Menstrual suppression: current perspectives

Figures & data

Table 1 Medical conditions that may benefit from menstrual suppression

Gynecologic conditions

Chronic pelvic pain^Citation32

Dysmenorrhea^Citation33

Endometriosis^Citation34,Citation35

Heavy menstrual bleeding^Citation30,Citation32

Uterine leiomyomata

Anemia due to heavy menstrual bleeding

Irregular bleeding/anovulation

Polycystic ovary syndrome (PCOS)^Citation36

Perimenopausal symptoms^Citation32

Premenstrual syndrome (PMS)/premenstrual dysphoric disorder (PMDD)^Citation37^–^Citation39

Pre-procedure

Obstructing utero-vaginal anomalies pending definitive surgery^Citation40

Pre-operative endometrial thinning prior to endometrial ablation^Citation41

Menstrual molimina^Citation42

Breast pain

Headaches

Nausea/cyclic vomiting

Hematologic conditions

Anticoagulation^Citation43

Malignancy requiring chemotherapy/BMT^Citation44

Inherited anemia/bleeding disorders^Citation45,Citation46

Sickle cell disease^Citation47

Thalassemias

Fanconi anemia

Von Willebrand disease^Citation48

Hemophilia, clotting factor deficiencies

Other hematologic conditions

ITP/thrombocytopenia^Citation49

Mental retardation/developmental delay^Citation50,Citation51

Behavioral issues/PMS symptoms

Contraception

Hygiene/inability to manage menstrual products

Neurologic disease

Migraine headaches^Citation52,Citation53

Menstrual migraines

Menstrual-associated migraines

Seizure disorders^Citation54^–^Citation56

Catamenial seizures

Other conditions associated with menstrual exacerbation^Citation57,Citation58

Anaphylactoid reactions^Citation59

Asthma^Citation60,Citation61

Catamenial pneumothorax^Citation62

Diabetes mellitus^Citation63

Irritable bowel syndrome^Citation64,Citation65

Pancreatitis^Citation66

Rheumatoid arthritis

Skin conditions

Acne^Citation60

Other

Deployed military personnel^Citation67

Female athletes^Citation32

Physical difficulty with managing menstrual hygiene

Cerebral palsy

Rheumatoid arthritis

Abbreviations: BMT, bone marrow transplant; ITP, idiopathic thrombocytopenic purpura; PMS, premenstrual syndrome.

Table 2 Options for inducing therapeutic amenorrhea

Medication	Dosing	Frequency	Limitations	Amenorrhea	Advantages	Disadvantages
Continuous combined oral contraceptives (COCs)	Multiple formulations; monophasic formulations discarding placebo pills or dedicated packaging for extended cycle	Daily	BTB; other hormonal side effects;^Citation28 risk of VTE^Citation68	~70% at 1 year with continuous use;^Citation69 extended cycle use	Long history and clinical experience with both cyclic and extended use	Daily compliance required; variable duration of menstrual suppression before BTB
Transdermal combination contraceptives	Patch used continuously or extended cycle	Weekly	Similar to COCs;^Citation28 skin reaction; possible increased risk VTE cf with COC^Citation70	Extended 84/7 cycle fewer days of BTB than monthly use^Citation25	Weekly compliance easier than daily COCs	Risks of VTE; little data regarding continuous use
Vaginal contraceptive ring	Ring used continuously or extended cycle	Monthly	Similar to other combined methods	Rates of spotting not reduced with extended or continuous use compared with monthly use^Citation71	Monthly compliance easier than daily or weekly	Higher discontinuation rates because of BTB with both extended and continuous regimen
Depot medroxyprogesterone acetate (DMPA)	150 mg IM 104 mg sub-Q	Every 12 weeks	BTB; progestin related side effects; weight gain; reversible impact on bone density with prolonged use (>2 years)^Citation72	50%–60% at one year; ~70% at 2 years^Citation73	Every 12 weeks administration	Weight gain; potential impact on bone density (reversible)
Oral progestins	Varies by progestin, eg, norethindrone acetate 5 mg bid–tid; medroxyprogesterone acetate; megestrol up to 80 mg/d	Daily	Irregular bleeding; progestin-related side effects; adverse impact on lipids	Up to 76% with high dose progestins at two years^Citation74	May be useful if estrogens are contraindicated; oral dosing is adjustable compared to DMPA	Inconsistent achievement of amenorrhea; more expensive than COCs; need for consistent and strict compliance
GnRH analogs	Formulation-dependent: IM, subdermal implants, intranasal	Formulation-dependent: daily or more, to every 12 weeks	GnRH agonists have an initial stimulatory effect and bleeding prior to suppression; menopausal symptoms; impact on bone density with prolonged use	High rates	May provide ovarian protection from chemotoxic effects of chemotherapy^Citation44,Citation75,Citation76	Menopausal effects limit therapy but may be given with hormonal “addback” to minimize these side effects; very expensive; potential impact on bone density
Progestin-containing intrauterine system	Levonorgestrel release 20 μg per day	Five years	Initial BTB and possible hormonal effects improve with time	50% at 1 year;^Citation77 60% at 5 years^Citation78	Top tier contraceptive efficacy, with benefits demonstrated for medical conditions including heavy menstrual bleeding, endometriosis, adenomyosis, fibroids^Citation30,Citation79^–^Citation81	Initial expense and insertion-related pain/discomfort
Danazol	Typically 400–800 mg po per day^Citation82	Daily	Dose related: menopausal symptoms, weight gain, and androgenic side effects limit therapy^Citation71,Citation83	High rates		More side effects than progestins; expensive

Abbreviations: BTB, breakthrough bleeding; cf, compare; po, orally; GnRH, gonadotropin-releasing hormone; IM, intramuscular; bid, twice daily; tid, three times daily; sub-Q, subcutaneous; VTE, venous thromboembolism.

Table 3 Instructions to patients

1. No method of menstrual suppression is perfect. Irregular, unpredictable bleeding or spotting occurs in the initial months of treatment with all therapies. While this can be bothersome, it is usually not medically worrisome, doesn’t mean that the treatment isn’t working for birth control or that it won’t eventually cause bleeding to stop.

2. Write down or record electronically all bleeding (with a menstrual-tracking application for smartphone or tablet) so that you and your clinician can discuss management at a follow-up visit.

3. Irregular bleeding and spotting almost always get better after the first 1–3 months of treatment, although it may take up to a year (or occasionally longer for some people) for most bleeding to stop.

4. Not all irregular bleeding is due to the effects of hormones, especially if your initial irregular bleeding has stopped. Sometimes bleeding can signal a sexually transmitted infection (STI) or other cause (such as polyps, or uterine growths like fibroids). Talk with your clinician and be tested for STIs if you are at risk.

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