To Bleed or Not to Bleed

I am not a fan of cycle-stopping contraceptives. My refusal to accept menstrual suppression drugs, like the recently approved Lybrel, as just another reproductive choice is based on over 20 years of personal and professional experience.

This stance in no way compromises my pro-choice beliefs. As a veteran sexual and reproductive health advocate, all of it spent with Planned Parenthood affiliated organizations, I also happen to be a student of the menstrual cycle. I've observed, charted and interpreted my own menstrual cycle events since I was 27. At 53, this life skill now informs my passage towards menopause. I call the knowledge that comes with menstrual cycle charting "body literacy" (PDF). Literacy, in any form, is empowering.

I also belong to the Society for Menstrual Cycle Research (SMCR), a nonprofit, interdisciplinary research organization. Members are researchers in the social and health sciences, humanities scholars, health care providers, policy makers, and students with interests in the role of the menstrual cycle in women's health and well-being. And no, SMCR is not a hotbed of anti-choice advocacy.

That more of my colleagues are not active members of SMCR surprises me. After all, we've spent the last 50 years manipulating women's menstrual cycles with contraceptive drugs. You'd think we, as stewards of women's reproductive health, would be interested in learning everything we can about menstruation.

But maybe this is changing. In recent conversations with journalists and sexual health educators, I'm constantly asked, "What else should women know about the menstrual cycle?" If we were to believe the many gynecologists and drug executives who've been quoted in the Lybrel coverage, the answer would be, "nothing." Their comments suggest that menstruation is irrelevant, unneccesary and, possibly, even dangerous to our health.

Yet in September of 2004, the SMCR presented a scientific forum to the New York Academy of Sciences proposing that the menstrual cycle be considered the fifth vital sign of women's health. "The menstrual cycle is a window into the general health and well-being of women, and not just a reproductive event," said Paula Hillard, M.D., professor of obstetrics & gynecology and pediatrics at the University of Cincinnati College of Medicine. "It can indicate the status of bone health, heart disease, and ovarian failure, as well as long-term fertility."

So who's right? The doctors who champion menstrual suppression by telling us we don't need to bleed? Or the similarly respected medical professionals and researchers who present sound scientific reasons why normal ovulatory menstruation is important to women's health and well-being?

Consider this contradiction. If a woman not using hormonal birth control showed up at her doctor's office with amenorrhea of one year's duration she would be considered to have a serious endocrine disorder. Yet the same condition induced by a drug like Lybrel is considered safe, healthy, and comes highly recommended by many doctors.

In June 2007, the SMCR updated its position statement on menstrual suppression. It urges caution and clearly states that "menstruation is not a disease."

Neither is menstruation just about reproduction.

Maybe it's time we all become students of the menstrual cycle and start talking about its broader meaning in our lives. Maybe then we can exercise authentic informed choice and decide for ourselves if menstruation matters.

Here are some suggestions on how to do this:

1. Check out the Centre for Menstrual Cycle and Ovulation Research.

2. Arrange public or private screenings of the documentary Period: The End of Menstruation?, by Giovanna Chesler. Follow up with a panel or group discussion about what menstruation means in our lives.

3. Read a book that challenges menstrual suppression, such as No More Periods?, by Dr. Susan Rako.

4. Read books, articles and websites that promote body literacy:

5. Share information with friends and colleagues. Debate and discuss.

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  • invalid-0

    thanks for this post. i’ve been very, very frustrated by the disinterest in this important subject. long past it personally (had a total hysterectomy 30 years ago), as a grandmother to infant girls, i want to see more conversation on this.

    unfortunately, the focus is on work/not work mommies rather than substantive issues like this. will the SCMR organization visit websites and blogs by younger women who might address this? or are we now entirely at the mercy of drug companies–rhetorical question.

  • invalid-0

    Thanks for bringing a different and well-informed alternative position to the discussion. While I certainly don’t discourage or disparage menstruation, I have been one who advocates for choices for women regarding their menstrual cycles: if they want to bleed every month great, and if not (even if it isn’t about excrutiatingly painful menses), then those women should have an option as well.

    I will definitely read more about the SMCR as a result of this post. But — without further reading at this point — I wonder, are you opposed to OC’s in general since most oral contraceptives inhibit ovulation and a “real” menstrual cycle? Are the health indicators mentioned above still valid with withdrawl bleeding during OC use?

    Thanks again for the info!

  • invalid-0

    Has anyone seen the tape from the 1980’s about the use of the canola? It is a simple device for removing the mensa blood within 30 minutes so that you don’t need to use a pharmaceutical. It has been around for decades but is illegal in this country so the Kotex, and other products can be used to make bunches of money from women. The new pills and patches for suppressing the mentrual cycle are just other means using women as a profit function.

    Why do women allow other women to be like men and use them for making the almighty dollar! The Canola can also be used in the first month and maybe even first trimester for a self administered perfectly safe abortion. No holy rollers would ever want that anymore than would doctors and now the nurse midwife professions.

  • invalid-0

    As an Ob/Gyn I have to point out that there are some mistakes in your premises. For example, you say:

    “Consider this contradiction. If a woman not using hormonal birth control showed up at her doctor’s office with amenorrhea of one year’s duration she would be considered to have a serious endocrine disorder. Yet the same condition induced by a drug like Lybrel is considered safe, healthy, and comes highly recommended by many doctors.”

    The reason that these two cases of amenorrhea differ is because of the *cause* of the amenorrhea. Amenorrhea on the pill is safe and has a clear reason. Amenorrhea in a woman who is not on the pill can be caused by several things and needs to be evaluated. The harmful causes of amenorrhea would need to be ruled out or addressed if present.

    It is not appropriate to present these two cases as the same and then say it’s a contradiction that doctors view them differently. It’s like calling it a contradiction for doctors viewing the enlarged uterus of pregnancy differently than an enlarged uterus of cancer. Different causes mean different levels of concern or safety.


  • invalid-0

    There is absolutely no need to make this into a controversy.

    For some women who suffer with their periods and prefer not to have periods, this is a safe effective way to contracept and to not have periods.

    For women who prefer to have periods for whatever reasons they have, they are not forced nor required to take birth control pills in this way. They can safely use birth control pills in the standard cyclic way or may opt for any of several other methods of contraception.

    One size does not fit all. The more safe options that we can provide for women the better chance they have of finding a contraceptive method that works for them.

    Everyone is entitled to their opinion of whether or not they want to have periods. However, everyone is not entitled to make up their own facts about safety.

  • laura-wershler

    Good question.  

    I think one of the most interesting outcomes of the growing discussion on cycle-stopping contraceptives is the questions it raises about our use of hormonal contraception in general and about ovulation in particular. Many women using traditional hormonal formulations that include a withdrawal bleed do not realize they do not ovulate on these medications or that they do not experience a true menstrual bleed. It is news to many that they are not having a "real period" while on the pill, patch or ring. Which begs the question of just how much girls and women actually know about a) how a healthy, normal cycle unfolds, and b) how hormonal contraception actually works. The issue is one of informed choice, not whether or not I think anyone should use these drugs. The reason I wrote the commentary is to invite all women to learn more about normal menstrual cycle functioning and the many ways in which ovulation is connected to our sexual, reproductive and overall health. My major concern is what I perceive to be a disconcerting lack of body literacy in young women. We, the sexual and reproductive health community, have some serious work to do to change this. I am also keenly committed to making sure that the growing numbers of young women who are seeking alternatives to hormonal drugs to manage fertility and menstrual cycle disorders, have access to information, research, opinions and services that support this choice. (All four are much harder to find than you might think.)  As a pro-choice advocate, this is my obligation. 

  • laura-wershler

    I find it difficult to understand how inviting women to become students of the menstrual cycle so that they can decide for themselves if menstruation matters to them, is creating a controversy. Knowledge is power and fully informed choice is the goal.

  • invalid-0

    Indeed menstrual extraction is a legitimate back up option, for times of need. However, I cannot support “times of need” to be understood as every menstrual cycle, as menstrual extraction can have problematic outcomes – even those done most carefully. I suggest Body Literacy for a woman, that is, for her to become a student of her own menstrual cycle and its patterns of fertility and infertility. Body Literacy is her first line of defence against having her reproductive choice manipulated by others, and the need for menstrual extraction would be rare if at all because she would know whether or not she was pregnant or had cause to think that she might be. It seems foolhardy to me to educate a woman to practice a potentially problematic procedure every cycle before one educates her to observe, chart, and interpret her menstrual cycle events so she can have safe and healthful governance of her reproductive body all the time for purposes of avoiding or achieving pregnancy, and for monitoring the maintenance of her health as is reflected in her menstrual cycle events. It all starts with literacy on all levels.

  • invalid-0

    Accurate information, knowledge and informed discussion are power. I fully support women making informed decisions about whether or not they want to menstruate and what type of contraception they would like to use.

    However, presenting menstrual suppression as unhealthy or presenting it as a “contradiction” that pill-induced amenorrhea and amenorrhea of unknown cause are treated differently is not providing accurate information. Adding inaccurate information does not improve knowledge or informed decision-making– it worsens it. That is my complaint.

    If you are inviting women to learn about their menstrual cycles or any health issue (and we all should), please make sure that they get information from reliable, credible, best-evidence medical sources.


  • invalid-0

    Naomi, I will give you an AMEN! And before anyone flames me – no I’m not in the health field. I AM a data research analyst.

    I would consider using Lybrel after a ‘sperm cessation’ contraceptive was ‘successfully’ developed. I have searched for articles, and not found an indication that research was being conducted. If anyone has found indication, I would be very interested in reading it.

    Why are women the guinea pigs in birth control? Could you answer that, alleged OB/GYN that commented. It takes two – why are women made the prescription seekers? Condoms are not ingested and not part of the discussion.

    I agree with Laura’s INFORMED and well written article. Menses is not a disease, it’s not a curse. It is a normal biological function. Stopping the cycle is not normal. Yes, OCs disrupt the cycle, the uterine lining is shed, as it would without OCs. With Lybrel, that doesn’t occur. How that effects the woman’s body we won’t know for a few years yet. As the case with OCs. The list of contraindications became longer and longer as more women had problems with OCs.

    Stopping one’s cycle for convenience is, in my opinion, odd.
    And WHY would a drub manufacturer develop such a thing? For the Dept of Defense? Do you have any insight as to how this drug came to market, Laura?

  • laura-wershler

    The amennorrhea "contradiction" was stated to make the point that an endocrine disruption is an endocrine disruption is an endocrine disruption, whatever caused it.  And the endocrine system, as any endocrinologist will tell you, is about more than reproduction. Ergo, it is worthwhile to learn much more about how healthy, ovulatory menstruation impacts other aspects of women's health – bone, breast, cardiovascular, digestion, metabolism, thyroid function, immune system, sex drive –  before we wholeheartedly accept that there are no value added benefits to menstruation and that menstrual suppression denies us nothing when it comes to our health.  It is a choice to use or not to use these drugs. Obviously, welcoming alternative opinions and seeking out information that may contradict those who espouse the use of these drugs is also a choice.

  • invalid-0

    It sounds like what you are saying–and correct me if I am wrong–is that women shouldn’t use menstrual suppression until there is more evidence about it. I disagree and feel that there is enough evidence to support the use of menstrual suppression for some women who choose it. I think we are in agreement that all women should be informed accurately of the risks and benefits of all medications as well as the risks and benefits of not using those medications.

  • invalid-0

    There is no need to call me “alleged”. I am an Ob/Gyn who went to medical school and completed an obstetrics and gynecology residency because I care about the health, safety and well-being of women. You can choose to believe this or not.

    >”Why are women the guinea pigs in birth control? Could you >answer that, alleged OB/GYN that commented. It takes two – >why are women made the prescription seekers? Condoms are >not ingested and not part of the discussion.”

    This is an interesting question. Several years ago there was a big upset in that women were often excluded from studies and the information gained from studies on men were applied to woman with the assumption that they would respond the same way. This was considered a big problem and there was a big push to include women in studies to better assess how women respond to medications.

    There have been many studies on contraception in the past and continue in the present. You can go to a medical library and do a medline search on specific contraceptive methods and find an abundance of research. There is a journal dedicated to contraception (called “Contraception”). There is more research on contraception for women for a few reasons. One, there has been more success in creating effective hormonal contraception for women. I believe China has been looking at a male method that affects sperm count. Secondly, sadly-some women don’t have enough power in their relationships to demand condom use. This is a problem that should be corrected. In the meantime, since the burden of reproductive events occur to women, there is continued study for what women can do to protect themselves against unintended pregnancies and prevent STIs. And you should know, condoms are frequently and highly recommended by doctors to their patients–hormonal methods do not protect against STIs.

    I didn’t mention condoms in my previous posts because the issue was menstrual suppression. In practice I often recommend patients double up on contraception to maximally avoid pregnancy and STIs (OCPs plus condoms, depo plus condoms, IUD plus condoms). WHen women desire permanent contraception I always suggest vasectomy for their spouses/partners as an option and let them know it is safer than tubal ligation. (I usually point out that they went through childbirth and it seems the least the partner can do…)

    Yes, the burden of responsibility to prevent unintended pregnancies should be shared as equally as possible. When it is not possible, women need choices to protect themselves. Past research and continued research on contraception is essential to promote the health and safety of women and to guide the prescription practices of the doctors who provide care to women.

  • laura-wershler

    No, I’m not saying women shouldn’t use menstrual suppression until there is more evidence about its long-term use. What I will say is that I believe there is an extreme emphasis and reliance on hormonal methods, at the expense of women having access to knowledge and information about their own bodies and about non-pharmaceutical alternatives.  All I am suggesting is that, as sexual health professionals, we have an obligation to ensure our patients, clients and students have a broader, deeper understanding of normal menstrual cycle functioning before we can feel confident that real informed choice is being made. Ask around. So many women feel they don’t have a choice but to use drugs when it comes to birth control or a solution for menstrual cycle problems. Yet there are effective, safe, non-hormonal choices for both. It is my experience, based on extensive discussions with young and not-so-young women, that these choices are not readily made available to them, nor encouraged by doctors or sexual health clinic staff. In other words, self-determination is not always being served. When women request alternatives to drugs, many are discouraged from pursuing these alternatives. I am sure you are a physician who puts her patient’s needs and desires first, but I can assure you that some doctors do not. Scolding, coercion and shaming are some of the tactics described to me by women who have told their doctors they do not want to use hormonal contraception. Their doctors, it seems, just do not have anything else to offer them. I’ve been in a session where doctors and nurses were given counseling tips by an obgyn on how to "convince" their patient's to accept menstrual suppression. I’ve read journal articles that tell doctors to manage their patient’s "side effect expectations" to reduce “premature method discontinuation.” Are these situations common? Probably. Are they acceptable? Not to me. The good thing about this menstrual suppression discussion is the opportunity to raise these kinds of issues with thoughtful, well-meaning individuals and professionals.