Eliminating periods with continuous birth control may sound like a woman’s dream, but is it safe?
By Katherine Kam
Reviewed by Louise Chang, MD
May 17, 2007
Karen Manser hated her periods. “I just had a horrible time. They made me miserable. Sometimes I would lay curled up like a little ball in the bed in pain.” So she did something drastic: she stopped her periods cold. At 44, she hasn’t menstruated in 10 years.
Now, women are quickly catching on to what Manser has known for a long time: Menstruation is becoming another lifestyle choice.
Manser, who lives in Washington, first opted out of periods with Depo-Provera, an injectable hormonal contraceptive. Then with her gynecologist’s approval, she began taking birth control pills continuously, without the placebo break, to suppress periods.
“Life is more convenient,” she says. “You can go on vacation and not worry about it. You can wear white clothes and not worry about it. It’s just wonderful.”
But is it a good thing to banish periods?
The Era of Optional Periods
In past decades, doctors have used birth control, sometimes in unorthodox ways, to help certain patients suppress periods. But the optional period entered a new era in 2003. That year, Barr Pharmaceuticals launched Seasonale, the first FDA-approved, extended-cycle birth control pill designed to give women only four periods a year. The company has also released Seasonique, a second-generation drug that also advertises four periods annually.
Women may soon be able to stop periods even longer. If the FDA approves, Wyeth Pharmaceuticals’ Lybrel would be the first continuous birth control pill to stop periods for one year. The experimental low-dose contraceptive contains estrogen and progestin.
But menstrual suppression, as experts call it, is a hot-button iss
ue. Manser says that women are often baffled and alarmed when they find out she’s not menstruating. “They’re kind of horrified. It’s like, ‘You have to have periods because you have to shed your lining. This is terrible for you.’”
The American College of Obstetricians and Gynecologists takes no official position on menstrual suppression. But several doctors talked to WebMD about the pros and cons of eliminating periods.
What Do Doctors Say?
That first menstrual period may be cause for celebration at sixth-grade slumber parties. But for many women, the thrill fades fast when they’re beset with monthly bouts of pain, discomfort, bloating, crankiness, and the blues. Some women are so debilitated that they miss work or school.
Menstrual suppression can often ease troublesome periods or conditions that worsen around that time of month, says Sharon Mass, MD, an ob-gyn in Morristown, N.J. She has suppressed her own periods and often helps patients to do the same. “Initially, it was for patients who had medical indications, for example, a history of endometriosis, menstrual migraines, symptomatic periods with bloating, breast tenderness — things like that,” she says.
The convenience factor is a newer concept, and women are slowly coming around, says Leslie Miller, MD, associate professor of obstetrics and gynecology at the University of Washington. Miller stopped her own periods for “convenience” during a grueling medical residency. Later, she began medical research on using oral contraceptives to help women skip periods. Patients have told her that they’ve wanted to skip periods for honeymoons, vacations, and sports.
Despite the hassles, many women view menstruation positively, she says. “When you say to a woman, ‘Is the menstrual period healthy?’ they’re going to say ‘yes.’ It’s a sign that you’re young and capable of getting pregnant. There are lots of good things about being able to have periods.”
But she explains that women on birth control pills aren’t having normal menstrual periods. Because birth control pills block ovulation, women are only getting withdrawal bleeding when hormone levels drop during the week that they take placebo pills. As a result, the uterine lining breaks down and bleeding starts.
Hormones and Placebos
The makers of oral contraceptives purposely designed the 21-days-on hormones and the seven-days-on placebo pills to make women bleed to increase their comfort levels with the drugs. By replacing the placebo phase with active hormones, the newer continuous pills attempt to suppress this withdrawal bleeding.
Women can still choose to bleed if they want, for example, four times a year with Seasonale, Miller says. But there’s no medical reason that they have to go through withdrawal bleeding at all, she adds.
It’s really up to each woman to choose how often she has withdrawal bleeding, Mass says. “There’s no magic number.”
How safe are extended and continuous oral contraceptives? Advocates point to a generally good safety profile for standard oral contraceptives, which have been studied heavily since their introduction in 1960. In addition, oral contraceptives can cut the risk of endometrial and ovarian cancers and anemia, Mass says.
Still, Miller says that the long-term effects of the new regimens aren’t fully known. “When you don’t have the week off, you are going to get extra hormones.” In particular, she’s planning to study the effects of menstrual suppression on bone density. “If we drop the estrogen low enough so that you don’t bleed, are the bones OK? I think it’s going to be OK, but we don’t have proof of that.”
“Is continuous pill use an experiment? Sure,” Mass adds, “Nobody knows what’s ideal.”
Do Periods Matter?
Jerilynn C. Prior, MD, professor of endocrinology and metabolism at the University of British Columbia, takes a different view — especially when women stop menstruating for the sake of convenience.
“I think that the normal menstrual cycle is absolutely crucial to women’s health. My perspective is that the normal menstrual cycle is incredibly complex, it’s created from the brain, and it serves a general health purpose, not just a reproductive purpose.” She says that normal menstruation has beneficial effects on women’s bone and cardiovascular health.
“To reduce it to ‘periods don’t matter’ is totally unscientific,” she says.
Role of Culture
Why the interest in stopping periods? Prior says that our society rejects menstruation because it’s associated with women — and therefore, of inferior status, she says. “Our culture certainly sees menstruation as negative, a wound, something messy or dirty and to be hidden, especially from men. There’s a taboo about menstrual cycles.”
Menstruation would shoot up in status if it happened in men, she says. “Men would probably be having competitions over pad counts or who had the most regular periods.”
Prior also serves on the board of the Society for Menstrual Cycle Research, a group of researchers that includes doctors, nurses, and social scientists.
While the Society for Menstrual Cycle Research acknowledges that menstrual suppression may be useful for severe menstrual problems such as endometriosis, its web site states: “We do not believe that continuous oral contraception should be prescribed to all menstruating women out of a rejection of a normal, healthy menstrual cycle.”
So far, there’s not enough data to declare menstrual suppression safe, the group says. It calls for greater research into the health effects of menstrual suppression, including effects on bone health, risks for blood clots and strokes, and effects on fertility, among other issues.
Prior worries, too, that continuous oral contraceptive use could increase risk of breast cancer. “My impression as somebody who cares about normal physiology is that the breasts need a break from hormones each month. That’s why during menstrual flow, estrogen and progesterone levels are low.” With continuous hormones, “the breasts never get a break.
“I think that there are acceptable side effects of hormonal contraception,” she says. For example, a woman may be willing to accept increased risk of blood clots as a trade-off for preventing pregnancy. “But if you’re going to use this not as a contraceptive, but as a lifestyle thing — as something just because ‘I want to get rid of my period’ — then you have to look at the risks in a totally different light.”
How to Talk With Your Doctor
Opting out of periods is so new that doctors have no consensus on how many years a woman should go through normal menstruation before she tries menstrual suppression. Nor are there any age guidelines.
But here are some pointers to help women and their doctors to decide:
Effectiveness. Menstrual suppression isn’t a sure bet, Miller says. “It doesn’t always work. Irregular bleeding is very common, especially in the first three to six months, and that’s a hard thing to go through. A lot of women don’t get those four perfect periods.”
By six months, 70% of women on extended birth control will have no more bleeding, she says. By one year, the figure rises to 90%. Still, researchers are trying to figure out how to reduce irregular bleeding. Women who don’t want to deal with surprise bleeding may want to avoid the new drugs, Miller says.
Age. Which groups should avoid extended or continuous birth control? What about adolescents? “That’s a hard thing,” Miller says. While no age guidelines exist, Miller says that women aged 18-22 might be the youngest age group that she would recommend for prescriptions.
There’s not much research about effects on adolescent girls, but Miller expresses concerns that the drugs could affect bone density. “That’s an important consideration in girls still growing,” Miller says.
Pregnancy. If menstrual-suppressing pills are used according to instructions, they seem to work as well as standard birth control pills to prevent pregnancy, Miller says.
Without periodic bleeding, how can a woman tell if she’s pregnant? That’s a real drawback, Mass says. Miller suggests that women can do frequent urine pregnancy tests at home. “Urine pregnancy tests are very sensitive and good, so first of all, you could use a lot of that. However, the longer that women do the everyday [contraception], the more they trust it. You are very unlikely to ovulate.”
On the flip side, some women worry that they won’t be able to get pregnant if they’ve been on continuous birth control. But recent research presented in May 2006 at an American College of Obstetricians and Gynecologists’ meeting should offer some reassurance. It found that among 187 women taking the experimental Lybrel, 99% either returned to menstruating or became pregnant within 90 days of stopping the drug.
Sexually Transmitted Diseases. No birth control pills will protect against STDs or HIV infection, so women who try period-suppressing oral contraceptives may still need other forms of protection, such as having their partners use condoms.
Other Conditions. Women with certain conditions shouldn’t use oral contraceptives of any kind, for example, those with a history of blood clots, stroke, heart attack, or smokers, especially those over age 35.
SOURCES: Leslie Miller, MD, associate professor of obstetrics and gynecology, University of Washington. Sharon Mass, MD, clinical assistant professor, University of Medicine and Dentistry of New Jersey. Jerilynn C. Prior, MD, professor of endocrinology and metabolism at the University of British Columbia, Canada; scientific director, Center for Menstrual Cycle and Ovulation Research, University of British Columbia, Canada. “Return to Menses After Continuous Use of a Low-Dose Oral Contraceptive,” American Association of Obstetricians and Gynecologists, abstracts presented May 8, 2006.