Pediatric Annals

CME 

Monthly Periods—Are They Necessary?

Sarah E. Strandjord, BS; Ellen S. Rome, MD, MPH

Abstract

Menstrual suppression—the use of hormones to delay or eliminate menses—is often used in adolescents to manage conditions associated with the menstrual cycle and to accommodate lifestyle preferences. Reducing the frequency of menstrual bleeding does not cause any known physiologic harm and has potential short-term and long-term advantages. Different methods used for menstrual suppression, however, have associated risks and side effects that need to be weighed against the benefits of controlling menses. This article reviews the advantages and disadvantages of menstrual suppression and the different methods available for adolescents. [Pediatr Ann. 2015;44(9):e231–e236.]

Abstract

Menstrual suppression—the use of hormones to delay or eliminate menses—is often used in adolescents to manage conditions associated with the menstrual cycle and to accommodate lifestyle preferences. Reducing the frequency of menstrual bleeding does not cause any known physiologic harm and has potential short-term and long-term advantages. Different methods used for menstrual suppression, however, have associated risks and side effects that need to be weighed against the benefits of controlling menses. This article reviews the advantages and disadvantages of menstrual suppression and the different methods available for adolescents. [Pediatr Ann. 2015;44(9):e231–e236.]

Menstrual suppression, the use of hormones to delay or eliminate menses, has gained popularity in the last few decades but is not a new phenomenon. Before the advent of our modern lifestyles, women suppressed menses naturally through later onset of menstruation, frequent pregnancies, and prolonged breastfeeding. Women historically experienced around 300 less periods than women experience today, according to theoretical estimates.1 This change in menstrual pattern has a wide range of health effects that influence both medical and psychosocial well-being during adolescence and beyond.

Menstrual suppression using artificial hormones first became possible in 1960 after the approval of mestranol/norethynodrel by the US Food and Drug Administration (FDA), the first contraceptive drug.2 In the development of mestranol/norethynodrel, researchers chose to mimic the physiologic menstrual cycle, with 21 days of active pills followed by 7 days of placebo, to promote acceptability among women, clinicians, and the Catholic church as “a morally permissible variant of the rhythm method.”3 However, this regimen was arbitrary and not physiologically necessary. Since the 1970s, studies have demonstrated the safety and effectiveness of extended use of oral contraceptives, typically in an 84/7 day regimen.4,5 This concept of menstrual suppression through extended cycles has become increasingly popular in clinical practice and among the general population.6 Multiple methods of menstrual suppression have now been developed and studied in addition to oral contraceptives.7 This review discusses the advantages and disadvantages of menstrual suppression as well as the currently available methods for adolescents.

Advantages of Menstrual Suppression

Whether an adolescent uses hormonal contraceptives primarily to prevent pregnancy or to treat a menstrual disorder, withdrawal bleeding is not medically necessary. Furthermore, as discussed below, decreasing the frequency of menses has several benefits for both health and lifestyle.

Numerous conditions in adolescents demonstrate improvement with menstrual manipulation (Table 1). Menstrual disorders, such as metrorrhagia (irregularly timed periods), menorrhagia (heavy periods), menometrorrhagia (irregularly timed, heavy periods), and dysmenorrhea (painful periods), affect up to 90% of young women.8–10 Traditional cyclic contraceptives can improve these conditions by inducing menstrual regularity and reducing flow. Extended cycle regimens often provide further benefits by decreasing the frequency of withdrawal bleeding and therefore the frequency of accompanying symptoms.11,12

Reasons for Menstrual Suppression in Adolescents

Table 1.

Reasons for Menstrual Suppression in Adolescents

Other conditions directly related to menses, such as premenstrual syndrome and endometriosis, also benefit from oral contraceptive use, especially when used in an extended or continuous regimen.11,13 Studies in patients with endometriosis demonstrate decreases in both dysmenorrhea14 and recurrence15 with continuous use compared to cyclic use of oral contraceptives after surgical excision. Reductions in menstrual symptoms, particularly menorrhagia and dysmenorrhea, also occur with long-acting contraceptives, such as intrauterine systems.16,17

Menstruation can also indirectly exacerbate a wide variety of disorders (Table 1). Some medical problems, referred to as “catamenial” conditions, vary with the menstrual cycle, including migraines, epilepsy, asthma, and numerous others.18 Menstrual suppression helps to reduce the severity and occasionally eliminate many of these conditions.18,19 In a prospective study on headache severity, women (n = 102) placed on an extended regimen (168/7 day) of oral contraceptives experienced a significant improvement in headache severity along with improvement in work productivity compared to when on a 21/7-day regimen.19 Studies show similar improvements with other combined contraceptives, such as the patch or the vaginal ring,20 with only limited data available for progestin-only options, such as depot injections and intrauterine systems.21

In addition to medical conditions, lifestyle is often an important factor in menstrual suppression. Parents or other caregivers, particularly those caring for adolescents with cognitive or physical disabilities, may request menstrual suppression due to challenges with menstrual hygiene.22 Suppressing menses for these adolescents may relieve some of the burden placed on them and their caregivers every month. In a survey of women from the United States (n = 297, age 18 years and older), about 70% disliked their periods and 60% preferred to menstruate less frequently than once a month.23 Similar results are reported for European populations,24–26 with higher percentages among adolescents.26 Induced amenorrhea provides adolescents with more flexibility and less interference with daily activities.5 Oral contraceptives, for example, can be used to adjust the timing of menses to accommodate specific activities, such as an important test in school, sports competition, artistic performance, or vacation.

Several benefits of contraceptive use persist into adulthood. Hormones involved in menstruation influence hyperplasia and cancer development in various organs throughout the body. In the breasts, combined contraceptive use decreases the risk of benign breast disease without increasing the risk of cancer.27 Combined contraceptive use also has a protective effect against endometrial and ovarian cancer that increases with duration of use. In the ovaries, combined contraceptive use decreases the risk of cancer by 75% with more than 10 years of use and protection persists for over 10 years after cessation of use.28,29 Similarly, protection against endometrial cancer reaches 80% risk reduction after 10 years of use and persists for at least 20 years after cessation of use.28 Limited studies also indicate a reduction in cancer risk, including endometrial, ovarian, pancreatic, and lung cancer, among levonorgestrel intrauterine system (LNG-IUS) users30,31 and a reduction in endometrial cancer risk among depot medroxyprogesterone acetate (DMPA) users.32 Therefore, contraceptive use during adolescence has potential benefits not only during use but for decades after the cessation of use.

Disadvantages of Menstrual Suppression

Menstrual suppression in itself does not cause any known physiologic harm.7 Disadvantages of menstrual suppression are largely based on the side effects of different methods, which are discussed in more detail below. In general, most side effects are similar to those reported for traditional cyclic contraceptives. Notable exceptions include increased breakthrough bleeding observed in patients using extended-use contraceptives or DMPA injections,33–35 decreased bone mineral density observed in patients using DMPA injections,36 and increased thromboembolism risk, possibly observed in patients using the transdermal patch.37 Providers, patients, and families should evaluate these side effects against the benefits of each method and the needs of each individual patient. For a number of patients or their parents, the concept of menstrual suppression in itself is objectionable because bleeding less frequently feels “unnatural” or could delay recognition of pregnancy.5 Although providers can often allay these concerns with education, some patients will likely prefer other options. In addition, as with any nonbarrier contraception, all methods for menstrual suppression do not protect against sexually transmitted infections. Therefore, regardless of the method of menstrual suppression, providers should encourage adolescents to use a barrier method of contraception to prevent infections in all encounters and provide additional protection against pregnancy for those patients involved in sexual activity.

Methods of Menstrual Suppression

Combined Oral Contraceptives

Table 2 summarizes the common methods of suppression available for adolescents.

Advantages and Disadvantages for Different Menstrual Suppression Methods

Table 2.

Advantages and Disadvantages for Different Menstrual Suppression Methods

Combined oral contraceptives (COCs), which contain both an estrogen and a progestin component, are the most common method used for menstrual suppression.7 COCs can be administered using three different approaches—cyclic, extended, or continuous. Cyclic administration refers to the traditional design developed in the 1960s,2 with 21 to 24 days of active pills followed by 4 to 7 days of placebo. Extended administration is when the active pills are taken for a longer duration, usually 42, 63, or 84 days followed by placebo. Continuous administration is when active pills are taken continuously without placebo. Amenorrhea is achieved in about 80% of patients by 1 year of continuous use.34,35 Breakthrough bleeding may occur during the first few months of extended or continuous use but usually improves over time. Other common side effects of COCs, regardless of the administration regimen, include breast tenderness, headaches, and nausea.38 COCs are also associated with an increased risk of venous thromboembolism (VTE), with an absolute risk of about 0.05% per year in a healthy adolescent.39 COCs should, therefore, not be prescribed in patients with any condition predisposing to thrombotic disease. The efficacy of extended or continuous use of COCs is similar to that of cyclic use, with an annual pregnancy rate of 0.3% with perfect use and 9% with typical use.38

Vaginal Ring

The vaginal ring (0.015-mg ethinyl estradiol and 0.12-mg etonogestrel) is a hormone-releasing ring traditionally left in the vagina for 21 days and removed for 7 days to allow for withdrawal bleeding. The package insert for the vaginal ring states that one ring can be used for up to 28 days. Each ring, however, contains enough hormones to last up to 35 days, making it possible to replace the ring once a month.38 This simple regimen may be desirable for patients with poor pill compliance, although it may not improve adherence compared to COCs.40 Efficacy is similar to that of COCs with regards to pregnancy risk.38 Only one trial is available comparing extended use to cyclic use of the vaginal ring,41 which demonstrated fewer overall days of bleeding but increased spotting with the extended regimen. With nonextended use, 8% report amenorrhea and 19% report spotting.42 Common side effects of the vaginal ring are similar to COCs with the addition of vaginal symptoms, including discharge and vaginitis.38

Transdermal Patch

The transdermal patch (0.750-mg ethinyl estradiol and 6-mg norelgestromin) is a patch applied to the skin on a weekly basis, with a typical regimen of 3 weeks with a patch followed by a week without a patch for withdrawal bleeding. Findings on the efficacy of the transdermal patch for menstrual suppression are similar to those for the vaginal ring, with limited data suggesting fewer bleeding days but increased spotting with extended use.43 Efficacy is comparable to that of COCs and the vaginal ring for pregnancy prevention, although efficacy may be reduced in women weighing over 90 kg. Common side effects are similar to those of COCs with the addition of local effects, including hyperpigmentation, contact dermatitis, and other skin irritation. Studies also suggest that the patch increases serum estrogen levels to 1.6 times the levels measured for low-dose COCs,44 potentially increasing the risk of VTE.37,45 These findings led to a “black box” warning from the FDA in 2011. Therefore, the transdermal patch should be rarely used as a first-line choice for extended cycling, particularly in patients with thrombotic risk factors.

Depot Medroxyprogesterone Acetate Injections

DMPA is a long-acting contraceptive injected intramuscularly (150 mg) or subcutaneously (104 mg) every 3 months. Advantages of this method include less frequent dosing and easy administration without extensive provider training. Efficacy of DMPA is similar to that of combined contraceptives, with a pregnancy rate of 0.2% with perfect use and 6% with typical use. About 60% of patients achieve amenorrhea by 1 year and 80% achieve amenorrhea by 5 years, although irregular bleeding occurs in nearly all patients initially. Other common side effects include weight gain, acne, and depression.38 Weight gain typically does not occur in underweight girls but can result in up to 20-kg weight gain in obese adolescents.46 In addition, DMPA suppresses estradiol concentrations, resulting in decreased bone mineral density accrual.36 These findings led to a “black box” warning from the FDA in 2004 with a recommendation that DMPA use be limited to 2 years. Since this warning, however, studies have shown that adolescents recover bone mineral density after cessation of use without increased fracture risk.47–49 Regardless, during and after use, all patients should take at least 1,300 mg of calcium and 600 IU of vitamin D a day through diet or supplements and engage in regular weight-bearing exercise. In addition, providers should consider other risk factors for osteoporosis, such as eating disorders, chronic steroid use, tobacco use, or nonambulatory or “wheel-chair” bound status, when counseling patients on methods of menstrual suppression or contraception.

Levonorgestrel Intrauterine System

The LNG-IUS is a long-acting contraceptive system that is inserted into the uterus. Two progestin IUS are currently available, a higher-dose device that dispenses 20 mg of LNG daily and is approved for 5 years of use and a lower-dose device that dispenses 13.5 mg of LNG and is approved for 3 years of use. The lower-dose device is smaller, which may be advantageous for insertion in nulliparous women but also increases the expulsion rate.7 The rate of amenorrhea is 10% with the lower-dose LNG-IUS as opposed to 50% with the higher-dose system after 1 year of use.50 The latter may be preferable in adolescents with developmental delay, cerebral palsy, or other physical disabilities in which menstrual cessation improves quality of life.51 The primary advantages of the LNG-IUS are its low maintenance and its high efficacy, with only 0.2% of all patients becoming pregnant within a year.38 One of the main disadvantages is insertion, which requires a highly trained provider and can be uncomfortable, especially for nulliparous adolescents. Current evidence, however, demonstrates that these systems are safe for adolescents with nearly no risk of perforation and low risk of infection.38 Contraindications for insertion include current pelvic infection, pregnancy, or uterine anomalies that distort the uterine cavity. Common side effects include vaginal discharge, weight gain, and backaches.52

Subdermal Implant and Other Progestin-Only Therapies

The subdermal implant, a small rod containing etonogestrel (68 mg) inserted into the arm, is effective for up to 3 years. Benefits of the implant include its low maintenance, high efficacy, and simple insertion. Unpredictable bleeding, however, occurs frequently with the implant regardless of duration of use and amenorrhea occurs in less than 20%.53 The progestin-only pill (norethindrone 35 mcg) similarly induces amenorrhea in only about 10% and, because of the short half-life, requires precise compliance that is difficult to accomplish in adolescents.54 These contraceptive options are therefore not recommended for menstrual suppression.

Concluding Remarks

Many adolescents desire fewer menses and may derive considerable benefits, both in health and in lifestyle, from menstrual suppression. To date, no negative consequences of menstrual suppression have been identified, but each method of suppression has associated risks and side effects. Providers should educate patients and their families on the advantages and disadvantages of the different methods available, helping them to choose the method that best fits their individual needs.

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Reasons for Menstrual Suppression in Adolescents

Gynecologic conditions   Dysmenorrhea   Menorrhagia   Endometriosis   Ovarian cysts   Premenstrual syndrome Catamenial conditions   Acne   Headaches   Asthma   Epilepsy   Irritable bowel syndrome Hematologic disorders   Iron-deficiency anemia   Coagulopathy Menstrual hygiene   Developmental delay   Physical disability Personal preference

Advantages and Disadvantages for Different Menstrual Suppression Methods

Method Dosing Schedule Advantages Disadvantages
Oral contraceptives Daily Least invasive Flexible regimens Frequent missed doses Breakthrough bleeding
Transdermal patch Weekly Minimally invasive Simpler regimen Possible increased VTE risk Skin irritation Increased spotting
Vaginal ring Every month Minimally invasive Simpler regimen Vaginal symptoms Increased spotting
DMPA injections Every 3 months Easy administration No estrogen Frequent office visits Decreased bone density Irregular bleeding
Levonorgestrel IUD Every 5 years Least maintenance Lowest pregnancy risk No estrogen Invasive administration Initial breakthrough bleeding
Authors

Sarah E. Strandjord, BS, is a fourth-year Medical Student, Cleveland Clinic Lerner College of Medicine, and a Graduate Student, Department of Nutrition, Case Western Reserve University. Ellen S. Rome, MD, MPH, is the Head, Center for Adolescent Medicine, Cleveland Clinic Children’s Hospital; and a Professor of Pediatrics, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University.

Address correspondence to Ellen S. Rome, MD, MPH, Cleveland Clinic Children’s Hospital, A120, 9500 Euclid Avenue, Cleveland, OH 44195; email: romee@ccf.org.

Ellen S. Rome discloses consulting fees from the Merck Speakers Bureau and the Vaccine Advisory Board. The remaining author has no relevant financial relationships to disclose.

10.3928/00904481-20150910-11

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