BENEFITS OF MENSTRUAL MANIPULATION
Menstrual manipulation has a number of benefits in terms of both overall health and lifestyle.
For most women, using a long-acting hormonal contraceptive carries low risks and substantial health benefits. Women who take oral contraceptives are less likely to develop osteoporosis, ovarian or endometrial cancer, benign breast changes, or pelvic inflammatory disease. 49 Long-term use of an oral contraceptive can also preserve fertility by reducing and delaying the incidence of endometriosis,50 and is effective at treating acne vulgaris, which tends to be common among patients with polycystic ovary syndrome.51,52 In addition, this practice can be used to reduce overall blood loss, an application that is particularly important in women with a bleeding diathesis such as von Willebrand disease, who frequently suffer from menorrhagia.53
Reduced menstruation may also prove more convenient during particular occasions, such as vacations and athletic activities. Specifically, it may be useful to women serving in the military. In a study by Schneider et al,54 a cohort of 83 female cadets reported a significant perceived impact of premenstrual and menstrual-related symptoms on academic, physical, and military activities, as well as difficulties in obtaining, changing, and disposing of menstrual materials in a military setting. Likewise, reduced menstrual frequency or amenorrhea may play an important role in female athletes, who reportedly use oral contraceptives to control premenstrual symptoms, to protect bone health, and to manipulate the menstrual cycle in order to maximize performance.55
Adolescent girls are another group who may benefit from reduced or absent menses, once they have reached near-final height. By practicing menstrual suppression, girls can avoid dysmenorrhea and the inconvenience of menstruation during the school day, when their access to painkillers, sanitary pads or tampons, and a change of clothes may be limited. 56 Clinicians who discuss with teenage patients the benefits of innovative hormonal contraceptive schedules that reduce menstrual frequency may be able to improve the quality of life for these young women.
In a very short girl just after menarche, care must be taken not to start a hormonal method too early so as not to prematurely close epiphyses and stunt final height; after menarche, most girls still have 1 to 4 inches of potential growth. For a young lady 4 feet 11 inches tall, that extra inch may be important.
Finally, menstrual manipulation may also find a niche among the developmentally challenged. Women with cognitive impairment and physical disabilities may have difficulty with hygienic practice around menses. For a number of years, contraceptives have been used to manage menstrual hygiene in patients with catamenial (ie, menstrual) epilepsy, and to address caregiver concerns in women with severe mental retardation, with improved behavior noted in some patients.57–59 In this setting, an agent that suppresses menses and also provides contraception, especially for those girls and women at risk of abuse, may offer substantial benefits.
DISADVANTAGES OF MENSTRUAL MANIPULATION
Rates of adverse events and of discontinuation of extended and continuous oral contraceptive regimens are comparable with those reported for cyclic regimens, except for higher rates of breakthrough bleeding.
In a trial of continuous oral contraceptive use in more than 2,000 patients, 396 (18.5%) withdrew from the study as a result of bothersome uterine bleeding.60 However, while breakthrough bleeding often occurs during the first few months of extended oral contraceptive use, it usually decreases with each successive cycle of therapy and is comparable to that reported by patients on the conventional oral contraceptive regimen by the fourth extended cycle.12
The efficacy of extended and continuous oral contraceptive regimens is comparable with that of cyclic regimens.12,60,61 One reason for this may be better adherence to continuous regimens: women using this regimen have been shown to miss fewer pills than those on a cyclic regimen, especially during the critical first week of the pill pack.21
Several studies have shown that some women ovulate during the standard 21/7 oral contraceptive regimen even if they do not miss any pills or take pills off-schedule, putting them at greater risk of pregnancy.62 Large studies evaluating the efficacy of an extendedcycle regimen have shown a pregnancy rate during the 1-year study period that was either comparable with61 or lower than12,60 rates with standard regimens.
Heterosexual couples need to be advised to use condoms to further reduce the already low failure rate and to prevent sexually transmitted diseases.
ACCEPTABILITY OF MENSTRUAL MANIPULATION
Ever since the earliest trial of an extended oral contraceptive regimen, participants have expressed a favorable response to the resulting decrease in menstrual frequency; in the 1977 study by Loudon et al,6 patients on the extended regimen cited infrequent periods (82%), fewer menstrual problems (20%), and easier pill-taking (19%) as favorable features.
In 1999, den Tonkelaar and Oddens63 surveyed 1,300 Dutch women about their preferred frequency of menstruation and found that about 70% between the ages of 15 and 49 preferred a frequency of between every 3 months and never. A similar survey in the United States indicated that 58% preferred a bleeding frequency of either every 3 months or never to more frequent periods.64
While patients find menstrual manipulation generally acceptable, clinician approval has been more varied. Loudon et al reported that “the doctors and nurses on the clinic staff were less enthusiastic about this regimen than the volunteers themselves.”6 In a survey of 222 clinicians,65 90% of responders reported ever having prescribed extended or continuous dosing regimens to adolescents, and 33% reported that extended cycles made up more than 10% of their total oral contraceptive prescriptions.
Myths and misperceptions about menstrual manipulation abound. Many clinicians believe that routine use of an extended or continuous oral contraceptive regimen is inadvisable, despite the lack of evidence to support this notion.66 Therefore, many care providers need more education about the practice and benefits of menstrual manipulation.