Choosing When to Menstruate: The Role of Extended Contraception

Association of Reproductive Health Professionals

Updated on April 13, 2004

Program Description

Choosing to Menstruate began in December of 2001 when the Association of Reproductive Health Professionals (ARHP) hosted a panel of experts to examine the issue of “what is normal” when it comes to menstruation. The convened experts identified cultural and social issues in this paradigm, including a preliminary discussion about health benefits and potential side effects of continuous use of oral contraceptive.

ARHP’s Extended Contraception Expert Medical Advisory Committee developed the CME curriculum and patient education based on the outcomes of national and clinician surveys, roundtable discussions, and current research on extended regimen contraception. This curriculum is basis for our 2004 visiting faculty program.

This program is made possible through an unrestricted educational grant from Barr Laboratories.


Program Components

ARHP is placing 12 sessions at various national venues. Some sessions are still available. If your institution is interested in hosting a presentation, please fill out a Choosing When to Menstruate lecture request form or call Cynthia Lopez at (202) 466-3825.

ARHP’s Menstrual Suppression Study evaluated women’s and health care providers’ attitudes toward menstrual suppression with extended use oral contraceptives through qualitative and quantitative surveys. The survey was conducted in three parts: 1) written survey of women (1,500), 2) clinician interviews of women (18), and 3) written survey of health care providers (500). The women surveyed were English-speaking, between the ages of 18 and 40; had a uterus and ovaries; had menstruated for at least one year since menarche; and neither were pregnant and nor attempting pregnancy.

National Survey
In July–August 2002, ARHP conducted a nationwide survey to examine women’s attitudes and experiences regarding monthly menstruation, including the use of contraceptives to control the frequency of menstruation.

ARHP/NPWH Clinician Survey: In a further effort to gain insight from clinicians about menstruation and continuous-regimen contraception, registrants of ARHP’s and NPWH’s annual meetings were surveyed in September 2002.

ARHP/NPWH Roundtable Discussions: Two linked clinician roundtable meetings co-sponsored by ARHP and the National Association of Nurse Practitioners in Women’s Health (NPWH). Highlights of the meeting proceedings and additional educational and practical content are summarized in a special joint edition of Clinical Proceedings: Choosing When to Menstruate: The Role of Extended Contraception.

Visiting Faculty Program
The results of the information from ARHP/NPWH roundtable discussions are the basis of a clinical curriculum on extended-regimen contraception. This clinical curriculum features information on counseling issues, clinical

The results of this meeting are published in a Special Edition of The Female Patient®: Continuous Use of Oral Contraceptives.

Learning Objectives

  1. Describe the impact of menstruation on lifestyle and medical conditions
  2. Name five health advantages of medically regulating menstruation
  3. Name four types of candidates for extended-regimen contraception
  4. List six hormonal methods for reducing bleeding
  5. Describe obstacles to health care providers prescribing and to women using extended contraceptives


Summary and Recommendations


More women are becoming interested in reducing or eliminating their periods.1 For example, the majority of the women in the 1996 Dutch study and the women interviewed through the Harris poll in 2002 preferred to menstruate less than once a month or never.2,3 Also, according to recent research by Sulak et al. and Miller et al., the majority of women who try an extended regimen choose to continue with it.5,6

Providers are also recognizing the benefit of extended contraception. Of the 117 ARHP and NPWH’s meeting registrants who were surveyed, 77 percent said they prescribed extended contraceptives.4

Yet, numerous barriers to regulating menstruation still exist. With the release of Seasonale®—a dedicated product for extended contraceptive use—some of these barriers, such as acceptability, awareness, insurance coverage, and safety, will be lessened. However, increasing the awareness and knowledge of health care providers and women about extended contraceptives and creating counseling tools for providers are also essential. Recommendations include:

Educate providers about regulating menstruation:

  • Benefits and effects of regulating menstruation
  • Surveys on women’s attitudes and beliefs about menstruation and regulating it
  • Various hormonal therapies to alter menstruation and related research
  • Different cultural values and beliefs about menstruation

Improve patient counseling:

  • Explaining the female reproductive system and the effect of extended contraception on the system
  • Addressing myths about the need to menstruate
  • Developing better counseling tools for providers
  • Describing the endometrial safety of extended use of combination hormone therapy

Increase the awareness and knowledge of women about extended contraception, through provider counseling and media venues:

  • Need to menstruate while on contraceptives
  • Ways to alter menstruation
  • Health and lifestyle advantages to regulating menstruation
  • Research findings on health effects of extended contraceptive methods

Conduct further research to answer questions:

Extended Regimen Method

  • What patterns of bleeding can women expect with extended use over time
  • Is an extended regimen appropriate for new oral contraceptive (OC) users?
  • What are the health effects, if any, of the long-term use of extended contraceptives?


  • How can health providers counsel women on taking OCs consistently?
  • What are the cultural differences in how women and families view menstruation?
  • How do women feel about spotting with the extended regimen?

Facilitating an Extended Regimen

  • How can providers best integrate the extended use of contraceptive regimens into their practices?
  • How can pills be packaged to make them easier to take?
  • How can the cost of extended OC regimens be reduced?

Women should be able to choose whether and how to regulate their menstrual cycles. To choose, they and their providers need to be knowledgeable about the benefits and risks of various extended regimens. Providing women with this choice has the potential to improve not only their reproductive health but also the quality of life during their reproductive years.

  1. Association of Reproductive Health Professionals. Continuous use of oral contraceptives. A supplement to The Female Patient, April 2002.
  2. den Tonkelaar I, Oddens, BJ. Preferred frequency and characteristics of menstrual bleeding in relation to reproductive status, oral contraceptive use, and hormone replacement therapy use. Contraception 1999;59:357-362.
  3. Association of Reproductive Health Professionals. Extended regimen oral contraceptives. Harris Poll. June 14-17, 2002.
  4. Sulak PJ, Kuehl TJ, Ortiz M, et al. 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.
  5. Miller L, Notter KM. Menstrual reduction with extended use of combination oral contraceptive pills: randomized controlled trial. Obstet Gynecol 2001;98(5 Pt 1):771-778.
  6. Association of Reproductive Health Professionals and National Association of Nurse Practitioners in Women’s Health. Annual meeting registrant survey. August-September 2002.



Author: Leslie Carol Botha

Author, publisher, radio talk show host and internationally recognized expert on women's hormone cycles. Social/political activist on Gardasil the HPV vaccine for adolescent girls. Co-author of "Understanding Your Mood, Mind and Hormone Cycle." Honorary advisory board member for the Foundation for the Study of Cycles and member of the Society for Menstrual Cycle Research.