Alerts

FDA warns consumers about caffeine powder. 

FDA advises consumers to stop using any supplement products labeled as OxyElite Pro or VERSA-1. Please see the following advisories: FDA -10/08/13, FDA - 10/11/13 and CDC - 10/08/13.

OPSS Hompage Button tall

Natural Medicines Homepage Button tall

Announcements

New article on reporting side effects of supplements
Just published in The New England Journal of Medicine: A recent article brings up dietary supplement issues you need to be aware of and discusses how dietary supplement side effects could be monitored better. A PDF of the April 3rd article is available free online.

3rd International Congress on Soldiers’ Physical Performance
August 18-21, 2014
The ICSPP delivers innovative scientific programming on soldiers’ physical performance with experts from around the world.

DMAA list updated for April 2014

Fueling Performance Photo Campaign
Share photos of how you fuel your performance and be featured on our Facebook page!

Dietary supplement module
Earn continuing education credits (if eligible) for this two-hour online module.

Operation LiveWell

Performance Triad

hprc_slogan_banner.png

HPRC's human performance optimization (HPO) website is for U.S. Warfighters, their families, and those in the field of HPO who support them. The goal is Total Force Fitness: Warfighters optimized to carry out their mission as safely and effectively as possible.

You are here: Home / Physical Fitness / Women-Specific Resources / Methods Of Suppressing Menstrual Cycle

Methods Of Suppressing Menstrual Cycle

Question from the Field

Is there a way to postpone my period?

Overview

Suppressing your menstrual cycle

B.L.U.F.*

Women can successfully suppress menstruation over a period a time by using certain contraceptives continuously.

Background

Contemporary women have more menstrual cycles (i.e., over a longer span of years) than in previous times due to changes in nutrition, physical activity, childbearing, and breastfeeding patterns. Now many women, particularly deployed military women, want to eliminate menstruation because it can be inconvenient and even burdensome in austere environments. Because many more women are being deployed to combat zones and perform many of the same tasks that men do, informing women in the military of successful ways to suppress menstruation is becoming increasingly important.

Myths and/or Claims

Many statements about menstrual suppression have not been substantiated by the scientific literature and are discussed further under “Facts and Evidence” below. These include:

  • Monophasic pills are more effective than triphasic pills for menstrual suppression.
  • When contraceptives are used continuously, the lining of the uterus (endometrium) continually builds up in an unsafe manner.
  • Contraceptives can cause cancer.
  • Menstruation affects women’s behavior, mental stability, and ability to perform certain tasks well.

Facts and Evidence

Women can successfully suppress menstruation over a period a time by using certain contraceptives—pills, patches, vaginal rings, intrauterine devices, and injections—continuously.

Oral contraceptives currently approved by the Food and Drug Administration (FDA) for menstrual suppression are Seasonale®, Seasonique®, and Lybrel®. Other OCAs such as Beyaz®, Loestrin® 24 Fe, and Mircette® can be used by women who do not want to skip periods but desire shorter menses and lighter flow. These oral contraceptive agents (OCAs) require daily compliance; however, contraceptive patches (i.e., Ortho Evra®) and vaginal rings (i.e., NuvaRing®) do not. The patch releases enough hormones to last a week, and the ring is worn for 21 days at a time. Nonetheless, the patch and ring, like OCAs, can be used in an extended regimen to suppress menstruation and shorten bleeding duration. Similarly, the intrauterine device Mirena® and the injectable hormonal contraceptive Depo-Provera® can be used to suppress menstruation.

Scientific research does not support some of the myths and claims regarding menstrual suppression. First, although anecdotal evidence suggests that monophasic OCAs (those that have the same amount of hormones in all 21 pills) are better than triphasic pills (those that contain different amounts of hormones in each of three groups of seven pills) for menstrual suppression, scientific evidence suggests that triphasic pills are just as effective, with few adverse reactions.1 All the same, further research is needed. Second, some believe that contraceptives, when used continuously, cause the lining of the uterus (endometrium) to continually build up in an unsafe manner. However, scientific evidence suggests that continuous exposure of the endometrium to progesterone/progestin may actually restrain endometrial build-up,2 which could help reduce the long-term risk of endometrial cancer.3 In addition, many of these contraceptives, by suppressing menstruation, prevent or mitigate cycle-related symptoms such as premenstrual syndrome (PMS), a condition that has significant effects on physical and mental functions and negatively affects women’s activities at home, work, and school.4,5

Cautions

To ensure safety, women desiring to reduce or stop menstruation should consult their physician or other healthcare provider prior to using any type of contraception. General and serious side effects from contraceptive use include bloating, nausea, irregular bleeding, blood clots, heart attack, stroke, high blood pressure, other heart diseases, certain cancers, liver disease, gallbladder disease, and defects in carbohydrate and lipid metabolism. These risks are higher among women who smoke and/or are over the age of 35. Also, although menstrual suppression methods can prevent pregnancy if used correctly, none can prevent sexually transmitted diseases or HIV infection.

Military Relevance

Menstruation does not preclude exceptional performance in theatre, but regular menstruation can be problematic for many deployed military women stationed in austere environments. Thus, education on safe and effective ways to reduce and/or suppress menstruation is of military significance. Contraceptive use may also be of military importance because it improves conditions associated with menstruation—such as menstrual pain and migraine, PMS, ovarian cysts, pelvic pain, and endometriosis6—that could translate into reduced or lost duty days and reduces the risk of debilitating conditions that could require evacuation from theater.

Summary

Many women, especially those deployed, can safely manage their menstrual cycles. However, women should be mindful of the advantages and disadvantages of the various methods when deciding which best fits their lifestyle and physical conditions and should always consult with a healthcare professional before beginning any regimen.



* Bottom Line Up Front

Research Summary

Suppressing your menstrual cycle

Key Points

  • Contemporary women have more menstrual cycles within a lifetime compared to past generations.
  • Most modern women, especially military women deployed to severe environments, prefer fewer menstrual cycles.
  • Women can successfully suppress menstruation over a period a of time by using oral contraceptives continuously.
  • Triphasic pills may be as effective and well tolerated as monophasic pills in suppressing menstruation.
  • Exposing the lining of the uterus (endometrium) to progesterone/progestin continuously does not cause an unsafe thickening of the lining.
  • Some common side effects of the newer hormonal contraceptives include irregular bleeding, bloating, and nausea.
  • Some serious side effects associated with the use of contraceptives are blood clots, stroke, and heart attack.
  • Women who smoke, especially those who are 35 or older, have a greater risk of experiencing side effects.

    Background

    The functionality of menstruation is still debatable. Some argue that menstruation is simply a consequence of not being pregnant, whereas others argue that “biologically costly and useless processes do not persist in nature”.1 However, it is well established that, during their lifetime, modern women have more menstrual cycles (i.e., over a longer span of years) than in previous times. Reasons for this increase include changes in nutrition, physical activity, childbearing, and breastfeeding patterns.2,3 More specifically, modern women tend to start bearing children later, have fewer pregnancies, and breastfeed for a shorter period of time.3 Now many women, especially military women on deployment, want to eliminate menstruation4 because it can be inconvenient and even burdensome in environments with limited privacy and resources. In a recent study,5 66% of women indicated that they desired menstrual suppression.

    Whether menstruation is functional or not, methods of reducing its occurrence are currently available. This brief covers how contraceptives can be used to suppress menstruation and will examine how safe and successful these methods are. This topic is of increasing importance because many more women are being deployed to combat zones and perform tasks similar to those of their male counterparts than in earlier times. The methods discussed here include contraceptive pills, patches, vaginal rings, intrauterine devices, and injections.

    Myths and/or Claims

    The following statements have not been substantiated by the scientific literature and are discussed further under “Facts and Evidence” below.

    • Monophasic pills are more effective than triphasic pills for menstrual suppression.
    • When contraceptives are used continuously, the lining of the uterus (endometrium) continually builds up in an unsafe manner.
    • Contraceptives can cause cancer.
    • Menstruation affects women’s behavior, mental stability, and ability to perform certain tasks well.

    Facts and Evidence

    This section discusses the available contraceptives—pills, patches, vaginal rings, intrauterine devices, and injections—available to suppress menstruation and the scientific evidence supporting or refuting the myths and claims above.

    Oral contraceptive agents (OCAs), or birth control pills, usually are taken for 28-day cycles: 21 days of hormone-containing pills followed by seven days without hormones (sometimes using hormone-free spacer pills during that time) to induce regular monthly bleeding.6 This regimen was developed to mimic normal menstrual cycles and to assure users that they were not pregnant.3 OCAs differ in the amounts of hormones provided in each dose: monophasic pills have the same amount of hormones in all 21 active pills, whereas triphasic pills contain a different amount of hormones in each of three groups of seven active pills. Anecdotal evidence suggests that monophasic pills are better than triphasic pills for menstrual suppression. However, scientific evidence suggests that triphasic pills are as effective, with few adverse reactions,7 although additional studies are needed to determine this conclusively.8

    Seasonale®, Seasonique®, and Lybrel® are oral contraceptives currently approved by the Food and Drug Administration (FDA) that also delay the menstrual cycle. Seasonale® and Seasonique® reduce menstruation from once a month to once every three months (i.e., four times per year), and Lybrel® suppresses menstruation for as long as it is taken. However, brands not intended for menstrual delay or suppression may also be used to reduce menstrual bleeding by skipping the seven-day hormone-free interval.9 This method has been used for decades, and the safety and effectiveness of this practice has been confirmed in many well-designed studies.6 Some OCAs—Beyaz®, Loestrin® 24 Fe, and Mircette®—are formulated with fewer placebo (spacer) pills than standard OCAs and can be used by women who do not want to skip periods but desire shorter cycles (i.e., shorter menses and lighter flow).

    OCAs that reduce the hormone-free period (i.e., Seasonale® and Seasonique®) are referred to as OCAs with extended regimens; those that eliminate it completely (i.e., Lybrel®) are known as OCAs with continuous regimens. Individuals on an extended regimen use OCAs for longer than the traditional time period of 28 (21+7) days, with regimen lengths of 49 or 91 days. The 91-day regimen equates to 84 days of hormone pill use followed by seven days of placebo/spacer pills (i.e., every four months). For continuous regimens, individuals use the hormone pills without interruption for an unlimited period of time.3 For most women, menstruation resumes about two months after discontinuing the use of extended- or continuous-regimen OCA pills.4

    Unlike OCAs, the transdermal contraceptive system—or contraceptive patch—does not require daily compliance. Once applied, it releases enough hormones to last for a week. One contraceptive patch available on the market is Ortho Evra®. This single 20-cm2 contraceptive patchdelivers 150 mg of a progestin (norelgestromin) and 20 mg of ethinyl estradiol daily for the seven days it is worn [13]. This method has higher compliance compared to OCAs13 since it only requires weekly recollection. Like OCAs, the patch can be used in an extended regimen to suppress menstruation and shorten bleeding duration.14

    Vaginal rings can also be used to suppress menstruation. NuvaRing®, for example, contains progestin (120 mg etonogestrel) and ethinyl estradiol (15 mg); it is normally worn for 21 days, followed by a ring-free week [15]. However, the rings differ from OCAs in that the gastrointestinal tract or first-pass hepatic metabolism is bypassed,15 which results in increased hormone bioavailability. In addition, it does not require daily compliance. Similar to OCAs, contraceptive vaginal rings can used for extended periods, with bleeding delayed for the period of use, although it has been found that spotting occurs and is more frequent with increased length of extended use.15

    The intrauterine device Mirena®—a levonorgestrel-releasing intrauterine system (LNG-IUS)—and the injectable hormonal contraceptive Depo-Provera® can also be used to suppress menstruation. The LNG-IUS has been shown to be cost efficient when compared with other methods and is FDA-approved for use up to five years.16 Women who use LNG-IUS experience reduced menstrual bleeding; many experience no menstruation within six months of use. Depo-medroxy-progesterone (Depo-Provera®), the most common injectable hormonal contraceptive available in the United Stated, is injected every three months, and more than half of those who use Depo-Provera experience no menstruation within 12 months after beginning use.17 However, women who wish to conceive shortly post-deployment may wish to consider other contraceptive methods for menstrual suppression.

    As stated above, some believe that contraceptives, when used continuously, cause the lining of the uterus (endometrium) to continually build up in an unsafe manner. However, scientific evidence suggests that continuous exposure of the endometrium to progesterone/progestin may actually restrain endometrial build-up,18 which could help reduce the long-term risk of endometrial cancer.19 However, users should note that irregular spotting/bleeding can occur during the first few months of introducing any new hormonal contraceptive agent while the endometrium stabilizes.

    In addition, the side effects of contraceptives are not as severe as they used to be. A large body of evidence suggests that although contraceptives may increase one’s risk of some cancers, they also can reduce the risk of endometrial and ovarian cancer.19, 20

    Also, many of these contraceptives, by suppressing menstruation, prevent or mitigate cycle-related symptoms such as cramping and pelvic pain that occur prior to/at the beginning of menstruation (dysmenorrhea), excessive blood flow (menorrhagia), irregular menstruation (perimenopausal symptoms), and premenstrual syndrome (PMS). The last condition, PMS, is a recurrence of physical and psychological symptoms (e.g., headache, irritability, fatigue, anxiety, and depression) associated with the menstrual cycle and is experienced at some level by most of women.3, 21 Evidence suggests that PMS does have significant effects on physical and mental functions, which negatively affects their activities at home, work, and school.22, 23

    Cautions

    To ensure safety, women desiring to reduce or stop menstruation should consult their physician or other healthcare provider prior to using any type of contraception.

    Bloating, nausea, and irregular bleeding can occur during the first three months after beginning any hormonal contraception. Additional side effects associated with the use of vaginal rings are vaginal irritation and infection. These initial side effects sometimes cause new users to discontinue use. For this reason, any new method of menstrual suppression should begin well in advance of the user’s deployment.

    Serious risks associated with contraceptive use include blood clots, heart attack, stroke, high blood pressure, other heart diseases, certain cancers, liver disease, gallbladder disease, and defects in carbohydrate and lipid metabolism. These risks are higher among women who smoke and/or are over the age of 35.

    Also, there are limitations with certain types of contraceptives. For instance, one major shortcoming of the patch is that it may lose adhesiveness and/or cause skin irritation.24 Contraceptive injections such as Depo-Provera® may not be suitable in austere environments, as refrigeration is required for storage, and the injections must be delivered every three months. And Depo-Provera® should not be used for longer than two years due to its adverse effects on bone mineral density. It may also lead to weight gain, depressed mood, and a delayed return to fertility.17

    Although menstrual suppression methods can prevent pregnancy if used correctly, none can prevent sexually transmitted diseases or HIV infection.

    Military Relevance

    Menstruation does not preclude exceptional performance in theatre, but regular menstruation can be problematic for many military women who deploy to austere environments such as Iraq and Afghanistan.5, 25 Because of the inconveniences—reduced privacy, limited storage and disposal of hygiene products, unsanitary conditions, extreme temperatures, and strenuous physical activity/tasks—many deployed women wish to reduce or suppress menstruation.5, 25 Thus, education on safe and effective ways to reduce and/or suppress menstruation is of military significance. In fact, a majority of women (85%) in a recent survey indicated that they would welcome mandatory education about menstrual suppression.5 Contraceptive use may also be of military importance because it improves conditions associated with menstruation—such as menstrual pain and migraine, premenstrual syndrome, ovarian cysts, pelvic pain, and endometriosis4—that could translate into reduced or lost duty days and reduces the risk of debilitating conditions that could require evacuation from theater. In addition, OCAs have been shown to reduce the frequency of anemia and improve the strength of anterior circulate ligaments, which could be of particular benefit to the military.5

    Summary

    Many women, especially those deployed, can safely control their menstrual cycles. Depo-medroxy-progesterone (Depo-Provera®) and the levonorgestrel-releasing intrauterine system (Mirena®) will cause a reduction and/or elimination of menstruation for many women. Skipping the hormone-free interval of combination OCAs also results in reduced menstrual bleeding. The contraceptive vaginal ring (Nuva Ring®) and transdermal patch (Ortho-Evra®) can be used without a hormone-free interval to reduce menstruation. However, women should be mindful of the advantages and disadvantages of the various methods when deciding which best fits their lifestyle and physical conditions and should always consult with a healthcare profession before beginning any regimen.

    References

    Suppressing your menstrual cycle

    1. Howes M. Menstrual function, menstrual suppression, and the immunology of the human female reproductive tract. Perspect Biol Med. 2010;53(1):16-30.
    2. Nelson AL. Extended-regimen contraception: effects on menstrual symptoms and quality of life. J Fam Pract. 2006;55(2):S1-8.
    3. Lin K, Barnhart K. The clinical rationale for menses-free contraception. J Womens Health (Larchmt). 2007;16(8):1171-80.
    4. Wright KP, Johnson JV. Evaluation of extended and continuous use oral contraceptives. Ther Clin Risk Manag. 2008;4(5):905-11.
    5. Powell-Dunford NC, Cuda AS, Moore JL, Crago MS, et al. Menstrual suppression for combat operations: advantages of oral contraceptive pills. Womens Health Issues. 2011;21(1):86-91.
    6. Miller L, Notter KM. Menstrual reduction with extended use of combination oral contraceptive pills: randomized controlled trial. Obstet Gynecol. 2001;98(5 Pt 1):771-8.
    7. Shulman L. The use of triphasic oral contraceptives in a continuous use regimen. Contraception. 2005;72(2):105-10.
    8. van Vliet HA, Grimes DA, Lopez LM, Schulz KF, et al. Triphasic versus monophasic oral contraceptives for contraception. Cochrane Database Syst Rev. 2006;3:CD003553.
    9. Anderson FD, Hait H. A multicenter, randomized study of an extended cycle oral contraceptive. Contraception. 2003;68(2):89-96.
    10. 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.
    11. Miller L, Hughes JP. Continuous combination oral contraceptive pills to eliminate withdrawal bleeding: a randomized trial. Obstet Gynecol. 2003;101(4):653-61.
    12. Edelman AB, Gallo MF, Jensen JT, Nichols MD, et al. Continuous or extended cycle vs. cyclic use of combined oral contraceptives for contraception. Cochrane Database Syst Rev. 2005(3):CD004695.
    13. Burkman RT. The transdermal contraceptive system. Am J Obstet Gynecol. 2004;190(4 Suppl):S49-53.
    14. Stewart FH, Kaunitz AM, Laguardia KD, Karvois DL, et al. Extended use of transdermal norelgestromin/ethinyl estradiol: a randomized trial. Obstet Gynecol. 2005;105(6):1389-96.
    15. Miller L, Verhoeven CH, Hout J. Extended regimens of the contraceptive vaginal ring: a randomized trial. Obstet Gynecol. 2005;106(3):473-82.
    16. Shimoni N. Intrauterine contraceptives: a review of uses, side effects, and candidates. Semin Reprod Med. 2010;28(2):118-25.
    17. Greydanus DE, Patel DR, Rimsza ME. Contraception in the adolescent: an update. Pediatrics. 2001;107(3):562-73.
    18. Moyer DL, Felix JC. The effects of progesterone and progestins on endometrial proliferation. Contraception. 1998;57(6):399-403.
    19. Burkman RT. Oral contraceptives: current status. Clin Obstet Gynecol. 2001;44(1):62-72.
    20. Casey PM, Pruthi S. The latest contraceptive options: what you must know. J Fam Pract. 2008;57(12):797-805.
    21. Doyle C, Ewald HA, Ewald PW. Premenstrual syndrome: an evolutionary perspective on its causes and treatment. Perspect Biol Med. 2007;50(2):181-202.
    22. Dennerstein L, Lehert P, Backstrom TC, Heinemann K. The effect of premenstrual symptoms on activities of daily life. Fertil Steril. 2010;94(3):1059-64.
    23. Braverman PK. Premenstrual syndrome and premenstrual dysphoric disorder. J Pediatr Adolesc Gynecol. 2007;20(1):3-12.
    24. Archer DF, Cullins V, Creasy GW, Fisher AC. The impact of improved compliance with a weekly contraceptive transdermal system (Ortho Evra) on contraceptive efficacy. Contraception. 2004;69(3):189-95.
    25. Trego LL. Military women's menstrual experiences and interest in menstrual suppression during deployment. J Obstet Gynecol Neonatal Nurs. 2007;36(4):342-7.