Campus Chronicle

Issue date: 4/28/08 Section: Pulse

Dr. George

Q: What are the consequences associated with not getting your period every month when using the new birth control pills that allow you to go four months without one?

A:?For a guy, I hope you realize this is difficult for me to address. I, like millions of other guys, still won't (even under threat of death or disability) go into my wife's purse to get something for her. I'll bring it to her for her to find whatever. We men are terrified of what we might find in a woman's purse. What is it that puts terror into the hearts of macho men? You know. "It" is anything related, no matter how remotely, to women's periods.

Ironically, some women feel guilty at the concept of fooling Mother Nature and shirking their duty to have their monthly "curse." Rather than being judged narcissistic by avoiding some pre-ordained obligation to welcome "their friend" monthly, it turns out that a woman today actually goes through more menstrual periods than her mother and grandmother. An earlier onset of periods (known as menarche), fewer pregnancies, reduced duration of breastfeeding, and later "change of life" (menopause) have combined to give today's woman many more menstrual cycles than decades ago. So, look at it as "payback" if you get to skip a few periods, I say.

Parenthetically, there is a name for couples who have unprotected sex. They are called "parents." For most of you, that is something best delayed until your education, and your time for being irresponsible and self absorbed, have played out. Nothing wrong with it. However, once you become Mommies and Daddies, the "I" word disappears from your vocabulary and your life. Your desires become secondary to the needs of your child(ren). Trust me on this one. Nevertheless, if history is any measure, some of you will play, in your ignorant bliss, "sexual roulette" as often as you can find a willing partner.

To understand how the newer, longer suppression of menses pills work, it is necessary to have a short lesson in human physiology. Unless you were one of the people paying attention in health class when they covered this, many of you are without a clue as to how a normal menstrual period happens. In a typical month of a woman of reproductive age, ovulation (release of an egg from one of the ovaries) takes place at roughly mid-cycle-the time in the middle between periods. Meanwhile, the inner lining of the uterus is undergoing a hormonally-controlled proliferation of tissue. This is in preparation for that egg, if fertilized, to become implanted in the uterus. If all goes well, in nine months, give or take, a baby results. If the egg is not fertilized, however, that hormonal surge ceases resulting in sloughing of that same inner uterine tissue.

Ovulation can be prevented for a prolonged period by the estrogen/progesterone containing birth control pills that have been in use for 30 or more years. With no ovulation, no period occurs. Birth control pills cause a negative feedback on the release of a third hormone (long name, it won't be on the test) that triggers ovulation to occur. With no ovulation, there is no amplification of endometrial tissue. This lack of buildup of uterine tissue can be prolonged for three months, a whole year, or even indefinitely!

The concept that monthly bleeding is necessary and healthy has been taken as a matter of course for generations. It has also been perpetuated by the original oral contraceptives that were initially designed to mimic the average length of normal menstrual cycles. The length of this "artificial period" was chosen partly to be acceptable to skeptical women, but was really entirely arbitrary. Not only can the cycle length be expanded for as long as desired, but there are many beneficial medical reasons for extending it for several months or more.

Of great importance, fewer periods mean a reduction in the risk of ovarian and endometrial (uterine) cancer. With less bleeding, anemia also, becomes much less common. Dysmennorhea, or painful cramping with periods and all the symptoms characterized as premenstrual syndrome are reduced proportionate to the lengthening of the cycle. Menstrual associated migraines are similarly minimized.

Benefits also exist for women related to cost and convenience. When informed that monthly bleeding is not necessary for good health, most women much prefer less frequent menses. No surprise there. Avoidance of uterine bleeding is especially desirable during vacations, business travel, camping, military maneuvers, academic exams, and athletic competitions. Hygiene for mentally and physically disabled women is also difficult during menses, so fewer periods are advantageous for them and their caretakers. Cost savings with extended use oral contraceptives can be quite substantial. Savings include fewer pads and tampons, analgesics, iron replacement therapies, and missed work days.

Hormonal contraception can be fashioned to reduce or even eliminate monthly uterine bleeding. Extending the use of active hormones continuously over several cycles, based on the individual's preference, decreases the number of times that she will experience a hormone free interval and the consequent withdrawal bleeding. One regimen, marketed under the trade name of Seasonale, was designed specifically to decrease menstrual bleeding to four (i.e. seasonal) times per year. Lybrel is the first low dose oral contraceptive designed to be taken 365 days a year, without a placebo phase or pill free interval to cause withdrawal bleeding. Theoretically, one could continue a menses free existence for several or even many years. Cessation could be used for the purposes of child bearing, at a women's discretion.

Contraceptive effectiveness, excellent for traditional oral contraceptive pills, remains superb. Importantly, there appears to be no abnormalities of the uterine lining that are not reversed when the pill is discontinued. 50 percent of women have a period within 30 days, and within 90 days, 98 percent of women have either become pregnant or have return of spontaneous menses. Of minor concern, there is some breakthrough spotting that tends to become spaced out and stops over time.

Extended use oral contraceptives are not for every woman. There remain some of the concerns that surfaced with the original birth control pills, although they have been minimized by the use of lower dose estrogen and progestin containing pills. Stroke and coronary artery disease may still be increased in women taking birth control pills. There are conflicting studies, but even with a several fold increase (which is higher even than the studies that suggest any increase have suggested) incidence of stroke and myocardial infarction (heart attack) are so low in this population that these risks are far exceeded by the hazards of pregnancy. Blood clots are also probably more common with the use of oral contraceptives, especially in smokers. You don't need to be a rocket scientist to see how to manage that problem. The risks and benefits of oral contraceptives is a complicated decision that one should discuss with their doctor before use.?

My professional opinion on the subject is that the extended use oral contraceptives are very appealing for many women. Take this advice with a grain of salt, however. A man giving advice about women's menstrual problems is like a woman giving advice about erectile dysfunction. In other words, "thanks for the info, but you really can't understand."

Dr. George is an Emergency Room physicians with the University of Illinois at Chicago's Medical Center.

As with all medical advice, consult your physician before beginning any regimen or if symptoms persist for more than five days.

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