Menstrual suppression

Menstrual suppression refers to the practice of using hormonal management to stop or reduce menstrual bleeding. In contrast to surgical options for this purpose, such as hysterectomy or endometrial ablation, hormonal methods to manipulate menstruation are reversible.

There are a number of medical conditions for which fewer menstrual periods and less blood loss may be beneficial.[1][2] In addition, suppression of hormonal cyclicity may benefit menstrual-related mood disorders or other conditions which increase in frequency with menses.[3] Management of menstruation may be a challenge for those with developmental delay or intellectual disability, and menstrual suppression can benefit individuals with specific job or activity-related needs.[1][4] There is increasing attention being given to menstrual suppression for individuals who were assigned female at birth, but whose gender identity is male, and who may experience dysphoria with menstruation.[5] Menstrual suppression is also being used by individuals with a variety of personal reasons to have less frequent or no menses, including honeymoon, vacations, travel, or other specific reasons.

Most options for the suppression of menstrual bleeding are not immediately 100% effective, and with many options, unscheduled bleeding (termed "breakthrough bleeding") can occur; for many options for menstrual suppression, breakthrough bleeding becomes less frequent with time.[6]

Medical uses

Hormonal therapies to reduce or stop menstrual bleeding have long been used to manage a number of gynecologic conditions including menstrual cramps (dysmenorrhea), heavy menstrual bleeding, irregular or other abnormal uterine bleeding, menstrual-related mood changes (premenstrual syndrome (PMS), or premenstrual dysphoric disorder (Menstrual suppression)), and pelvic pain due to endometriosis or uterine fibroids.[1][7][8][2][9] Medical conditions that are associated with anemia or excessive blood loss, including sickle cell disease, iron deficiency anemia, Fanconi anemia, von Willebrand disease, low platelets (thrombocytopenia) from immune thrombocytopenia, or other blood/hematologic disorders such as clotting factor deficiencies could all benefit from menstrual suppression.[1][2] In patients with malignancies who will receive chemotherapy that could result in low blood counts or anemia, or individuals with recurrent malignancies who will receive a stem cell transplant, excessive menstrual bleeding during this treatment could be medically serious, and thus menstrual suppression might be indicated.[1][10] In addition, there are a number of other medical conditions with menstrual exacerbation that may benefit from menstrual suppression, including catamenial seizures, menstrual migraine headaches, irritable bowel syndrome, asthma.[1]

Menstrual hygiene issues, as in those individuals with developmental delay or intellectual disability or other manual dexterity or mobility/wheelchair challenges such as spina bifida or cerebral palsy may prompt an individual or caregiver to request menstrual suppression.[11][12] Job or activity-related indications for menstrual suppression may include deployed military as occurred during Operation Desert Storm, travel, wilderness camping, or athletes with concerns about menses occurring during competition or training.[1] There is also a growing recognition that some individuals who were at assigned female at birth, but who now identify as male (transgender men) or non-binary, may experience dysphoria with menses, and thus may request medical therapy for menstrual suppression.[13][14]

Contraindications

The use of hormonal methods containing estrogen (combined oral contraceptives, the contraceptive patch or contraceptive ring), may be associated with risks that outweigh benefits for individuals with specific medical problems, such as migraine headaches with aura, a history of breast cancer, or a history of deep vein thrombosis.[15] Thus these options would be contraindicated for menstrual suppression with such conditions. Progestin-only options (depot medroxyprogesterone acetate, oral progestins) are appropriate for these individuals. Drug-drug interactions are also important to consider, particularly with combined hormonal options.

Safety

Because extended cycle regimens of combined hormonal contraceptives provide a greater cumulative dose of steroid hormones, questions have been raised about their safety. Data currently provide reassurance that these options are safe.[7][8][16]

Options

While some forms of birth control do not affect the menstrual cycle, hormonal contraceptives work by disrupting it. Progestogen negative feedback decreases the pulse frequency of gonadotropin-releasing hormone (GnRH) release by the hypothalamus, which decreases the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) by the anterior pituitary. Decreased levels of FSH inhibit follicular development, preventing an increase in estradiol levels. Progestogen negative feedback and the lack of estrogen positive feedback on LH release prevent a mid-cycle LH surge. Inhibition of follicular development and the absence of a LH surge prevent ovulation.[17][18][19]

Combined hormonal contraceptives

The use of combined hormonal contraceptives (combined oral contraceptives, the contraceptive patch, and the contraceptive vaginal ring) are methods of contraception that contain both a synthetic estrogen and a synthetic form of progesterone. These methods have traditionally been used in a cyclic fashion, with three weeks (21 days) of hormones, followed by a 7-day hormone-free interval (with combined oral contraceptives, often with a week of placebo pills) during which time withdrawal bleeding or a hormonally-induced menstrual period occurs, mimicking an idealized spontaneous menstrual cycle. When these methods are taken without the hormone-free week, the withdrawal bleeding is reduced or eliminated. Thus extended cycle combined hormonal contraceptives are commonly used for menstrual suppression, although breakthrough bleeding is common in the initial months of use. (See also) The rate of amenorrhea (no bleeding) is in the range of 60% for users who are continuing to use combined hormonal contraceptive pills at the end of a year.

Combined hormonal contraceptives include both an estrogen and a progestogen. Estrogen negative feedback on the anterior pituitary greatly decreases the release of FSH, which makes combined hormonal contraceptives more effective at inhibiting follicular development and preventing ovulation. Estrogen also reduces the incidence of irregular breakthrough bleeding.[17][18][19] Several combined hormonal contraceptives—the pill, NuvaRing, and the contraceptive patch—are usually used in a way that causes regular withdrawal bleeding. In a normal cycle, menstruation occurs when estrogen and progesterone levels drop rapidly.[20] Temporarily discontinuing use of combined hormonal contraceptives (a placebo week, not using patch or ring for a week) has a similar effect of causing the uterine lining to shed. If withdrawal bleeding is not desired, combined hormonal contraceptives may be taken continuously, although this increases the risk of breakthrough bleeding.

Progestin only contraceptives

Progestin only medications, including progestin only pills and a slow-release (depot) injectable medication, depot medroxyprogesterone acetate do not contain a synthetic estrogen. Depot medroxyprogesterone acetate is given as an injection every 90 days, and is typically associated with amenorrhea in about 50-60% of users at the end of one year. Progestins that are not typically used for birth control, such as norethindrone acetate, may be used to induce amenorrhea.[21]

The degree of ovulation suppression in progestogen-only contraceptives depends on the progestogen activity and dose. Low dose progestogen-only contraceptives—traditional progestogen only pills, subdermal implants Norplant and Jadelle, and intrauterine system Mirena—inhibit ovulation in about 50% of cycles and rely mainly on other effects, such as thickening of cervical mucus, for their contraceptive effectiveness.[22] Intermediate dose progestogen-only contraceptives—the progestogen-only pill Cerazette and the subdermal implant Nexplanon—allow some follicular development but more consistently inhibit ovulation in 97–99% of cycles. The same cervical mucus changes occur as with very low-dose progestogens. High-dose, progestogen-only contraceptives—the injectables Depo-Provera and Noristerat—completely inhibit follicular development and ovulation.[22]

Hormonal Intrauterine Devices (IUDs)

Hormonal IUDs containing the hormone levonorgestrel have the side effect of inducing amenorrhea, and some types of hormonal IUDs have been shown to markedly decrease menstrual blood loss, and thus are efficacious in treating heavy and abnormal menstrual bleeding.[23] The rate of amenorrhea after one year of use is in the range of 20-50%, although most users of the hormonal IUDs Mirena and Liletta experience a marked decrease in menstrual bleeding, which is beneficial and has led to reported high rates of user satisfaction.

Levonorgestrel intrauterine devices have also been used been shown to induce amenorrhea. The lower dose device has a lower rate of achieving amenorrhea compared to the higher dose device where 50% of users have been found to achieve amenorrhea within 1 year of use. A concern for usage of these devices is the invasive administration and initial breakthrough bleeding while utilizing these devices however they have the advantage of the most infrequent dosing schedule of every 5 years. Use of intrauterine devices have also shown to reduce menorrhagia and dysmenorrhea.[10][24]

Others

Gonadotropin releasing hormone (GnRH) analogs (both antagonists and agonists) are associated with amenorrhea, and have been used to induce therapeutic amenorrhea. Among oncologists caring for adolescents with cancer, GnRH analogs were the most commonly recommended treatment for menstrual suppression to prevent or treat heavy bleeding during therapy.[10] The medication danocrine was once used for the treatment of endometriosis, and was associated with amenorrhea, but its use was limited by androgenic side-effects such as the potential for permanent lowering of the voice or hair growth. Because these side effects may be desired in transgender men, there has been some consideration of this option for menstrual population in this group of individuals.

Injections such as depo-provera (DMPA) became available in the 1960s and later became used to also achieve amenorrhea. A majority of patients will achieve amenorrhea within 1 year of initiating DMPA therapy. DMPA therapy is typically successful in achieving amenorrhea but also has side effects of decreased bone mineral density that must be considered before beginning therapy.[10]

When using the subdermal progestin only implants, unpredictable bleeding continues and amenorrhea is not commonly achieved amongst patients.[10] Progestogen-only contraceptive pills (sometimes called the 'mini pill') are taken continuously without a 7-day span of using placebo pills, and therefore menstrual periods are less likely to occur than with the combined pill with placebo pills. However, disturbance of the menstrual cycle is common with the mini-pill; 1/3-1/2 of women taking it will experience prolonged periods, and up to 70% experience break-through bleeding (metrorrhagia). Irregular and prolonged bleeding is the most common reason that women discontinue using the mini pill.[25]

History

Historically, women and girls had far fewer menstrual periods throughout their lifetimes, a result of shorter life expectancies, as well as a greater length of time spent pregnant or breast-feeding, which reduced the number of periods they experienced.[26]

When the first birth control pill was being developed, the researchers were aware that they could use the contraceptive to space menstrual periods up to 90 days apart, but they settled on a 28-day cycle that would mimic a natural menstrual cycle and produce monthly periods. The intention behind this decision was the hope of the inventor, John Rock, to win approval for his invention from the Roman Catholic Church. That attempt failed, but the 28-day cycle remained the standard when the pill became available to the public.[27]

Historically, the concept that menstruation did not have beneficial effects, and that menstruation could be controlled was raised in the 1990s, by Dr. Elsimar Coutinho.[28] The English language version, title, "Is Menstruation Obsolete: How suppressing menstruation can help women who suffer from anemia, endometriosis, or PMS?" was published in 1999.

References

  1. 1 2 3 4 5 6 7 Altshuler, Anna Lea; Hillard, Paula J. Adams (2014). "Menstrual suppression for adolescents". Current Opinion in Obstetrics and Gynecology. 26 (5): 323–331. doi:10.1097/GCO.0000000000000098. ISSN 1040-872X. PMID 25110977. S2CID 43436578.
  2. 1 2 3 Kaunitz, A. M. (2000). "Menstruation: choosing whether...and when". Contraception. 62 (6): 277–284. doi:10.1016/s0010-7824(00)00182-7. ISSN 0010-7824. PMID 11239613.
  3. ↑ Rapkin, Andrea J; Lewis, Erin I (2013). "Treatment of Premenstrual Dysphoric Disorder". Women's Health. 9 (6): 537–556. doi:10.2217/WHE.13.62. ISSN 1745-5065. PMID 24161307.
  4. ↑ "ACOG Committee Opinion No. 448: Menstrual Manipulation for Adolescents With Disabilities". Obstetrics & Gynecology. 114 (6): 1428–1431. 2009. doi:10.1097/AOG.0b013e3181c6f922. ISSN 0029-7844. PMID 20134299.
  5. ↑ Schwartz, Amanda R.; Russell, Kristen; Gray, Beverly A. (2019). "Approaches to Vaginal Bleeding and Contraceptive Counseling in Transgender and Gender Nonbinary Patients". Obstetrics & Gynecology. 134 (1): 81–90. doi:10.1097/AOG.0000000000003308. ISSN 0029-7844. PMID 31188325. S2CID 186205682.
  6. ↑ Nelson, Anita L. (2007). "Communicating with Patients about Extended-cycle and Continuous Use of Oral Contraceptives". Journal of Women's Health. 16 (4): 463–470. doi:10.1089/jwh.2006.0206. ISSN 1540-9996. PMID 17521249.
  7. 1 2 Nappi, Rossella E.; Kaunitz, Andrew M.; Bitzer, Johannes (2016-03-03). "Extended regimen combined oral contraception: A review of evolving concepts and acceptance by women and clinicians". The European Journal of Contraception & Reproductive Health Care. 21 (2): 106–115. doi:10.3109/13625187.2015.1107894. ISSN 1362-5187. PMC 4841029. PMID 26572318.
  8. 1 2 Edelman, Alison; Micks, Elizabeth; Gallo, Maria F; Jensen, Jeffrey T; Grimes, David A (2014-07-29). Cochrane Fertility Regulation Group (ed.). "Continuous or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception". Cochrane Database of Systematic Reviews. 2014 (7): CD004695. doi:10.1002/14651858.CD004695.pub3. PMC 6837850. PMID 25072731.
  9. ↑ Archer, David F. (2006). "Menstrual-cycle-related symptoms: a review of the rationale for continuous use of oral contraceptives". Contraception. 74 (5): 359–366. doi:10.1016/j.contraception.2006.06.003. PMID 17046376.
  10. 1 2 3 4 5 Close, Allison G.; Jones, Kelley A.; Landowski, Allison; Switzer, Galen E.; Kazmerski, Traci M.; Miller, Elizabeth; Friehling, Erika (2019-08-23). "Current practices in menstrual management in adolescents with cancer: A national survey of pediatric oncology providers". Pediatric Blood & Cancer. 66 (12): e27961. doi:10.1002/pbc.27961. ISSN 1545-5009. PMID 31441217. S2CID 201618230.
  11. ↑ Chuah, Irene; McRae, Alexandra; Matthews, Kim; Maguire, Ann M.; Steinbeck, Katharine (2017). "Menstrual management in developmentally delayed adolescent females". Australian and New Zealand Journal of Obstetrics and Gynaecology. 57 (3): 346–350. doi:10.1111/ajo.12595. PMID 28299789. S2CID 4444056.
  12. ↑ American College of Obstetricians and Gynecologists Committee on Adolescent Health Care (2009). "ACOG Committee Opinion No. 448: Menstrual manipulation for adolescents with disabilities". Obstetrics and Gynecology. 114 (6): 1428–1431. doi:10.1097/AOG.0b013e3181c6f922. ISSN 1873-233X. PMID 20134299.
  13. ↑ Chrisler, Joan C.; Gorman, Jennifer A.; Manion, Jen; Murgo, Michael; Barney, Angela; Adams-Clark, Alexis; Newton, Jessica R.; McGrath, Meaghan (2016). "Queer periods: attitudes toward and experiences with menstruation in the masculine of centre and transgender community". Culture, Health & Sexuality. 18 (11): 1238–1250. doi:10.1080/13691058.2016.1182645. ISSN 1369-1058. PMID 27212580. S2CID 205798509.
  14. ↑ Pradhan, Shashwati; Gomez-Lobo, Veronica (2019). "Hormonal Contraceptives, Intrauterine Devices, Gonadotropin-releasing Hormone Analogues and Testosterone: Menstrual Suppression in Special Adolescent Populations". Journal of Pediatric and Adolescent Gynecology. 32 (5): S23–S29. doi:10.1016/j.jpag.2019.04.007. PMID 30980941. S2CID 113407509.
  15. ↑ Curtis, Kathryn M.; Tepper, Naomi K.; Jatlaoui, Tara C.; Berry-Bibee, Erin; Horton, Leah G.; Zapata, Lauren B.; Simmons, Katharine B.; Pagano, H. Pamela; Jamieson, Denise J. (2016-07-29). "U.S. Medical Eligibility Criteria for Contraceptive Use, 2016". MMWR. Recommendations and Reports. 65 (3): 1–103. doi:10.15585/mmwr.rr6503a1. ISSN 1057-5987. PMID 27467196.
  16. ↑ Mendoza, Nicolás; Lobo, Paloma; Lertxundi, Roberto; Correa, Marta; Gonzalez, Esteban; Salamanca, Alberto; Sánchez-Borrego, Rafael (2014). "Extended regimens of combined hormonal contraception to reduce symptoms related to withdrawal bleeding and the hormone-free interval: A systematic review of randomised and observational studies". The European Journal of Contraception & Reproductive Health Care. 19 (5): 321–339. doi:10.3109/13625187.2014.927423. ISSN 1362-5187. PMID 24971489. S2CID 28881452.
  17. 1 2 Trussell J (2007). "Contraceptive Efficacy". In Hatcher, Robert A., et al. (eds.). Contraceptive Technology (19th rev. ed.). New York: Ardent Media. ISBN 978-0-9664902-0-6.
  18. 1 2 Speroff L, Darney PD (2005). "Oral Contraception". A Clinical Guide for Contraception (4th ed.). Philadelphia: Lippincott Williams & Wilkins. pp. 21–138. ISBN 978-0-7817-6488-9.
  19. 1 2 Brunton LL, Lazo JS, Parker K, eds. (2005). Goodman & Gilman's The Pharmacological Basis of Therapeutics (11th ed.). New York: McGraw-Hill. pp. 1541–71. ISBN 978-0-07-142280-2.
  20. ↑ Weschler 2002, pp. 361–2.
  21. ↑ Hillard, Paula (2014). "Menstrual suppression: current perspectives". International Journal of Women's Health. 6: 631–7. doi:10.2147/IJWH.S46680. ISSN 1179-1411. PMC 4075955. PMID 25018654.
  22. 1 2 Glasier A (2006). "Contraception". In DeGroot LJ, Jameson JL (eds.). Endocrinology (5th ed.). Philadelphia: Elsevier Saunders. pp. 3000–1. ISBN 978-0-7216-0376-6.
  23. ↑ Matteson, Kristen A.; Rahn, David D.; Wheeler, Thomas L.; Casiano, Elizabeth; Siddiqui, Nazema Y.; Harvie, Heidi S.; Mamik, Mamta M.; Balk, Ethan M.; Sung, Vivian W. (2013). "Nonsurgical Management of Heavy Menstrual Bleeding: A Systematic Review". Obstetrics & Gynecology. 121 (3): 632–643. doi:10.1097/AOG.0b013e3182839e0e. ISSN 0029-7844. PMC 4414119. PMID 23635628.
  24. ↑ Schmidt, Elizabeth O.; James, Aimee; Curran, K. Michele; Peipert, Jeffrey F.; Madden, Tessa (October 2015). "Adolescent Experiences With Intrauterine Devices: A Qualitative Study". The Journal of Adolescent Health. 57 (4): 381–386. doi:10.1016/j.jadohealth.2015.05.001. ISSN 1879-1972. PMC 4583802. PMID 26126950.
  25. ↑ Kovacs, G. (October 1996). "Progestogen-only pills and bleeding disturbances". Human Reproduction (Oxford, England). 11 Suppl 2: 20–23. doi:10.1093/humrep/11.suppl_2.20. ISSN 0268-1161. PMID 8982741.
  26. ↑ Lind A, Brzuzy S (2007). Battleground: Women, Gender, and Sexuality: Volume 2: M–Z. Greenwood. p. 348. ISBN 978-0-313-34039-0.
  27. ↑ "Do you really need to have a period every month?". Discovery Health. 27 January 2009. Archived from the original on 8 February 2013. Retrieved 20 September 2011.
  28. ↑ Coutinho, Elsimar M. (1999). Is menstruation obsolete?. Segal, Sheldon J. (Sheldon Jerome), Coutinho, Elsimar M. New York: Oxford University Press. ISBN 1423760409. OCLC 65181385.
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