Overview of Menstrual Suppression
Menses, or periods, are when the lining of the womb sheds monthly. This happens for about 26% of the world’s population. But what if you could control this cycle using medications? This specific use of hormonal contraceptives or other drugs, known as medication-induced secondary amenorrhea, can purposefully reduce period frequency or stop them altogether. Best part? This manipulation of your menstrual cycle is generally safe and doesn’t harm your health despite common notions that regular periods are necessary.
Why would anyone want to control their periods? There are many reasons! To name a few, people might do this to decrease painful symptoms around their period, reduce blood loss, make handling their period hygiene easier, and improve their overall quality of life. The ability to control periods can also help manage other health issues such as heavy menstrual bleeding, painful periods (dysmenorrhea), a condition where womb-lining tissue grows outside the womb (endometriosis), and excessive menstrual bleeding in those with bleeding disorders. Plus, certain groups of people may find it particularly useful, including teenagers, people with developmental or physical disabilities, those who identify as a different gender than assigned at birth, military service members, athletes, and individuals undergoing treatment for cancer.
Given these potential benefits, doctors specialising in health conditions affecting women and primary care clinicians should counsel their patients on controlling their periods. The American College of Obstetricians and Gynecologists (ACOG), issued a guide in 2022 to help doctors help their patients decide on this. According to ACOG, various medications can be used to control periods, including continuously taken or extended-use contraceptive pills, patches, intravaginal rings, progestin-only pills, and injections. Exclusively hormonal long-lasting contraceptives like specific intrauterine devices (IUDs) and implants are also options. Other less common methods involve use of hormone-releasing drugs and testosterone. However, achieving complete stoppage of periods can be difficult. The success of these treatments vary and they come with different side effects. Therefore, patients should know what to realistically expect from each method. Managing period cycles should aim to reduce the number of bleeding days and make it easier to handle, rather than completely stopping periods.
Anatomy and Physiology of Menstrual Suppression
The menstrual cycle, which starts with the first day of menstrual bleeding, is split into two main parts. The first part is the follicular phase, which lasts from the first day of menstruation until ovulation (usually around 14 days in a 28-day cycle). The second part is the luteal phase, which is from ovulation until the next period starts (usually from day 14 to 28). These cycles are controlled by various hormones within your body.
The follicular phase is all about preparing the body for ovulation. Hormones from the brain trigger the ovaries to release an egg for fertilization and to produce estrogen. Estrogen, in turn, stimulates the lining of the uterus (endometrium) to grow and prepare for pregnancy. As this phase ends, there’s a surge in hormones that triggers ovulation, where the mature egg is released from the ovary.
The luteal phase begins after ovulation. The empty egg follicle (corpus luteum) starts producing progesterone, which helps the endometrium to thicken and get ready to support a pregnancy. This phase lasts about two weeks. If pregnancy doesn’t occur, hormone levels drop and menstruation begins, starting the cycle anew.
Menstruation typically begins for girls between 10 and 15 years of age, known as menarche. Young girls often have irregular cycles due to an immature hormonal system, but over time, it stabilizes and the cycles become more regular.
Certain medications, including hormonal contraceptives like birth control pills, can stop menstruation. These medications work in a couple of ways. Firstly, they block the release of hormones from the brain, reducing estrogen levels, which prevents the endometrium from growing. Secondly, they contain synthetic progesterone which typically produces a thinner endometrial lining. The result is less shedding of endometrial tissue when bleeding happens, which is often lighter and shorter than a typical period. This also has potential health benefits, such as protecting against certain types of cancer and helping with conditions like heavy bleeding or endometriosis.
Once these medications are stopped, the body’s natural cycle typically resumes after a few months, and the endometrium starts to grow again, although this can vary between individuals. It’s important to note that hormonal birth control hasn’t been shown to cause fertility issues.
Why do People Need Menstrual Suppression
Some people who have periods or their caregivers may decide to stop their monthly cycle for personal or health-related reasons. Interestingly, a research revealed that up to 59% of women in the US said they would like to put a stop to their monthly periods. For many adult females, reasons for wanting to suppress menstruation might include lessening bleeding and pain, managing certain health conditions, reducing the drawbacks of menstrual hygiene, and minimizing the use of disposable hygiene products. It would also help in improving quality of life and managing symptoms around their period.
When a Person Should Avoid Menstrual Suppression
Stopping your menstrual cycle, or menstrual suppression, may not be suitable for everyone. Certain health conditions may prevent some from using hormonal birth control methods, which are usually used to stop periods.
If you’re considering using a birth control pill that contains estrogen, certain health issues might mean you can’t take it. These include problems that might make your blood more likely to form dangerous clots, such as having certain diseases of the blood or liver, suffering migraines with visual disturbances, being a smoker (especially if you’re older than 35), having heart issues, a history of diabetes with related complications, diseases affecting blood vessels in the brain and limbs, or if you’ve had a lung clot, a clot in the veins of the legs, or a stroke in the past.
Estrogen-based birth control is also not recommended if you have or had certain types of cancer, particularly breast cancer, as there may be a risk of the cancer coming back or growing faster. However, for ovarian and endometrial, or lining of the womb, cancers, the US Center for Disease Control and Prevention says that these types of birth control are okay while you’re waiting for treatment. It’s important to consider the risks of clots in your blood against getting pregnant while you’re waiting for cancer treatment. If you have high blood pressure that’s not under control, or have known heart disease, these birth control methods might also be unsafe because they could worsen these conditions. In those cases, progesterone-only options, which are just as effective but safer, should be considered.
Progesterone-only pills, another type of birth control, have only a few reasons you shouldn’t take them. The main one is active breast cancer. If you have lupus – an autoimmune disease – with certain abnormal antibodies, severe liver disease, liver tumors, or if you’ve had weight loss surgery that disrupts your digestion, it’s also advised not to use these pills. Levonorgestrel-releasing IUD, a type of intrauterine device or ‘coil’, isn’t suitable if you have abnormal shapes or septum in your womb, an active infection in your genital or urinary systems, or current breast, endometrial, or cervical cancer. It’s also not recommended if you have lupus with abnormal antibodies, complicated organ transplant, or severe liver disease.
Injectable medroxyprogesterone acetate, a birth control shot, should be used with caution in people who have lower than normal bone density or are at high risk of bone-related problems. This includes athletes or members of the military who do a lot of weight-bearing exercises, have a history of bone stress injury, a diet lacking in nutrients, middle aged, have long-term use of steroids, or have limited mobility. This form of birth control is typically not the first choice for young women who have not reached their peak bone density a few years after their first period. Healthcare professionals should discuss the risks and other safer contraceptive options that do not affect bone density.
You should be careful when choosing a method to stop your periods if you’re taking medication for seizures because these might interact with the hormonal birth control. Some of these medicines could make the birth control less effective and control periods less reliably. As a result, you may experience irregular bleeding or may need to take higher doses. Seizure medicines with enzyme-inducing properties are not recommended alongside estrogen pills or the progesterone-only pill. The seizure medicines do not usually impact the effectiveness of hormonal birth control, except for a medicine called lamotrigine which is less effective when taken with estrogen. If you are taking lamotrigine with hormonal birth control, you may need to adjust your dosage, and it is recommended you discuss this with your doctor. Data suggests that certain epilepsy medicines like gabapentin, levetiracetam, and valproate have limited effects on hormonal birth control pills.
Last but not least, menstrual suppression should not be started in young girls before their first period. Before considering this, doctors usually ensure that the girl has normal sexual organs and usual physical changes associated with puberty.
How is Menstrual Suppression performed
Hormonal contraceptives can be used to control or suppress menstrual bleeding. These can include oral contraceptive pills, contraception patches, vaginal contraceptive rings, progestin-only pills, and long-acting reversible contraceptives like the Intrauterine Device (IUD) and the etonogestrel implant. Other methods include the use of medications like Gonadotropin-releasing hormone (GnRH), a hormone that controls the menstrual cycle, and testosterone. However, completely stopping periods might not be achievable for everyone, and the success rate varies depending on the method used. Therefore, while it’s possible some people might stop menstruating completely, it’s important to manage expectations realistically, aiming primarily to reduce the number of days of bleeding and its impact.
Combined Oral Contraceptive Pills
One of the most well-known ways to suppress menstrual bleeding is by continuously taking combined oral contraceptive pills without having a break week which usually causes a withdrawal bleed. In packs with 21 active and 7 inactive pills, the patient would take the active pills and then start a new pack immediately the next day. Combined oral contraceptives contain two hormones: ethinyl estradiol and a progestin, and come in different formulations. It’s noteworthy that combined oral contraceptive pills have been associated with improvements in symptoms around menstrual periods, including menstrual pain, fatigue, bloating, and headaches. However, these pills need to be taken daily, and can’t be used by people who have a medical reason not to take estrogen. Also, there’s a risk of breakthrough bleeding (unexpected bleeding while on the pill), which can be bothersome.
Combined Transdermal Patch
The combined contraceptive patch is another option and can also be used continuously for menstrual suppression. It works in a similar way to the oral contraceptive pills, but the patch is replaced weekly without a break week. One advantage over the pills is that the patch only needs to be changed weekly, but it still carries risk of breakthrough bleeding, and can’t be used by people who have a medical reason not to take estrogen.
Intravaginal Ring
The combined intravaginal contraceptive ring can be used continuously, just like the patch and the oral pills. It is typically replaced every four weeks without a break. This method can be very effective in suppressing menstruation, with only one ring studied thus far for menstrual suppression. The main advantage of the ring is that it only needs to be replaced monthly, but it may also cause breakthrough bleeding. Another issue with the ring is that it needs to be stored in a fridge if it’s not going to be used within four months, which might be a problem for people without access to reliable refrigeration or electricity.
Possible Complications of Menstrual Suppression
Unexpected bleeding during menstrual suppression is a common occurrence, but it’s harmless. However, it can be unsettling or inconvenient and is often the reason people stop the treatment. Almost half of individuals might experience this bleeding, often with methods such as the subdermal etonogestrel implant and progestin-only pills. Doctors advise patients about this and assure that the bleeding decreases the longer they use continuous hormonal contraception, especially over six months.
To manage unexpected bleeding, the ACOG (The American College of Obstetricians and Gynecologists) suggests different strategies depending on the contraceptive method used. For combined hormonal contraceptives, they might recommend regular cycles for 3 to 6 months, then a shift to longer cycles, a 3 to 4-day hormone-free period, or occasional supplementation with estrogen. For progestin-only pills, they advise taking the pill at the same time each day or raising the dosage. They also suggest combined oral contraceptives or anti-inflammatory drugs for other contraceptive methods.
There can be complications with contraceptives that contain estrogen, like increasing the risks of blood clots, hypertension, heart issues for those with heart disease and liver issues. However, a study of over 46,000 women has shown having used contraceptives within their life reduces the risk of some cancers. Any increased risk of breast and cervical cancer goes away within 5 years after stopping contraception use.
Injectable contraceptives can lead to a decrease in BMD (Bone Mineral Density) when used for over two years, but the loss can be reversible. The loss grows with extended use, and users could lose up to 7.5% at two years. However, you are likely to recover fully from this BMD loss if used for less than two years.
There’s limited evidence showing a fracture risk in later life for injectable contraceptive users, and considerable recovery is seen within two years of stopping its use. In this case, patients with high-risk lifestyles like athletes or those with chronic steroid use should be cautious of increased bone loss. Some studies recommend taking calcium and vitamin D supplements simultaneously with injectable contraception to decrease adolescent BMD loss.
An etonogestrel implant and LNG-IUD do not result in BMD loss. Plus, these contraceptives have no apparent evidence suggesting an increased risk of breast cancer, heart disease, or blood clots.
GnRH agonists can lead to specific side effects resulting from the induction of a hypoestrogenic state, including BMD loss, risk for heart disease, headaches, and menopausal symptoms such as hot flashes, mood swings, and fatigue.
One common worry with menstrual suppression and hormonal contraception, in general, is the fear of altering baseline fertility after use. It seems that baseline fertility rates are not affected by any method beyond the average few cycles to return to fertility after discontinuation for all hormonal contraceptive methods. The time to return to fertility may be more extended with Depo-Provera use.
What Else Should I Know About Menstrual Suppression?
Almost a quarter of the world’s population experience menstruation, that’s around 800 million people on any given day. Menstrual related troubles such as heavy bleeding, cramps, premenstrual syndrome, bloating, and fatigue, affect millions of people every year. These discomforts can interfere with daily life, leading to missed work or school, less social and recreational activities, added expenses on menstrual products like pads and tampons, increased risk of urinary tract infections, and even excessive bleeding leading to anemia.
These negative effects of menstruation can be even harder for those living in poverty, young adolescents, people with developmental or physical disabilities, diverse gender individuals, military personnel, athletes and those affected by life threatening diseases like cancer (“period poverty”).
But there are ways to manage or even suppress menstruation, reducing or eliminating the difficult impacts of menstrual symptoms. These methods range from oral contraceptive pills (OCPs), which are effective for 88% of users by the end of 1 year, progestin-only pills (POPs) with effectiveness varying between 10% to 76%, depending on the formulation and dose, to Depo-Provera (DMPA), a type of contraceptive injection, that brings about no periods in up to 71% of users by the end of 2 years.
Other methods include intrauterine devices (IUDs) that release Levonorgestrel, resulting in no periods for half of users by the end of 1 year and 60% by the end of 2 years, and subdermal implants etonogestrel reducing periods in 13-22% of users. Gonadotropin-releasing hormone (GnRH) agonists are another option, suppressing periods in up to 96% of users, and testosterone therapy, although the effectiveness rates are still unclear.
Remember, different methods work differently for different people, and all have their own potential side effects, so consult your healthcare provider for the best choice for you.
