Elsevier

Contraception

Volume 62, Issue 6, December 2000, Pages 277-284
Contraception

Original research article
Menstruation: choosing whether … and when

https://doi.org/10.1016/S0010-7824(00)00182-7Get rights and content

Abstract

For many women in the United States, menstruation is a major health concern because menstrual disorders and other conditions that may be aggravated during menses (e.g., migraine headaches, epilepsy) carry substantial morbidity. Women today menstruate nearly 3 times as often as in primitive societies, and evidence suggests that frequent, repetitive menstrual cycles may increase health risks. Because the conventional 21/7 combination oral contraceptive (OC) regimen provides only limited relief for women with menstrual disorders, alternative OC regimens that reduce menstrual frequency have been proposed. A new OC formulation specifically designed to decrease menstrual bleeding to 4 times per year is currently under investigation. Most women welcome less frequent menses or even amenorrhea. Women who may derive particular benefit from reduced menstrual frequency include not only those with medical conditions directly caused or aggravated by menses, but also those serving in the military, female athletes, mentally-retarded women with menstrual hygiene problems, young teens, and perimenopausal women.

Section snippets

Menstruation—monthly nuisance or major cause of morbidity?

The burden of menstruation ranges from a monthly nuisance to a major health concern of women. In the United States, menstrual disorders are the most common gynecologic complaint, affecting nearly 2.5 million women aged 18 to 50 [1]. Two-thirds of these women contact a doctor regarding menstrual problems each year, and 31% report spending a mean of 9.6 days in bed annually [1]. Among young women, primary dysmenorrhea is the most common cause of time lost from work or school [2]. The costs of

Is monthly menstruation necessary?

Contemporary women in Western societies who live to age 50 will experience an estimated 450 lifetime ovulations or episodes of menses, whereas women in primitive foraging (i.e., hunter-gatherer) societies who lived to experience menopause would have had only one third as many cycles (160) [6]. There is evidence to suggest that this pattern of frequent, repetitive menstrual cycles may actually increase health risks. For example, characteristics found to be protective against breast and

Clinical experience with reducing menstrual frequency

As early as 1977, Loudon and colleagues studied the acceptability of an OC regimen that reduced menstrual frequency to once every 3 months [8]. A total of 196 women took a combination OC consisting of 50 μg ethinyl estradiol (EE) and 2.5 mg lynestrenol for 84 days followed by 6 pill-free days. The regimen provided good cycle control; only 8.5% (17) of the 196 women reported breakthrough bleeding in the first cycle, which was related to missed tablets in 6, and 24% (47) reported spotting. The

Benefits of reduced menstrual frequency/amenorrhea for women with medical conditions

Decreasing the frequency of menstrual bleeding or inducing amenorrhea can provide relief for a number of conditions directly caused by menses (see Table 1, Table 4). For example, because combination OCs reduce menstrual blood loss in women with normal menses as well as in those with menorrhagia, they are used as first-line therapy for dysmenorrhea and menorrhagia in women with uterine fibroids [17]. By reducing menstrual blood loss, the frequency of anemia can be reduced as well. Women with

Benefits of reduced menstrual frequency/amenorrhea in specific settings or patient types

Reduced menstrual frequency or amenorrhea offers specific benefits for women serving in the military [21], for female athletes [22], [23], and for women with severe mental retardation [24]. A survey of 158 freshman female Cadets at the United States Military Academy at West Point found that more than 60% reported menstrual and premenstrual symptoms that interfered with physical activities [21]. Problems changing, obtaining, and disposing of menstrual hygiene materials were experienced by 63%,

Interventions that can induce amenorrhea

Until the development of a variety of medical alternatives, hysterectomy was the only definitive treatment available for women with severe menorrhagia and/or dysmenorrhea associated with gynecologic disease. Developed in the 1980s, endometrial ablation represents an alternative surgical procedure that costs substantially less than hysterectomy, requires little if any hospital stay, and has a shorter recovery period [30]. Failure can occur up to 3 years after endometrial ablation and amenorrhea

Conclusions

As women become more knowledgeable about the safety, efficacy, and (for many women) desirability of the medical approaches described above, more of our patients will be choosing whether and when to bleed. When the OC was first introduced in the 1960s, many social, cultural, and religious pressures favored a regimen in which monthly withdrawal of hormones for 7 days was followed by bleeding, since this implied that the method-induced cycle was “natural.” Although there is no known medical

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