual period. Indeed, there is scarcely any built-
up uterine lining to be shed for these women. Rather, the
bleeding results from a drop in the hormone levels after
the 21st day when the woman stops taking active tablets
and switches to placebo. Women who use oral
contraceptives and feel that they are maintaining a
normal or natural cycle are being duped. There is no
evidence of any health benefit to taking the placebo tablets
for 1 week each cycle. Women taking oral contraceptives
might as well be told that with the exact same health risk-
benefit ratio, they could eliminate bleeding completely by
discarding the placebo tablets in each pack and using the
other tablets continuously. In this vein, even if convincing
health-based arguments touting the benefits of true
menstruation could be marshalled, the millions of women
currently using oral contraceptives to control their fertility
are already not menstruating in any medical sense. These
women at least should be offered the option of eliminating
the useless bleeding and related iron-deficiency anaemia
and other drawbacks they experience each month,
courtesy of the drug company marketing departments.
Such women should not feel alarmed that they are not
really menstruatingthe few health-based theories
supporting true menstruation do not convince; far more
evidence points to the protective properties of oral
contraceptive use and the advantages of being
amenorrhoaeic. As to the most significant popular fear
that of monthly shedding as protection against cancer
even true menstrual bleeding involves shedding only the
top layer of the endometrium, and not the basal layer
where cancer can start.
Women adapt to new technologies quickly. Once
informed about how to use oral contraceptives for
extended periods of time and the benefits involved,
women could use pills to adjust their cycles as convenient.
To date, in the clinical trials where continuous use has
been offered, women tend to like it.8,9 In more widespread
clinical practice, women most harmed by their cycles
might choose to suppress their periods for years at a time.
Others might simply reduce their annual number of
bleeds. Indeed, in the USA, the new Seasonale brand of
oral contraceptives will be specifically marketed for
continuous use over 3 months.
Criticisms of this view
There are of course some problems with this approach.
First, viewing menstruation as unnecessary and
medically controllable in some way pathologises it for
all women, even those for whom it is simply a practical
nuisance rather than the cause or correlate of serious
health problems. Rather than a natural event with
unpredictable and varying consequences, menstruation
might be viewed as a sickness and women who opted
not to suppress their cycles, and therefore to menstruate
naturally, might face censure. In fact, suppression
should be just one option for women, and those who
choose not to avail themselves of it certainly deserve to
have their choices respected and accommodated in
society, just as do women who choose to use natural
family planning methods in place of hormonal ones,
or natural menstrual sponges in place of commercial
tampons or sanitary pads, for instance. By extension,
treating the cycle as something undesirable that routinely
requires medical correction may give ammunition to
those who would like to discriminate against all women,
by barring them from high-paying jobs that require
923
ESSAY
consistent performance around the month, for instance.
But taking the opposite view, that menses, even
debilitating ones, are normal, stigmatises menstrual
disorders and deprives millions of women of legitimate
and easily available help.
Second, some may argue that synthetic hormones can
never approximate the fine balance created by the body.
Indeed, for certain women, particular synthetic hormonal
regimens may end up exacerbating the symptoms of PMS
or inducing other unwanted side-effects. Being wary of
technological approaches to achieve a desired natural years of discussion about this topic, and for sharing their books and
state, however, does not explain why the hormone
fluctuations associated with natural menstruation are
healthful or even benign for most women.
Third, some might opine that many of the same issues
that are problematic with regard to the use of oral
contraceptives taken for fertility control would also pose
problems for women taking the pills continuously for
control of their menstrual cycle. Forgotten pills that leave
women vulnerable to unwanted pregnancy and the lack
of protection offered by pills against sexually transmitted
diseases are two problems for women using oral con-
traceptives for family planning. In each case, however, the
pills cannot be expected to offer more than they are
designed to: they will generally work for women who use
them as directed for the purpose(s) promised. Particularly
for women already using pills for contraception, moving
from a 21/7 schedule of contraceptives to continuous
use does not change the need for information about the
importance of taking the pills correctly and protecting
oneself from infection.
Conclusion
Despite these counterarguments, menstrual control with
oral contraceptives could substantially improve womens
health and concurrently constitute a gain for society.
924
It may not be for all, but at the very least, health
professionals and women should know about the option
and its potential benefits. When such a safe, simple,
and inexpensive treatment is already so widely available,
women should not have to be driven loony by their lunar
cycles if they prefer not to bleed each month.
We thank: Kelly Blanchard, Christine Ellertson, Sandra Garcia, Angela
Heimburger, Paull Hejinian, Kristine Hopkins, and Annik Sorhaindo for
valuable assistance with earlier drafts of this essay; Sheldon Segal and
Elsimar Coutinho for their ideas and suggestions imparted over many
articles filled with much of the research that inspired and informed this
essay; and finally, Martha Campbell for her encouragement and ideas.
References
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University Press, 1999. Updated and translated from an earlier work
in Portuguese by EM Coutinho entitled Menstruao, a Sangria
Intil. Sao Paolo: Editora Gente, 1996.
2 Kjerulff KH, Erikson B, Langenberg PW. Chronic gynecological
conditions reported by US women: findings from the National Health
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3 Dalton K, Holton W. Once a month, 6th rev edn. Alameda, CA:
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4 Beral V, Hermon C, Kay C, Hannaford P, Darby S, Reeves G.
Mortality associated with oral contraceptive use: 25 year follow up of
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8 Loudon NR, Foxwell M, Potts DM, Guild AL, Short RV.
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