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Menstrual manipulation: Options for suppressing the cycle

Cleveland Clinic Journal of Medicine. 2010 July;77(7):445-453 | 10.3949/ccjm.77a.09128
July 1, 2010|Cleveland Clinic Journal of Medicine
Caitlin W. Hicks, BA;Ellen S. Rome;MD;Mph
Author and Disclosure Information

Caitlin W. Hicks, BA
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Ellen S. Rome, MD, MPH
Head, Section of Adolescent Medicine, Department of General Pediatrics, Cleveland Clinic Children’s Hospital

Address: Ellen S. Rome, MD, MPH, Department of General Pediatrics, A120, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail romee@ccf.org

ABSTRACTMenstrual manipulation, ie, adjusting the menstrual cycle by taking hormonal contraceptives, allows women to have their period less often or to avoid bleeding at inconvenient times. The authors review the various options, the benefits, and the disadvantages of this practice.

KEY POINTS

  • The options for menstrual manipulation are extended or continuous regimens of oral, transdermal, or vaginal hormonal contraceptives; a levonorgestrel-releasing intrauterine device; a progestin implant; and depot medroxyprogesterone injections.
  • Benefits include fewer menstrual-related syndromes, less absenteeism from work or school, and greater overall satisfaction. Medical indications for it are conditions exacerbated by hormonal changes around the time of menses.
  • The main disadvantage is a higher rate of breakthrough bleeding.
  • Myths and misperceptions about menstrual manipulation persist; some physicians believe it is somehow inadvisable.

THE RIGHT METHOD FOR THE RIGHT PATIENT

Manipulation and suppression of menstruation through continuous or extended use of oral contraceptives or by other means may have a number of advantages to women, including fewer menstrual-related syndromes, reduced absenteeism from work or school, and greater overall satisfaction.

For women whose goal is to reduce but not necessarily to eliminate monthly bleeding, the cyclic use of estrogen-progestin contraception (rather than progestins alone or continuous use of combined hormonal preparations) is suggested.

For women whose goal is amenorrhea, depot medroxyprogesterone acetate injections, continuous oral contraceptives, and the levonorgestrel intrauterine device are all effective.67 Although randomized trials comparing these methods have not been done, depot medroxyprogesterone appears to have the highest rate of amenorrhea, while the levonorgestrel intrauterine device is the most convenient and appears to be associated with fewer bothersome side effects than progestin injection.68 Patients using depot medroxyprogesterone should have their bone density followed to detect and prevent bone loss, while users of estrogenprogestin pills, the transdermal patch, or the vaginal ring should not have any contraindications to the use of contraceptive doses of estrogen (Table 2).69

Clinicians should not overestimate the risks of oral contraceptives and other hormonal methods, but rather educate themselves so that they can utilize menstrual manipulation safely to match the individual patient’s needs.

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