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/PMDD), 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 for menstrual suppression

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.

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.[17]

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.[18] 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.

Other options for menstrual suppression

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.

Cultural issues

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.[19] 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.

The concept that women can choose when and whether to menstruate has been debated. The Society for Menstrual Cycle Research maintains that menstruation is not a disease, and thus calls for more research on long-term effects of cycle-stopping contraceptives.[20] Most evidence to date supports the safety of menstrual suppression. [7][8][16]

References
  1. 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.
  2. 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.
  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.
  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.
  7. 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. 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. 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). doi:10.1002/pbc.27961. ISSN 1545-5009. PMID 31441217.
  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.
  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.
  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.
  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.
  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.
  17. 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.
  18. 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.
  19. Coutinho, Elsimar M. (1999). Is menstruation obsolete?. Segal, Sheldon J. (Sheldon Jerome), Coutinho, Elsimar M. New York: Oxford University Press. ISBN 1423760409. OCLC 65181385.
  20. "SOCIETY FOR MENSTRUAL CYCLE RESEARCH CALLS FOR MORE RESEARCH ON LONG-TERM EFFECTS OF CYCLE-STOPPING CONTRACEPTIVES: Menstruation Is Not A Disease" (PDF). Society for Menstrual Cycle Research Position Statements. 2007-06-08. Retrieved 2019-09-25.
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