Clinical Review

Using contraceptives to alter bleeding patterns

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Most women want shorter, lighter, less-frequent menses. Modern contraceptive methods offer options for manipulating the menstrual cycle.


 

References

KEY POINTS
  • Women prefer to menstruate less often, and modern contraceptive methods give them that choice.
  • Among the contraceptives that can significantly alter menstruation patterns are depot medroxyprogesterone acetate, levonorgestrel implants, oral contraceptives (OCs), and the levonorgestrel intrauterine device (IUD).
  • The levonorgestrel IUD is one of the most effective means available of reducing menstrual blood loss.
  • To manipulate bleeding patterns and manage hormone-withdrawal symptoms, the duration of active OC pills can be extended.
Given the problems associated with menstruation, it is not surprising that women prefer to menstruate less often—and modern contraceptive methods give them that option. This article describes current options and factors to consider in counseling patients.

Compared with today’s women, who have access to effective birth control, past generations had earlier and more frequent childbearing, longer periods of breastfeeding, later menarche, and earlier menopause. During their reproductive years, they were more likely than today’s women to be pregnant or breast-feeding than to be menstruating, and they had far fewer total menstrual episodes during their lifetimes.

As a result, today’s woman is more likely to have menstruation-related gynecologic complaints, which lead to diagnostic tests and surgical procedures. Indeed, as Ob/Gyns are all too aware, menstrual disorders and premenstrual symptoms account for a significant proportion of office visits. Furthermore, when these problems recur month after month for years, ovulation and menstruation may be associated with anemia, endometriosis, ovarian cysts, and increased risk of ovarian cancer.

Survey: Most women prefer less-frequent periods

Although some women like having a period each month, most would prefer less-frequent periods to prevent the problems associated with monthly menstruation, according to a recent investigation.1 These findings were similar to those of other studies.

Active pills can be extended by a specific number of consecutive weeks or by continuous days until breakthrough bleeding occurs.

In a telephone survey of more than 1,300 women in The Netherlands, 80% of currently menstruating women said they would prefer 1 or more changes in bleeding patterns, including less-painful menses, shorter menses, lighter menses, and even no menses.1 The majority (about 70% on average across 3 age groups: 15 to 19 years, 25 to 34 years, and 45 to 49 years) selected bleeding intervals ranging from every 3 months to never, and the remaining 30% said they would prefer monthly menses (TABLE 1). Told that menstruation can be manipulated by OCs, women expressed similar bleeding-frequency preferences.

TABLE 1

Preferred frequency of menses1

AGE OF RESPONDENTS
PREFERRED FREQUENCY15–19 years (n = 322)25–34 years (n = 325)45–49 years (n = 324)
Monthly29.5%35.1%30.2%
Every 3 months34.5%23.7%10.2%
Every 6 months6.2%6.2%4.0%
Yearly3.1%4.0%4.9%
Never26.4%31.1%50.6%
Reprinted from Contraception; vol 59; den Tonkelaar I, Oddens BJ; Preferred frequency and characteristics of menstrual bleeding in relation to reproductive status, oral contraceptive use, and hormone replacement therapy use; 357-362; 1999 with permission from Elsevier.

Effects of contraceptives on menses

Among the contraceptives that can significantly alter menstruation patterns are depot medroxyprogesterone acetate (DMPA), levonorgestrel implants, oral contraceptives (OCs), and the levonorgestrel intrauterine device (IUD). Which of these methods is best for an individual woman depends on her bleeding preferences, as well as traditional considerations such as efficacy, convenience, cost, health status, and side effects. Counseling women about alterations in menstruation is a critical component of initiating and continuing contraception. Attitudes about menstruation greatly influence contraceptive choices and affect a woman’s adherence to a particular method.

DMPA, which must be injected every 3 months, causes menstrual changes in almost all users. In most women, bleeding patterns are unpredictable in the first few months of use; the frequency and length of bleeding episodes then decrease, with most patients becoming amenorrheic over time.

Levonorgestrel implants, which are inserted subcutaneously in the upper arm, cause irregular bleeding in about two thirds of women during the first year of use. About a quarter continue to have regular menses, and a minority (about 10%) have no menses at all. After 5 years, most women resume a regular bleeding pattern.

Levonorgestrel IUDs reduce menstrual bleeding because the levonorgestrel released from the device inhibits the endometrial proliferation that normally would occur during the ovulatory cycle. This endometrial suppression is a local effect and is not immediate. The uterine lining thins only after several months. As a result, the user spots frequently during the first 4 months of use. After 12 months, bleeding is greatly diminished in about 80% of women and is completely lacking in the remaining 20%. The levonorgestrel IUD is one of the most effective means available for reducing menstrual blood loss.

OCs, the most popular form of reversible contraception in the United States, help regulate cycle length, making the timing of menses more predictable. Bleeding duration and volume are decreased in most users, as is dysmenorrhea.

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