IFYOU’RE a woman, here’s a tempting offer: stop having your periods now. Renounce the cramps, the bloating, the migraines, the moodiness and discomfort that take over your life once a month. Use your brain for something other that deciding between light and super-absorbent, deodorant or unscented. And best of all, feel good about it, because it’s actually better for your health.
Sounds too good to be true? Perhaps. But that’s the controversial proposal made by a growing number of doctors who believe there is no medical reason for women to have regular menstrual cycles. “It is a needless loss of blood,” says Brazilian reproductive biologist Elsimar Coutinho in his book Is Menstruation Obsolete? In fact, monthly periods could even be detrimental to women’s health.
And so the plan is to get rid of them. In principle, that’s quite simple. Taking contraceptive hormones continuously, either in the form of a pill, an injection or an implant, will stop menstruation for months or even years at a time. Those methods are economical and broadly available. Indeed, millions of women using contraceptives like Depo-Provera (DMPA) know at first hand that one of the perks can be no periods.
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But here’s the twist—Coutinho and like-minded scientists are pushing for a change in thinking. They’d like to see contraceptives given continuously not just for birth control, but as a means of suppressing periods to improve a woman’s health and quality of life.
The first product to embrace this new attitude will soon hit the market in the form of Seasonale. It is identical to the good-old birth control pill, only packaged differently. The “regular” pill, made with synthetic versions of oestrogen and progesterone, is designed to be taken for 21 days in a row. The steady hormone levels fool your body into thinking you’re pregnant, and so suppress ovulation. After this there is a week of either placebo pills or no pills, when women have their periods—the bleed is the body’s response to the sharp drop in hormone intake. But with Seasonale you take placebo pills only at the end of the third month, meaning just four periods a year.
Even though Seasonale is made of the same hormones as the regular pill, its makers have had to design clinical trials to prove that taking those hormones continuously is safe and effective. Phase III clinical trials are under way, and if the US Food and Drug Administration gives its approval, by early 2003 Seasonale will be the first contraceptive specifically marketed to suppress women’s periods for several months. “Once patients and physicians understand the benefits, this is going to be the way to take the pill,” says Patricia Sulak of the department of Obstetrics and Gynecology at Texas A&M University.
According to Sulak, who is not shy about admitting that her career goal is “to eliminate monthly periods”, some of the best evidence that incessant menstruation is not what nature intended comes from our ancestors. Year after year of regular periods was not the norm for women until recently. “Ordinarily the pattern has been for a woman to be pregnant and lactating,” says Sheldon Segal of the Population Council, and co-author of Coutinho’s book.
Studies of contemporary hunter-gatherer societies suggest that women in prehistoric times had about 160 periods in their lifetime, compared with an average of 450 for women today. Better nutrition and higher standards of health in many countries mean women start their periods much earlier—at age 10 or 12—and reach menopause later. Also, these days it’s common to delay childbearing until the late twenties, or even later, and the average number of children per woman is much lower. Thus, women now spend most of their reproductive lives menstruating every month, with few breaks for pregnancy or breastfeeding in between.
Not only was menstruation rare for our ancestors, but it’s actually an unusual event in the rest of the animal kingdom too. Only a few species of monkeys, bats and shrews seem to menstruate. Clearly, shedding uterine tissue at the end of a fertile cycle is not nature’s favourite female design.
At the very least, incessant menstruation is inconvenient, and for many women the distress goes deeper than that: anaemia, migraines, cramps, fatigue and mood swings are a few of the symptoms commonly associated with periods. Most women put up with them as natural manifestations of the monthly event, but Charlotte Ellertson of the Population Council in Mexico begs to differ. She argues that the symptoms often incapacitate women and affect their productivity. “This is surely an anomaly in medicine,” states Ellertson in a provocative essay published in the medical journal The Lancet. “There can be no other disease or condition that affects so many people on such a regular basis…which is not prioritised in some way by health professionals or policy makers.”
But perhaps more importantly, repeated menstruation has been linked to a higher incidence of serious illness. Endometriosis, a condition that results when uterine tissue lodges inside the body cavity causing terrible abdominal pain during menstruation, has become more prevalent in many countries as women have begun to experience more menstrual periods, say Coutinho and Segal in their book. Also, it is now clear that the prevalence of reproductive diseases like ovarian cancer is closely linked to the number of periods in a woman’s lifetime. Several studies show, for example, that women who’ve never had children, and thus have had no breaks from ovulation, have a higher risk of developing reproductive cancers. One theory is that the constant growing and re-building of tissue in the uterus predisposes a woman to cancer, another is that prolonged exposure to cycling hormones somehow triggers it. Either way, the link between lots of periods and a higher risk of cancers seems well established.
But ask women if they’d like to get rid of their periods, and the answers will be visceral, passionate and conflicting. Suppressing menstruation goes against the hard-wired notion that the monthly period is one of the key hallmarks of womanhood. It has always had a special, mythical role in women’s lives—it is curse and blessing, pride and taboo.
Several large studies by the World 91ɫƬ Organization and other institutions reveal that not all cultures are equally receptive to suppressing menstruation. A recent survey of women in seven countries showed that the majority did not want to modify their periods, let alone eliminate them altogether. In fact, such an outcome was a great source of concern for women considering long acting contraceptives like DMPA or Norplant. Women in India and Thailand, for example, opposed the idea because they believe menstruation is good for their health and their looks.
In Western societies, women seem more open to giving up their periods, perhaps because of a stronger focus on lifestyle and career. In a recent Dutch study based on interviews with over 300 women, about 70 per cent of those between 15 and 50 would rather have their periods less than once a month, and of these the majority would prefer periods either every three months or never. Several small studies in other countries, including Britain and Sweden, produced similar results. Also, from a less scientific but more lively survey, hundreds of women have posted replies to the question “Would you stop menstruating if you could?” at the online Museum of Menstruation. This gem of a website is a virtual repository for everything you ever wanted to know about women’s periods. “I’d say it’s five to one in favour of stopping,” says site founder Harry Finley.
But it’s obvious that even those seriously considering the change are deeply torn about stopping periods merely for convenience. There is indeed a cultural bias against stopping periods without a good reason. In fact, this is the motive behind the original 21-day regime for the pill. When a woman takes the pill, the hormones prevent ovulation, but also most of the usual tissue growth that happens in the uterus as it prepares for implantation of an egg. Then, once placebo pills are started, or the gap week is reached, the uterine tissue reacts to the drop in hormones by breaking down, even though there is not much tissue to shed. The bleed actually has little biological resemblance to a real period.
So why take a break from the hormones at all? Because the pill’s creators figured that women (and the church, for that matter) would feel more comfortable with a schedule that seemed to mimic the real thing. “That’s why the pill was so successful,” says Sulak. “They could have put 36 or 42 pills in the pack, but they chose 21 because they knew.” In fact, the “period” is, in a way, as artificial as the hormones themselves. Sulak argues that it’s not any less natural to skip those placebo pills and continue to take the hormones uninterrupted.
There is one fundamental problem, though, with the available hormones. To be sure, they are very effective contraceptives. But for reasons that still puzzle researchers, women who take these hormones continuously often get unpredictable bleeding, or spotting. With DMPA or Norplant, it’s common for most women to have irregular bleeding for a few months, until their body gets used to the schedule. And it’s one of the most common reasons women give up on long-acting contraceptives. Freedolph Anderson of Eastern Virginia Medical School, who is overseeing the clinical trials with Seasonale, says that taking the pill at the same time every day is proving crucial to stopping breakthrough bleeding.
A contraceptive called Mirena, which releases the same hormone as Norplant but via an intrauterine device, apparently reduces intermittent bleeding quite successfully. Also, a new generation of compounds, called anti-progestins, seem to be excellent contraceptives and effectively stop spotting. Anti-progestins work differently from conventional hormone contraceptives by blocking the action of the body’s own progesterone, which is vital for a viable pregnancy. Doing this prevents both ovulation and much of the build-up of uterine tissue. But an additional effect is the temporary atrophy of blood vessels in the region, which seems to prevent spotting quite efficiently.
But even if problems with spotting are resolved, taking the no-periods trend into the mainstream will require significant effort. For example, it will be hard to convince some women to let go of the comforting monthly bleed that reassures them they are not pregnant. Experts argue that if women follow the rules, it is very unlikely that they will get pregnant, since prolonged use of contraceptives leads to a uterus that, as long as they are still taking the hormones, increasingly cannot support a pregnancy.
Conversely, women will want to be reassured that fertility will return shortly after they stop taking the hormones—which studies so far show is indeed the case. In fact, according to a titillating but very preliminary theory, the treatment might even prolong fertility if we can find the right compound to suppress ovulation at its earliest stages. “So it might be that if you retain the eggs, the quality [later on] might be better. The window of fertility could be held back,” says Roger Gosden, scientific director of the Jones Institute at Eastern Virginia Medical School. There are a few candidates for such a “career pill” already. But at the moment, Seasonale will not offer such a perk—it does block ovulation, but the eggs still begin to mature in the ovary, and so wither away and die as they would during a normal menstrual cycle.
Also, women are unlikely to accept the shift unless they are convinced it’s safe. There’s a solid case for the long-term safety of injectable progestin-based contraceptives such as Depo-Provera for most women. But there are isolated reports of serious adverse effects and unpleasant side effects like a tendency to gain weight. And while oral contraceptives can significantly reduce the risk of reproductive cancers, there are no studies of the long-term effects of taking oral contraceptives without the placebo break. After all, the non-stop schedule means exposing women to the hormones for 25 per cent longer. Oestrogen in the pill has been associated with a slightly higher risk of stroke, especially in smokers or women with conditions like diabetes and hypertension. So doctors will have to look at how the extra exposure might affect health. “We don’t have all the evidence yet for doing this for years on end, but most physicians would agree that doing it for months at a time has been perfectly safe,” says Ellertson.
But researcher Lawrence M. Nelson from the National Institutes of 91ɫƬ worries about branding menstruation as unimportant. “We think the menstrual cycle doesn’t get the respect it deserves as a sign of good health,” he says. He believes that the cycle is like the body’s thermostat, a sensor of hormonal balance and general well being. By giving women contraceptives, serious conditions like ovarian dysfunction, which causes infertility, could be masked and go undiagnosed for years. Taking the hormones, argues Nelson, would “remove the vital sign,” which is the period.
In fact, Ellertson says that some feminist groups have reacted negatively to arguments in favour of suppressing women’s periods. They complain that doctors are making the menstrual cycle look like a sickness that needs to be “cured”. And that the whole argument about what’s normal is pointless—it’s akin to saying that our ancestors were hungry more often, and therefore hunger should be the “normal” state. In the end, no amount of advertising or pressure from doctors will make women adopt a concept they don’t feel comfortable with. But Anderson is convinced. “Women will ask for this.”
- Further reading:
Is Menstruation Obsolete? by Elsimar M. Coutinho and Sheldon J. Segal, Oxford University Press, 1999 - The Museum of Menstruation is at