Birmingham ObGyn Dr. Wendy Gregory Explains Menstrual Suppression—Life Without Periods!

woman making red check marks on a calendarDid you know, it is possible to safely lighten or eliminate your monthly period? The use of birth control pills or other hormonal birth control products to control the timing of your period or avoid it entirely is called menstrual suppression. Women can choose to suppress their periods for a short time or even for many months or years.

As a gynecologist for over two decades, I know that a monthly period and the discomfort that often accompanies it never happen at a convenient time in a woman’s life. As a busy mother of two, I understand the frustration. Multiply this inconvenience by, on average, 450 periods in a lifetime, and that adds up to a lot of nuisance days.

It’s disappointing when one has to feel less than 100% or deal with menstrual hygiene products during a long-awaited special event (perhaps a honeymoon or an important job interview). More seriously, when significant discomfort or heavy bleeding is a part of every month, it can interfere with success in your education or career. In my years of experience helping women with menstrual difficulties, I find that most are not aware of treatment options. Women whose periods are very heavy or painful should always consult with their gynecologist, but options are also available for a woman whose periods are only mildly uncomfortable or just inconvenient.

For my patient whose quality of life would be improved by suppressing monthly periods, I suggest a hormonal medication. Most often a birth control pill is my first recommendation. The pill is familiar to most women. The common dose packs contain a 21 to 24-day supply of active pills, followed by 4 to 7 inactive or placebo pills. The placebos contain no active medication. Soon after a woman begins taking the placebo pills each month, she will usually have vaginal bleeding. We refer to this as withdrawal bleeding, rather than a true menstrual period, since ovulation has not occurred. (An egg has not been released from the ovary).

The placebo pills actually serve no medical purpose. Those who developed the first birth control pills in the 1950s proposed that a few days of withdrawal bleeding each month would make the new pills seem more “natural.” Some women still prefer to have these days that mimic a “normal” menstrual period, and some appreciate having evidence that they are not pregnant. But the pill provides equally effective birth control without the placebos and withdrawal days.

Menstrual Suppression: How it Works

Today women can avoid withdrawal bleeding by choosing a pill that provides either an extended cycle or continuous dosing. An extended cycle product typically contains 84 active pills and 7 placebos. The user can expect 4 episodes of withdrawal bleeding per year. Continuous dosing means that, regardless of which brand or pill pack is chosen, the user takes no placebo pills. (Placebo pills are discarded). The goal of continuous dosing is to eliminate withdrawal bleeding.

Women appreciate the obvious practical benefits of menstrual suppression, but they also want to know that it is a safe option. Menstrual suppression does not interfere with future fertility. When birth control pills or other hormonal treatment is discontinued, your previous menstrual pattern will generally return within about three months. Another form of birth control should be started immediately, however, if pregnancy is not desired. I reassure my patients that avoiding a period does not interfere with their health. It does not increase a woman’s cancer risk. Hormonal birth control is not recommended for individuals with certain health conditions. When I advise patients about these options, we also discuss their individual risk factors.

Unfortunately, I cannot guarantee that using extended or continuous hormonal birth control will eliminate periods entirely for every woman. Periods will become shorter and lighter, and most will achieve no bleeding within a few months. Effective suppression with birth control pills requires that pills are taken reliably every day. But realistically, the possibility of occasional spotting or breakthrough bleeding will still remain. About half of women choosing continuous dosing, on average, report no bleeding within about 2 months. After one year, about 88% reach complete suppression. Using higher dose pills increases the chance of reaching this point. (…from the American College of Obstetricians and Gynecologists’ review of medical literature). However, some women find unpredictable breakthrough spotting or bleeding unacceptable, even if it is light and infrequent.

Individualizing Birth Control and Precautions

These general guidelines can be individualized. For example, if breakthrough spotting or bleeding is a problem, this may be improved by stopping the pill for 4 to 7 days, and then resuming continuous daily dosing. The pill provides effective birth control as long as it has been taken continuously every day for the previous 21 to 24 consecutive days. After that number of days, it is possible to skip 4 to 7 days without losing protection from pregnancy. Withdrawal bleeding (an artificial period) will then occur. When the active pills are restarted (within 4 to 7 days), episodes of breakthrough spotting or bleeding may improve.  It is important to discusses with your gynecologist exactly how to individualize your dosing schedule without risking pregnancy. You should have a clear understanding of how the pills can remain effective.

Understanding exactly how the pills work and remain effective can also provide reassurance if pills are forgotten or accidentally missed. After taking active pills for 21 to 24 consecutive days, protection against pregnancy will continue if doses are interrupted for less than 7 days. This information is also useful for women who are taking birth control pills on the usual cyclic schedule (21 to 24 active pills and 4 to 7 placebos; with several days of withdrawal bleeding in each cycle).  Although they are not trying to achieve menstrual suppression, the consecutive days of taking active pills can be extended beyond 24 days—and the placebo pills delayed—so that withdrawal bleeding is postponed until after a special event (wedding, vacation, whatever…).   It is important to discusses with your gynecologist exactly how to individualize your birth control dosing schedule without risking pregnancy. If your use of birth control pills has not followed your doctor’s instructions, begin using another method of birth control immediately and continue it as your doctor advises.

For women who find the commitment to a daily pill regimen unacceptable, a degree of menstrual suppression can also be achieved with other hormonal birth control products (IUD, birth control patch, vaginal ring, etc.). The likelihood of no breakthrough bleeding varies among these methods. A discussion with your gynecologist about your expectations and personal preferences will guide you in your choice.

Menstrual suppression with hormonal birth control products can be especially helpful for patients with special circumstances—for example, those deployed with the armed forces, individuals with developmental handicaps, transgender or gender-diverse persons, or adolescent patients. Menstrual suppression should not be started for adolescents who are not yet having periods.

The take-away from this discussion is that women do have options besides just tolerating the inconvenience of monthly periods. I encourage my patients let me know if monthly periods are interfering with their quality of life. We can explore the options that best meet your individual needs.