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PERSONAL VIEW J Fam Plann Reprod Health Care: first published as 10.1136/jfprhc-2016-101438 on 25 November 2016. Downloaded from Postponing menstruation: choices and concerns

Diana Mansour

Consultant, Community BACKGROUND a day it is equivalent to and Reproductive Since writing an editorial for this journal taking a 20–30 μg EE combined oral Health Care, New Croft Centre, 1 1 Newcastle upon Tyne, UK in 2014 I have been repeatedly asked contraceptive (COC) pill. As clinicians, about my views on postponing menstru- we need to ask ourselves if we would be Correspondence to: ation. Women in the 21st century want happy prescribing a COC to the women Dr Diana Mansour, Community Gynaecology and Reproductive to avoid periods when on holiday yet requesting a supply of norethisterone? If Health Care, New Croft Centre, have difficulty accepting highly effective, the answer is no, then we should offer a Market Street East, Newcastle reversible forms of contraception which safer alternative. upon Tyne NE1 6ND, UK; provide infrequent bleeding. Authors of a The SPC for norethisterone tablets [email protected] BMJ article published 16 years ago sug- (5 mg) states that “previous idiopathic or Received 1 June 2016 gested that prescribing to current venous thromboembolism (deep Revised 3 September 2016 delay periods was a lifestyle choice and vein thrombosis, pulmonary embolism), Accepted 7 November 2016 should not be funded by the National active or recent arterial thromboembolic Health Service.2 I am not sure I feel that disease (e.g. angina, myocardial infarc- strongly but I do think women need to tion), the presence or a history of pro- know all options and any potential risks dromi of a thrombosis (e.g. transient or side effects associated with each treat- ischaemic attack, angina pectoris), a high ment – they may think twice. risk of venous or arterial thrombosis or a history of migraine with focal neurological by copyright. symptoms” are contraindications to its NORETHISTERONE use.3 It warns about the potential risk of Only one drug is licensed to postpone VTE in users and advises immediate dis- menstruation in the UK and that is nor- continuation if symptoms of a VTE occur. . The Summary of Product Characteristics (SPC) state that at low dose’ (5 mg three times a day) norethis- OTHER OPTIONS terone may be used to treat “metropathia In practice, clinicians have a number of haemorrhagica, , alternatives for those women wishing to postponement of menstruation, dysmen- postpone menstruation. The first is to orrhoea, endometriosis and menorrha- choose a contraceptive method that will gia”.3 There is limited evidence to provide high levels of amenorrhoea. Depot http://jfprhc.bmj.com/ support these indications1 but it does acetate (DMPA), delay the onset of menses. Why has nor- whether it is given intramuscularly or sub- ethisterone been our preferred choice for cutaneously, will result in about 55% of this indication? First, it works; second, it women having no periods over a 90-day is cheap; and third, many women return reference period by the end of the first to our clinics requesting a further supply year of use.4 Levels of amenorrhoea are on September 27, 2021 by guest. Protected year on year when they head off to the lower for other hormonal methods sun in the summer. (Ta b l e 1 ) but rely on women starting these My reservations about the use of nor- methods well in advance of their travels. ethisterone in postponing menstruation What other options are available to are related to safety. There is evidence to those wishing to delay their periods? suggest that taking norethisterone at doses 1 5 mg norethisterone taken three times a day, of 10 mg or more a day may increase a started before the onset of menstruation and JFam To cite: Mansour D. person’s risk of venous thromboembolism continued until menstruation can be toler- Plann Reprod Health Care 1 – Published Online First: [please (VTE). Norethisterone is one of a few ated. Bleeding normally commences 2 3 include Day Month Year] progestogens that can be aromatised to days after discontinuing norethisterone. doi:10.1136/jfprhc-2016- (EE).1 Therefore when 2 10 mg DMPA taken three times a day, started 101438 women are taking between 10 and 15 mg before the onset of menstruation and

Mansour D. J Fam Plann Reprod Health Care 2016;0:1–2. doi:10.1136/jfprhc-2016-101438 1 Personal view J Fam Plann Reprod Health Care: first published as 10.1136/jfprhc-2016-101438 on 25 November 2016. Downloaded from

Table 1 Amenorrhoea achieved with different methods of REFERENCES 1 Mansour D. Safer prescribing of therapeutic norethisterone for women at risk of venous thromboembolism. J Fam Plann Amenorrhoea achieved over a Reprod Health Care – 90-day reference period (unless 2012;38:148 149. Method of contraception otherwise specified) 2 Shakespeare J, Neve E, Hodder K. Is norethisterone a lifestyle drug? Results of database analysis. BMJ 2000; Jaydess® IUS 11.6% over time5 320:291. ® 6 Mirena IUS 23.6% at 3 years 3 Norethisterone tablets: Summary of Product Characteristics ® 7 Nexplanon 20% over time (revision of text 11.9.2015). https://www.medicines.org.uk/ Depo-Provera® 55% at 12 months4 emc/medicine/7257 [accessed 30 May 2016]. Sayana Press® 56.5% at 12 months8 4 Depo-Provera 150 mg/ml : Summary of Product Standard combined hormonal <1%9 Characteristics. https://www.medicines.org.uk/emc/medicine/ contraception given in a 21/7 11121 [accessed 30 May 2016]. regimen 5 Jaydess 13.5 mg intrauterine delivery system: Summary of combined pills with 19.4–31% absent withdrawal Product Characteristics. https://www.medicines.org.uk/emc/ shorter -free intervals bleeds over time10 11 medicine/28672 [accessed 30 May 2016]. POP 20% at 12 months12 6 Gemzell-Danielsson K, Schellschmidt I, Apter D. A Traditional POPs 3% at 12 months12 randomized, phase II study describing the efficacy, bleeding profile, and safety of two low-dose -releasing IUS, intrauterine system; POP, -only pill. intrauterine contraceptive systems and Mirena. Fertil Steril 2012;97:616–622. continued until menstruation can be tolerated. Bleeding nor- 7 Nexplanon 68 mg implant for subdermal use: Summary of mally commences 2–3 days after discontinuing DMPA. It is Product Characteristics. https://www.medicines.org.uk/emc/ not licensed for this indication and there is no published evi- medicine/23824/SPC/Nexplanon+68+mg+implant+for dence to support its use for postponing menstruation, +subdermal+use/ [accessed 30 May 2016]. although it has been shown to reduce heavy menstrual 8 Sayana Press 104 mg/0.65 ml suspension for injection: 13 bleeding at this dose. Anecdotally, it may not be as effect- Summary of Product Characteristics. https://www.medicines. ive as norethisterone in delaying menstrual bleeding. org.uk/emc/medicine/27798 [accessed 30 May 2016]. 3 Starting a combined hormonal contraceptive (CHC) 9 Foidart JM, Wuttke W,Bouw GM, et al. A comparative

method such as a monophasic COC or before investigation of contraceptive reliability, cycle control and by copyright. menstruation may delay the next period. Advising tolerance of two monophasic oral contraceptives containing Eur J Contracept Reprod back-to-back administration can also be tried.14 A CHC pro- either or desogestrel. Health Care – vides contraception as well as cycle control, although break- 2000;5:124 134. 10 Ahrendt HJ, Makalová D, Parke S, et al. Bleeding pattern and through bleeding is more common in the first few months. cycle control with an estradiol-based oral contraceptive: A number of preparations now have information concerning a seven-cycle, randomized comparative trial of estradiol 15 16 the missing of a withdrawal bleed in their SPCs. valerate/ and ethinyl estradiol/levonorgestrel. 4 If there is some forward planning the timing of the Contraception 2009;80:436–444. period can be altered by either taking 5 mg norethister- 11 Mansour D, Verhoeven C, Sommer W, et al. Efficacy and one twice daily or DMPA 10 mg twice daily for 10 days tolerability of a monophasic combined oral contraceptive to induce a bleed. This should move the date of the sub- containing acetate and 17β-oestradiol in a 24/4 sequent period. regimen, in comparison to an oral contraceptive containing

ethinylestradiol and drospirenone in a 21/7 regimen. Eur http://jfprhc.bmj.com/ CONCLUSIONS J Contracept Reprod Health Care 2011;16:430–443. et al So to conclude, when faced with a mother requesting 12 Korver T, Dieben T, Vree M, . A double-blind study comparing the contraceptive efficacy, acceptability and safety of medication to delay her daughter’s period, or a two progestogen-only pills containing desogestrel 75 μg/day or woman wishing to avoid menstruating while on levonorgestrel 30 μg/day. Collaborative Study Group on the holiday or at a religious festival, we should discuss: Desogestrel-containing Progestogen-only Pill. Eur J Contracept 1 The relevant treatment options. Reprod Health Care 1998;3:169–178. 2 The potential VTE risks associated with CHCs and nor- 13 Fraser IS. Treatment of ovulatory and anovulatory on September 27, 2021 by guest. Protected ethisterone, especially if long-haul flights or prolonged dysfunctional uterine bleeding with oral progestogens. Aust N periods of immobility on coaches or in cars are planned. Z J Obstet Gynaecol 1990;30:353–356. 3 Contraceptive choices that may reduce menstrual blood loss. 14 Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Combined Hormonal Contraception. Competing interests Dr Mansour declares no support from any October 2011. https://www.fsrh.org/documents/ organisation for the submitted work. Dr Mansour has received combined-hormonal-contraception/ [accessed 1 June 2016]. research grants and honoraria for attending advisory board 15 Nuvaring: Summary of Product Characteristics. http://www. meetings, developing and delivering educational presentations from Aspen, Astellas, Bayer plc, Consilient Healthcare, HRA medicines.org.uk/emc/medicine/21419/SPC/nuvaring/ [accessed Pharma, Mithra, MSD and Vifor Pharma. No other 30 May 2016]. relationships or activities have influenced the submitted work. 16 Yasmin film-coated tablets 0.03 mg/3 mg: Summary of Product Provenance and peer review Not commissioned; externally Characteristics. https:// http://www.medicines.org.uk/emc/ peer reviewed. medicine/8777 [accessed 30 May 2016].

2 Mansour D. J Fam Plann Reprod Health Care 2016;0:1–2. doi:10.1136/jfprhc-2016-101438