REVIEW CME EDUCATIONAL OBJECTIVE: Readers will utilize menstrual manipulation safely to match each CREDIT patient’s needs CAITLIN W. HICKS, BA ELLEN S. ROME, MD, MPH Cleveland Clinic Lerner College of Head, Section of Adolescent Medicine, Medicine of Case Western Reserve Department of General Pediatrics, University, Cleveland, OH Cleveland Clinic Children’s Hospital Menstrual manipulation: Options for suppressing the cycle ■ ABSTRACT f they wish, women can have more con- I trol over when and if they menstruate. By Menstrual manipulation, ie, adjusting the menstrual using hormonal contraceptives in extended cycle by taking hormonal contraceptives, allows women or continuous regimens, they can have their to have their period less often or to avoid bleeding at in- period less often, a practice called menstrual convenient times. The authors review the various options, manipulation or menstrual suppression. the benefits, and the disadvantages of this practice. Actually, with the help of their clini- cians, women have been doing this for years. ■ KEY POINTS But now that several products have been ap- proved by the US Food and Drug Administra- The options for menstrual manipulation are extended tion (FDA) specifically for use in extended or or continuous regimens of oral, transdermal, or vaginal continuous regimens, the practice has become hormonal contraceptives; a levonorgestrel-releasing more widely accepted. intrauterine device; a progestin implant; and depot Reasons for suppressing menstrual flow med roxyprogesterone injections. range from avoiding bleeding during a particu- lar event (eg, a wedding, graduation, or sports competition) to finding relief from dysmenor- Benefits include fewer menstrual-related syndromes, less rhea or reducing or eliminating menstruation absenteeism from work or school, and greater overall in the treatment of endometriosis, migraine, satisfaction. Medical indications for it are conditions and other medical conditions exacerbated by exacerbated by hormonal changes around the time of hormonal changes around the time of menses.1 menses. Alternatively, some women may practice men- strual manipulation for no other reason than The main disadvantage is a higher rate of breakthrough to simply avoid menstruation. bleeding. ■ MENSTRUAL DISORDERS Myths and misperceptions about menstrual manipula- ARE TROUBLESOME, COMMON tion persist; some physicians believe it is somehow Each year in the United States, menstrual inadvisable. disorders such as dysmenorrhea (painful men- struation), menorrhagia (excessive or frequent menstruation), metrorrhagia (irregular men- struation), menometrorrhagia (excessive and irregular menstruation), and premenstrual syndrome affect nearly 2.5 million women age 18 to 50 years.2 Menstrual disorders are the leading cause of gynecologic morbidity in the doi:10.3949/ccjm.77a.09128 United States, outnumbering adnexal masses CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 77 • NUMBER 7 JULY 2010 445 Downloaded from www.ccjm.org on June 17, 2014. For personal use only. All other uses require permission. MENSTRUAL MANIPULATION TABLE 1 Current methods of menstrual manipulation M ETHOD N TRADE AME HORMONAL DOSAGE DOSING SCHEDULE ADVANTAGES DISADVANTAGES Continuous or Seasonale Ethinyl estradiol 0.03 mg Daily Least invasive Inconvenience of extended oral Seasonique and levonorgestrel daily dosing contraceptives Lybrel 0.15 mg a Intrauterine device Mirena IUS Levonorgestrel 20 μg Changed Can be used in 75% women released daily for 5 years every 5 years women in whom continue to have estrogen is con- regular cycles traindicated Medroxyprogesterone Depo-Provera About 1.6 mg/day Intramuscular 73% women Breakthrough injections (150 mg over 90 days) injection every achieve amenor- bleeding is 90 days rhea after 1 year common Transdermal patch Ortho Evra Ethinyl estradiol 0.02 mg Weekly Minimally invasive Possible increased and norelgestromin risk of thrombo- 0.15 mg released daily embolism in some users Vaginal ring NuvaRing Ethinyl estradiol 0.015 Every 3 weeks Produces most Increased mg and etonogestrel 0.12 uniform serum spotting mg released daily ethinyl estradiol levels Progestin implant Implanon Etonogestrel 0.06–0.07 Up to every Infrequent dosing 78% of women mg/day initially, 3 years continue to have declining over time regular cycles (68 mg over 3 years) a With Lybrel, ethinyl estradiol 0.02 mg and levonorgestrel 0.09 mg. (the second most common cause) by a factor In 1977, Loudon et al6 reported the results of three.2 In addition, these disorders extend of a study in which women took active pills for into the workplace, costing US industry about 84 days instead of 21 days, which reduced the 8% of its total wage bill.3 frequency of menstruation to every 3 months. Since then, extending the active pills beyond ■ A BRIEF HISTORY 21 days to avoid menses and other hormone- OF CONTRACEPTIVE DEVELOPMENT withdrawal symptoms has become popular in clinical practice, and many studies have in- The idea of using progestins for birth control vestigated the extended or continuous use of was first advanced in the 1950s by Dr. Gregory oral and other forms of contraception to delay Pincus, who proposed a regimen of 21 days of menses.7–18 active drug followed by 7 drug-free days to al- low withdrawal bleeding, mimicking the natu- ■ CURRENT METHODS ral cycle.4 This “21/7” regimen was designed OF MENSTRUAL MANIPULATION to follow the lunar cycle in the hope it would be, in the words of Dr. John Rock, “a morally A variety of available products prevent con- permissible variant of the rhythm method,”5 ception by altering the menstrual cycle: thereby making it acceptable to women, clini- • Oral estrogen-progestin contraceptive pills cians, and the Catholic Church. • A drug-releasing intrauterine device 446 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 77 • NUMBER 7 JULY 2010 Downloaded from www.ccjm.org on June 17, 2014. For personal use only. All other uses require permission. HICKS AND ROME • Depot medroxyprogesterone acetate injec- severe dysmenorrhea or other reasons to want tions to avoid flow). Patients could also try to man- • A transdermal contraceptive patch age flow by periodically taking a 3- to 5-day • A contraceptive vaginal ring break from hormone-containing pills to allow • An implantable etonogestrel contracep- flow. They can also try switching to another tive. oral contraceptive that has a different pro- Their use in menstrual manipulation is gestin that would spiral the arterioles of the summarized in TABLE 1. endometrium more tightly and thus more ag- gressively induce atrophy.13,17,21 For instance, Oral contraceptive pills levonorgestrel is 10 to 20 times more potent The most common way to manipulate the than norethindrone. Choosing a pill with a menstrual cycle is to extend the time between higher monophasic dosing of levonorgestrel or hormone-free weeks in an oral contraceptive a similar progestin may minimize unscheduled regimen. bleeding. If the patient is young, you can prescribe a Currently, several oral contraceptives are monophasic 21/7 oral contraceptive and tell approved for use in an extended regimen. her to take one active pill every day for 21 Seasonale was the first oral contraceptive days and then start a new pack and keep tak- marketed in the United States with an ex- ing active pills for up to 84 consecutive days, tended active regimen.22 It comes in a pack of skipping the placebo pills until she wants to 84 pills containing ethinyl estradiol 0.03 mg have her menstrual period. She can choose and levonorgestrel 0.15 mg, plus 7 placebo which week to have it: if the scheduled 12th pills. week of an extended-cycle oral contraceptive Seasonique is similar to Seasonale, but regimen is inconvenient, she can plan it for instead of placebo pills it has seven pills that week 10, or week 9, or whichever week is con- contain ethinyl estradiol 0.010 mg. venient. Lybrel is a low-dose combination contain- The rationale for using an 84-day (12- ing ethinyl estradiol 0.02 mg and levonor- week) cycle is that it still provides four periods gestrel 0.09 mg. Packaged as an entire year’s The most per year, alleviating fears of hypertrophic en- worth of active pills to be taken continuously common way dometrium.19 for 365 days without a placebo phase or pill- In this scenario, unscheduled or break- free interval,23 it is the only FDA-approved to manipulate through bleeding can be managed by taking continuous oral contraceptive available in the the menstrual a “double-up pill” from a spare pack on any United States. cycle is to day breakthrough bleeding occurs and until it resolves. Menstrual periods should not be An intrauterine device extend the days planned for intervals shorter than 21 days, Intrauterine devices were originally devel- of active oral owing to the risk of ovulation. Missed days oped as contraceptives. The addition of a of pills or use of placebo pills should also progestin to these devices has been shown contraceptive not exceed 7 days to prevent escape ovula- to reduce heavy menstrual bleeding by up to pills tion.20 90%.24,25 In some women with endometriosis and Mirena IUS, a levonorgestrel-releasing other medical reasons, continuous oral con- device, is the only medicated intrauterine de- traception with no placebo week can be pre- vice that is currently available in the United scribed. States. (“IUS” stands for “intrauterine sys- Unfortunately, the downside to suppress- tem.”) It was recently approved by the FDA to ing withdrawal bleeding is unscheduled or treat heavy menstrual bleeding in women who “breakthrough” bleeding. The best way to use intrauterine contraception as their meth- treat this unscheduled bleeding is not known. od of pregnancy prevention.26 About 50% of Patients who are not sexually active can be re- women who use this device develop amenor- assured that the goal of an atrophic endome- rhea within 6 months of insertion, while 25% trium can still be achieved, with resultant pill report oligomenorrhea.27 amenorrhea (particularly useful for those with The Mirena device can be left in the CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 77 • NUMBER 7 JULY 2010 447 Downloaded from www.ccjm.org on June 17, 2014.