In Our Control (29 page)

Just the Facts Ma’am: The Basics of Menstrual Suppression Drugs

There are currently several different hormonal methods that a woman can use to stop her periods (although as I have shown, this is an imprecise process at best). Depo-Provera and the hormonal IUD Mirena use only the hormone progestin to accomplish this end. In both cases the suspension of periods was an unanticipated side effect and originally seen as the price of using a more effective contraceptive, not a selling point of the drugs.
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The vaginal ring (NuvaRing), a clear flexible device that releases estrogen and progestin when placed in the vagina, has been tested for extended use,
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as have alternative distribution devices like the estrogen patch—although far less study is generally available on these devices, let alone on the specifics of use for eliminating or curtailing menstruation.

Seasonale offers estrogen and progesterone for eleven weeks and sugar pills for one week (when withdrawal bleeding happens), and Seasonique, a more recent product from the same manufacturer, replaces the week of sugar pills with pills containing low doses of estrogen. Lybrel offers continuous estrogen and progesterone.

Another option is the use of birth control pills that reduce the number of inactive pills and therefore the days of bleeding. This class constitutes a sort of middle ground between traditional OCs and newer menstrual suppression drugs. Some brand names include Yaz, Loestrin, and Alesse.

Traditional oral contraceptives, when used continuously by skipping inactive pills, provide the same results as using Lybrel. Some doctors believe this is a better option for women who choose to eliminate periods because it avoids the expense of buying a new drug and opens up the possibility of using cheaper generic prescriptions. Washington state–based gynecologist Leslie Miller advises, “I don’t think women need another
brand name contraceptive like Lybrel.”
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Bi- and tricyclic birth control pills should not be used for this purpose because the shift in hormones is too rapid without the inactive week, and irregular and spotty cycles are usually the result. If you are considering this regimen, talk to your doctor about whether it is the right option for you.

Menstrual suppression drugs work through the same mechanisms as older OCs—they prevent the brain from sending messages to the reproductive system to develop egg follicles. They also stem the growth of the uterine lining, so that if fertilization does occur, implantation is less likely, and they cause cervical fluids to remain inhospitable to sperm.

New menstrual suppression drugs carry approximately the same health risks as older OCs. The
American Family Physician
advises patients that they found “no difference in safety or effectiveness between cyclic and continuous or extended-cycle combined contraceptives” and that “patients’ satisfaction and adherence is similar for all types.”
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Taking the drugs in the short term doesn’t seem to harm the uterus
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or fertility. In a trial to test the ability of women to return to menstruation and ovulation after use of menstrual suppression, a researcher found that “99 percent of 187 participants experienced either a return to menses or become pregnant within 90 days after stopping the study drug.”
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Keep in mind that these participants took Lybrel for an average of one year—not a long time—and that 187 is a small study population.

Of course, new drugs always open up long-term safety questions that only time and further scientific study can answer. The question is what difference, if any, continuous exposure to hormones makes when compared with interrupted exposure over time. Remember that the longest trial of new menstrual suppression methods has lasted only two years. While this may seem like a long time, in the scope of comprehensive understanding of drugs, it is relatively short. Many side effects take decades—and populations of thousands taking a given prescription—to emerge. The Society for Menstrual Research cautions, “Long-term studies that address potential risks beyond the uterus, such as breast, bone, and cardiovascular health are still needed. Furthermore, there is an urgent need for studies that address impacts on adolescent development, since young women and girls are a target audience for cycle-stopping contraceptives.”
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Indeed, the question of how menstrual suppression drugs might affect
very young girls differently is an important one. Recall the case of Depo-Provera, the first menstrual suppressant. Often given to young girls because they are less reliable with daily pills and the injection need only be given every three months, the drug has been shown to cause a loss in bone density, leading to the placement of the FDA’s mandatory black box warning on patient package inserts.
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Similarly, menstrual suppression drugs are frequently marketed to women who suffer either painful or erratic periods. Young women in the first year or two of menstruation are far more likely to experience both of these problems, and it makes them a particularly lucrative population for drugmakers. Just as many women suffer greater discomfort for a few years at menopause (on average, 2.5) as cycles are winding down, so do girls adjusting to their hormonal and menstrual fluxes need time to let their body transition. For this reason, many gynecologists advise that girls not be given the drugs until they have had a chance to menstruate naturally for at least a year. It is hard to argue that a woman who has never experienced nonmedical periods has had adequate personal experience to make comprehensive, informed decisions about the value of such events.

There are serious practical concerns with menstrual suppression drugs. Something so basic that many don’t consider is that women use menstruation—and withdrawal bleeding—as a tool for determining whether they are pregnant. If a woman becomes pregnant and continues taking hormone drugs, serious complications may occur. Diethylstilbestrol (DES) was an estrogen drug given to women in the 1960s and 1970s to prevent miscarriages. It did not ultimately accomplish this task; however, it did cause sexual and reproductive problems for mothers, babies, and even the offspring of children born using DES. One of the important lessons of DES was the danger of exposing fetuses to estrogen drugs, particularly after the first months of gestation. It seems possible that a mother taking menstrual suppressants could have a similar outcome.

Delayed discovery of a pregnancy raises other issues for a woman who does not wish to carry it to term. Since accessing second trimester abortions in the United States is very difficult, prompt discovery of unwanted pregnancies is paramount for many women. Even where they are legal, terminations get more expensive with time, and a delay can make a procedure cost prohibitive.

For these reasons, the FDA recommends taking a pregnancy test each month when using drugs that eliminate or curtail bleeding, just to be on the safe side.
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There are other benefits to menstruation. Susan Rako points out that in focusing on ovulation and bleeding, doctors ignore related dynamic, ongoing hormonal processes. She insists there is a “popular ignorance of the particular health benefits that accrue to women as a result of normal hormonal fluctuations and the monthly bleed … Women’s reproductive hormones play a part in the normal functioning of every organ system in the body.”
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Indeed many of the complexities of female hormone cycles are still ill understood and pronouncing them useless is both premature and dangerous.

An example of the hazards of such thinking can be seen in changing ideas about the safety of performing oophorectomies in women. For generations, doctors insisted that once reproduction was over, organs such as the uterus and ovaries served no function except tempting the possibility of female cancers. For this reason, hyster- and oophorectomies became some of the most common surgical procedures in American life. To this day, one in three American women will have had her uterus surgically removed by the time she dies. It has since come to light that the ovaries do much more than make eggs and, by extension, babies. The ovaries continue to produce important female hormones even after menopause. Their removal, particularly before the menopause transition, increases a woman’s chances of dying from many illnesses. William Parker, a California-based gynecologist and medical school professor, found that in a group of 10,000 women, for every 47 who are saved from ovarian cancer by the surgery, an additional 838 will die from coronary heart disease when compared with women who kept their ovaries.
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A reductionary understanding of parts of the body and their processes can lead to avoidable tragedies. Women have historically been subject to an undue amount of these.

In the media blitz that surrounded the approval of both Seasonale and Lybrel, the Society for Menstrual Cycle Research provided a tempering voice. After a 2007 meeting, the Society released a paper calling for more research on long-term effects of the drugs. In addition to pointing out the importance of examining psychological factors as well as biological ones, they stress that these drugs “suppress the complex hormonal interplay
of the menstrual cycle. The impacts of this cycle on women’s health are not completely understood.”
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They conclude that “authentic choice is only possible when accurate and comprehensive information is widely available.”
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A “Natural” Choice

For many women, the fluctuations of the menstrual cycle provide unique opportunities for understanding their lives, their societies, and their emotions. This brings us back to the problem of negative cultural messages and how women can manage and understand their bodies in a world that wants to control, pathologize, and interpret them.

The various marketing campaigns for both Lybrel and Seasonale present a great example of how difficult this can be. They universally assume that women don’t like to menstruate. Tracy Clark-Flory writes, “To view the Lybrel Web site, you might think that women everywhere have been waiting desperately for the chance to postpone their periods … It turns out that not all women want to cure the curse. Wyeth’s own research says so.”
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Having assumed that no woman would want to miss out on the opportunity to suspend bleeding, drugmakers proceed to play on conflicting ideas of technology and nature, youth and affluence, illness and lifestyle, and of course, female liberation and traditional women’s roles.

I scan for examples of menstrual suppressants in the media and find
Sex and the City
author Candace Bushnell pushing Seasonale as though it were a pair of Manolo Blahniks. And an advertising campaign for Loestrin 24 follows the adventures of a fictional character named Cammie—as hip, urban, and well off as the characters in Ms. Bushnell’s book—as she negotiates life in New York City. Cammie is in her midtwenties with a boho apartment in Alphabet City loaded with fashionable clothes and a rocker boyfriend who fronts an indie band. For Cammie, a period that lasts only three days is a state-of-the-art-accessory—like an iPod or a designer handbag. In both these commercials, period control is sold as a marker of affluence and style, a natural accoutrement to modern life.

Such focus on modernity, technology, and choice functions in direct
contradiction to arguments about the so-called naturalness of menstrual suppression. It’s not about what all women have been doing for generations; it’s about what modern women can and should do right now. Drugmakers’ stress on lifestyle factors betrays their hopes that menstrual suppression will be adopted not to treat abnormal or problematic menstruation, but rather as just another lifestyle option for healthy women, like attending a yoga class or eating grass-fed meat.

In selecting “chick lit” imagery, pill makers have chosen a nuanced archetype that is at once independent and current and also fundamentally tied to traditional notions of female desire. Jaclyn Geller, among others, has pointed out that the characters in the television version of
Sex and the City
initially resist, but ultimately succumb, to social conventions regarding love, sexuality, and the social world.
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Carrie Bradshaw is both content in the nontraditional family structure her friends provide and desperately searching for the perfect man.

Likewise, period suppression drugs seek to convince women in the language of independence and self-sufficiency that they should cede control of their bodily functions to a drug company. Yaz, another period shortener, blasts punk music that effuses, “We’re not gonna take it!” Again, the rhetoric of cultural resistance is employed with the goal of ensuring pharmaceutical compliance. Much like early twentieth-century menstrual product makers, pill pushers have realized how effective co-opting the language of feminism can be.

A Seasonique advertisement depicts two identical but differently dressed women who identify themselves as “emotional” and “logical.” Emotional wants to take menstrual suppressants, but she is scared—it just doesn’t seem right somehow. Logical assures her that it is safe and, in fact, the rational and smart thing to do. This advertisement works on many levels, not the least of which is that it plays on women’s internalized fears of being perceived as irrational and driven by their feelings—something considered more true before and during menstruation. The advertisement encourages women to identify with the confident, scientific, self-controlled voice of logical over the insecure, timid persona of emotional. Even as this commercial plays on images of modern, take-charge women, it exploits deep and historic stereotypes of women in general and menstruating women in particular.