Menstrual suppression — What do women say?
While you may be comfortable with menstrual suppression through use of continuous oral contraceptives (OCs), are your patients? According to results from a national survey, more than 66% of women say that they are interested in suppressing their menstrual periods, but many of them aren't sure if it's safe. However, when physicians are polled, 97% say that continuous oral contraceptive therapy to suppress menstruation is medically safe and acceptable.1
What will it take to close the gap? Patient education and counseling will play important roles, predicts Kurt Barnhart, MD, MSCE, associate professor and director of clinical research for the Department of Obstetrics & Gynecology at the University of Pennsylvania School of Medicine. Barnhart presented results of the surveys at the fall meeting of the Association of Reproductive Health Professionals.
"The gap between physician and patient understanding concerning the necessity of monthly periods is obvious," Barnhart says. "It is our hope that based on these findings, physicians will begin to more readily initiate dialogue with their female patients about continuous therapy — helping to eliminate the misconception that periods are a medical necessity and to emphasize the safety and viability of menstrual suppression."
With a dedicated continuous oral contraceptive product (Lybrel; Wyeth Pharmaceuticals, Collegeville, PA) on the market, health care providers will need to deliver clear information to eliminate confusion regarding menstrual suppression.
Some of the confusion about menstrual suppression may lie in simple semantics, according to the surveys' results. Among the 12% of patients who said they had discussed the idea of eliminating or reducing periods with their doctor, nearly half said they were the ones to raise the issue, not their providers. In contrast, four out of five physicians reported discussing continuous-use oral contraceptive use with their patients, and 77% said they raised the topic.
Providers and their patients may discuss this topic differently, with providers using the medical term "menstrual suppression," while patients simply talk about not having a period. Providers need to break down the language barrier by speaking in simpler, more patient-friendly terms, says Barnhart.
A total of 500 women ages 18 to 49 participated in the online patient study, and 299 professionals were included in the practitioner survey.1
How do women feel?
The use of continuous or extended-cycle OC regimens that eliminate or decrease the menstrual cycle represents a viable and attractive option for many women. There is no physiological requirement for the monthly hormone withdrawal bleed that is experienced by women taking cyclic oral contraceptives.2
However, amenorrhea needs careful explanation, advises Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta. Hatcher presented on the subject at the recent Contraceptive Technology Quest for Excellence conference in Atlanta.3 For most women, the benefits of a hormonal contraceptive, vis a vis menstrual cycle symptoms (including no bleeding at all), exceed the side effects or complications related to the menstrual cycle, notes Hatcher.
Although bleeding less or not at all is desirable in the eyes of most clinicians, amenorrhea is the leading cause of discontinuation of Depo Provera (depot medroxyprogesterone acetate or DMPA; Pfizer, New York City) and an important discontinuation factor in all hormonal contraceptives taken in a continuous manner, says Hatcher. Be sure that women understand the rationale for dropping the scheduled period:
- The "pill period" is artificial/arbitrary, without health benefits.
- The potential for increased efficacy is present when the pill-free interval is eliminated. There is less follicular recruitment, the potential for fewer pregnancies, less confusion of start/stop, and fewer pharmacy trips.
Women need to understand that continuous use of pills will not make it more difficult to become pregnant once the continuous regimen is stopped, says Hatcher.3
Take the time
Women have assumed for years that a regular menstrual bleeding episode is a sign of normality, says David Archer, MD, professor of obstetrics and gynecology and director of the Clinical Research Center at the Eastern Virginia Medical Center in Norfolk. To change this perception will take a significant effort, he notes.
"The understanding of the suppression of ovulation and the thinning of the endometrium are two concepts that need long-term information and consumer understanding and acceptance," says Archer.
When clinicians first started making DMPA available, extra counseling regarding the absence of regular menses and the increasing likelihood of amenorrhea with ongoing use was the order of the day, reflects Andrew Kaunitz, MD, professor and associate chairman of the Department of Obstetrics and Gynecology at the University of Florida College of Medicine–Jacksonville. Now, while patients still benefit from such counseling, if they know other women who use DMPA, less time can be devoted to discussions of why it is acceptable not to bleed each month, says Kaunitz.
Women's acceptance of the absence of the monthly withdrawal bleed with oral contraceptives is a work in progress, says Kaunitz. As the approach becomes more common, and more patients know someone else who has done well with menstrual suppression on OCs, less counseling time and effort will be needed, he predicts.
"Meanwhile, women continue to benefit from clinicians who are willing to put extra time and effort into patient education regarding menstrual suppression or who effectively use other resources such as office staff or educational materials in this endeavor," says Kaunitz.
- Barnhart K. Knowledge and understanding of menses inhibition or reduction in women and physicians. Presented at the Reproductive Health 2007 conference. Minneapolis; September 2007.
- Lin K, Barnhart K. The clinical rationale for menses-free contraception. J Womens Health (Larchmt) 2007; 16:1,171-1,180.
- Hatcher RA. Challenging clinical cases in hormonal contraception. Presented at the Contraceptive Technology Quest for Excellence conference. Atlanta; November 2007.