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Contraception Corner

Suppressing Menstruation With Extended Hormonal Contraception

Barbara Clark, RN, MSN, MPH; Alison Edelman, MD, MPH

The concept of menstrual suppression with extended-cycle contraception appeals to most women. With more types of contraceptive options available, both physicians and patients have questions regarding how to achieve menstrual suppression with extended-cycle contraception and concerns regarding the safety.

For years, physicians have treated various medical conditions (eg, iron-deficiency anemia, dysmenorrhea, menorrhagia) by suppressing menstruation with continuous or extended dosing of combined progestin/estrogen oral contraceptives (OCs).1 In addition, menstrual suppression has been prescribed for nonmedical reasons (eg, sporting events, weddings, vacations).2 Several options are available for suppressing menstruation: the extended-use OC (levonorgestrel [LNG]/ethinyl estradiol[EE]), which provides 3 monthsê worth of active pills; the traditional cyclic OC (eliminating the hormone-free week, ie, > 28 days of active pills); the contraceptive vaginal ring (etonogestrel/ EE); and the transdermal patch (norelgestromin/EE). The latter three products can be dosed continuously, but the US Food and Drug Administration (FDA) has not approved this indication.3,4 Menstrual suppression is also an expected side effect that can occur with injectable medroxyprogesterone acetate, the LNG-releasing intrauterine system, and with progestin-only pills.

Women are increasingly receptive to delaying their menstrual periods, according to a 2005 survey by the Association of Reproductive Health Professionals (ARHP).5 In general, women reported that they do not like to have periods, they are familiar with hormonal contraception, and they are interested in menstrual suppression. Also, while more women are aware of menstrual suppression, many do not understand the physiologic process.

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EXTENDED REGIMENS


Extended contraceptive regimens6—including extended-use OCs,7 the transdermal patch,4 and the vaginal ring3—are all viable options for delaying or eliminating menstruation. Research shows that bleeding problems and menstrual symptoms with these extended regimens are either equivalent to or improved compared with standard cyclic dosing regimens.

Oral Contraception

A 2005 review of randomized trials compared traditional cyclic dosing of OCs (21 days of active pills and 7 days of placebo) with extended/continuous use (> 28 days of active pills).6 Researchers found that contraceptive efficacy, compliance, satisfaction, overall discontinuation, and discontinuation for bleeding problems were similar for both regimens. Of the few studies measuring menstrual symptoms (eg, headache, fatigue, dysmenorrhea), women using the extended cycle fared better than those using the 28-day cycle. In five of six studies, those using the extended cycle had either equivalent or improved bleeding patterns compared with those using the traditional 28-day cycle. Direct comparisons between regimens were difficult due to varying types of pills and length of regimen.

The extended-use OC package (84 days active, 7 days inactive) is a monophasic regimen using 150 mg LNG and 30 mcg EE. In a randomized, multicenter study of 1,394 women,7 results indicated that the extended regimen is comparable to the conventional regimen in efficacy, duration of withdrawal bleeding, and nonmenstrual side effects. Women had more frequent unscheduled bleeding days initially with the longer regimen, but these declined over time.

Contraceptive Patch

In a randomized study of 239 women, subjects used the transdermal contraceptive patch in an extended regimen—ie, weekly application for 12 consecutive weeks, 1 patch-free week, and 3 or more consecutive weekly applications. Controls used a cyclic regimen (4 consecutive cycles of 3 weekly applications and 1 patch-free week).4 Women using the extended regimen had fewer median bleeding days than those using the cyclic regimen (6 extended, 14 cyclic, P < .001), fewer bleeding episodes (1 extended, 3 cyclic, P < .001), and fewer bleeding and/or spotting episodes (2 extended, 3 cyclic, P < .001). (Episodes are defined as any set of one or more consecutive bleeding or spotting days [or bleeding and spotting days combined], bounded by bleeding-free days.) Those using the extended regimen also had a delayed median time to first bleed of 54 days compared with 25 days for the cyclic regimen. Both groups were highly satisfied. There were no statistically significant adverse events.

Recent attention has been focused on the contraceptive patch because of new information regarding its pharmacokinetic profile. The contraceptive patch appears to have a higher average EE level than either the contraceptive vaginal ring or an OC with a 35 mcg EE component. There is some evidence that during traditional cyclic use (3 consecutive weeks of patch use) the average EE level increases slightly with each successive week of use. At this time, it is unknown whether this increased estrogen exposure also increases the risk of adverse events, but the FDA has not made any changes to the prescribing recommendations for the patch. Currently, there is no published information regarding EE levels with longer than 3 weeks of consecutive patch use. Studies of extended-patch regimens show no increase in adverse events, but these studies are not large enough to detect rare adverse events (eg, thromboembolism). Based on this uncertainty, women considering off-label use of the patch for extended regimens should take this information into account.

Vaginal Ring

Another randomized trial compared a standard 28-day cycle (21 days of ring use followed by 7 ring-free days) to three different extended vaginal-ring regimens (a 49-day cycle, a 91-day cycle, and a 364-day cycle).3 The study enrolled 429 women but only 67% (289/429) completed the entire year. Overall, women tolerated the different cycle lengths well, but there was less drop-out in the shorter cycle groups. Women randomized to the extended cycles had fewer bleeding days, but more spotting days than those taking the standard cycle. There were no differences in adverse effects.

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CONSUMER AND CLINICIAN ACCEPTANCE

The ARHP commissioned an Internet survey of 1,021 women aged 18 to 40 years on menstrual suppression.5 The researchers also conducted in-depth interviews with 25 OB/GYNs, primary care physicians, nurse practitioners, and physician assistants.

When asked how they felt about their periods and the prospect of altering them, 77% of women said that menstrual periods are just something to –put up with,” while only 8% said that they enjoyed their periods in some way. While 78% would choose to have a period less than once a month, 40% would prefer never to have one.5

Although women are becoming more familiar with menstrual suppression, many still have misperceptions. For example, some women believe that continuous hormonal contraception does not stop menstruation. Womenês major concerns about menstrual suppression are safety (Table 1) and cost. To reduce costs, some physicians use traditional cyclic OCs rather than the dedicated 3-month OC to extend the menstrual cycle. However, some insurance programs do not allow pharmacies to give patients enough packs to support a continuous regimen.5

Table not available online

Table 1. Other Concerns Also Weighing Heavily5

Approximately 50% of the health care providers said that they offered continuous-regimen OCs to their patients, with many selecting candidates according to their insurance status and stage of life. They also noted that certain groups—eg, those with severe menstrual symptoms or lower income, and younger women—are more receptive to menstrual suppression than others.5

Other providers said that they wait for women to ask them about extended contraception, but many women fail to ask because they are unaware of this option. In addition, patients may fear that it confers a greater risk of gynecologic cancers and other problems.5

Women and health care providers are learning about menstrual suppression, but barriers remain: acceptability, awareness, cost, and safety. To help overcome such barriers, health care providers should educate women about continuous contraception and anticipate some common questions (Table 2).

Table not available online

Table 2. Extended-use Contraception: Patient Discussion Topics

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CONCLUSION

The time is ripe to offer women extended/continuous contraception. Women are ready and willing to learn more, and now they have a variety of extended-cycle options. Health care providers can address doubts and misconceptions about hormonal menstrual suppression through education, giving patients more control over symptoms and situations that can significantly impair their ability to function.

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Barbara Clark, RN, MSN, MPH, is a freelance writer in Arlington, Va. Alison Edelman, MD, MPH, is assistant professor, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland.

References

1. Kwiecien M, Edelman A, Nichols MD, Jensen JT. Bleeding patterns and patient acceptability of standard or continuous dosing regimens of a low-dose oral contraceptive: a randomized trial. Contraception. 2003;67(1):9-13.
2. Kaunitz AM. Menstruation: choosing whetherÄand when. Contraception. 2000;62(6):277-284.
3. Miller L, Verhoeven CH, Hout J. Extended regimens of the contraceptive vaginal ring: a randomized trial. Obstet Gynecol. 2005;106(3):473-482.
4. Stewart FH, Kaunitz AM, Laguardia KD, Karvois DL, Fisher AC, Friedman AJ. Extended use of transdermal norelgestromin/ethinyl estradiol: a randomized trial. Obstet Gynecol. 2005;105(6):1389-1396.
5. Menstruation and menstrual suppression: what women and health care providers really think. Association of Reproductive Health Professionals Web site. Available at: http://www.arhp.org/menstruation/. Accessed November 8, 2005.
6. Edelman AB, Gallo MF, Jensen JT, Nichols MD, Schulz KF, Grimes DA. Continuous or extended cycle vs. cyclic use of combined oral contraceptives for contraception. Cochrane Database Syst Rev. 2005;(3): CD004695.
7. Anderson FD, Hait H. A multicenter, randomized study of an extended cycle oral contraceptive. Contraception. 2003;68(2):89-96.
8. Van den Heuvel M, van Bragt A, Alnabawy A, Kaptein M. Comparison of ethinylestradiol pharmacokinetics in three hormonal contraceptive formulations: the vaginal ring, the transdermal patch, and an oral contraceptive. Contraception. 2005; 72(3):168-174.

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