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 Yale-New Haven Hospital, New Haven, Connecticut, USA HealthLINK: Women's Health
August 8, 2000

News this month
Are monthly periods necessary?

For decades physicians have known that women could eliminate their monthly periods with the continuous use of birth control pills. This particular use of birth control pills is "one of medicine’s best-kept secrets" according to a recent essay by Charlotte Ellertson, a reproductive health researcher, which appeared in a March issue of the international medical journal, The Lancet.

Women who experience difficult periods should be given the option of suppressing them.
–Charlotte Ellertson, reproductive health researcher

Ellertson, who works for the Population Council, an international reproductive health organization, works with women on reproductive health issues in Latin America. She says women who experience difficult periods should be given the option of suppressing them. She adds there is no evidence proving the medical value of menstruation for any woman whether they have difficult periods or not.

Women who use birth control pills to prevent conception typically take 21 active pills each month and seven inactive or placebo pills. When active pills are taken continuously during the whole month, hormone levels remain constant and menstruation is eliminated.

Doctors have prescribed the pill this way for the convenience of professional female athletes and performers as well as for women who want to avoid their periods for a honeymoon or other special occasion.

Fifty to 75 percent of women experience emotional or physical discomfort during or just before their periods, including PMS and painful cramping.

Health benefits?
Physicians have also prescribed continuous birth control pills for women who experience severe pelvic pain with their periods or who suffer from migraines linked to dips in their hormonal flow, so-called menstrual migraines. According to the American College of Obstetricians and Gynecologists, 50 to 75 percent of women experience emotional or physical discomfort during or just before their periods, including PMS and painful cramping. Women with endometriosis may also benefit from skipping periods.

Since the Food and Drug Administration originally approved the hormone pill in 1960 only for birth control and for a strict 21-day on, 7-day off cycle, physicians have had to prescribe the continuous use of oral contraceptives "off label." The story behind the pill’s design provides an explanation for the way it’s used today.

In the late 1950s, the pill’s creators wanted the use of birth control pills to mimic women’s natural monthly cycles, so the 28-day model with 21 days on and 7 days off was created. Even 50 years ago, however, researchers realized the pill’s schedule was not "set in stone." A cycle of any desired length could presumably be produced," said co-inventor Gregory Pincus, according to a recent New Yorker feature on the pill’s 40th anniversary.

Reproductive scientists have begun to seriously question not only the need for the traditional four-week regimen but also the need for monthly periods at all while on the pill.

New trimonthly pill in clinical trials
Reproductive scientists have begun to seriously question not only the need for the traditional four-week regimen but also the need for monthly periods at all while on the pill.

Endocrinologist Gary Hodgen of Eastern Virginia Medical School anticipates clinical trials on 1,350 women of his invention, called Seasonale, to begin soon. Women on this regimen menstruate only four times a year or once a season and rather than taking three weeks of hormone pills with one week off, women will take 12 weeks of hormones consecutively with one week off.

The myth of the monthly cycle
Ellertson says common misconceptions about periods need to be debunked before women are comfortable suppressing their monthly cycles. Anthropologists have described women’s natural reproductive cycles as varying enormously over the course of human history. Australian Aborigine women and women of some Southern African tribes experience only about 160 periods during their lifetime after undergoing an average of six pregnancies and three years of breastfeeding per child. A contemporary woman has an average of 450 periods in her lifetime.

According to Ellertson, women in industrialized countries begin having periods at an earlier age, have fewer children, breastfeed for shorter periods of time and experience menopause later in life than prior generations.

Women on birth control pills who think the bleeding they experience is natural menstruation are being "duped," said Ellertson. The bleeding is artificially induced by the drop in hormones. No ovulation occurs and there is virtually no build-up of the uterine lining, so a period is not necessary. Ellertson envisions a period-free future for many women.

"Pills are more frequently being used for reasons other than contraception, for instance to control acne, and menstruation suppression might grow to be just another use for pills," wrote Ellertson.


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Joel Silidker, M.D.

Good news for women with painful periods

If you find your monthly period uncomfortable, downright painful or even merely inconvenient, the recent focus on suppressing periods entirely or reducing the average of 12 each year to three or four may be welcome news.

"Oral contraceptives or birth control pills, otherwise known simply as ‘The Pill,’ have many more medical purposes than the prevention of pregnancy."

Oral contraceptives or birth control pills, otherwise known simply as "The Pill," have many more medical purposes than the prevention of pregnancy. We prescribe them to regulate irregular periods, lighten heavy periods and decrease the pain associated with some women’s periods. Some women with severe acne also benefit from taking the pill, as do those who experience premenstrual syndrome (PMS) or menstrual cycle-related headaches.

"The pill is in a way a menstrual cycle regulator as well as a pregnancy preventor."

We also prescribe the pill for nonmedical reasons—to prevent periods for special occasions such as weddings and other vacation travel—so the pill is in a way a menstrual cycle regulator as well as a pregnancy preventor. It’s important to note that no method of birth control is 100 percent effective—even the pill. If you miss a pill for whatever reason, you could get pregnant and not know it. Without your monthly messenger, that message can't be delivered.

How do birth control pills work?
Birth control pills keep your ovaries from releasing eggs, a process also known as ovulation. The number of times a woman ovulates in her lifetime is proportionate to her risk of developing ovarian cancer. By suppressing the release of an egg from your ovary, the pill also decreases your risk of getting ovarian cancer. The birth control pill has been shown to reduce the risk of ovarian cancer by 40 percent and endometrial cancer by 50 percent.

Most women on the pill take three weeks of a small amount of estrogen and progesterone hormones. During the fourth week, they take placebo pills that contain no hormones. This lack of hormones during that week results in a monthly period.

Your physician can manipulate the regimen of pills to prevent you from having a period entirely.

Your physician can manipulate the regimen of pills to prevent you from having a period entirely. If you skip the placebo week and begin a new pack of pills, you will not have a period.  It’s important, however to make a distinction. If you are not having periods when you otherwise should be–you’re not pregnant and you’re not menopausal–that’s not safe and you should see your doctor. You risk overgrowth of the uterine lining, which can lead to cancer.

If you’re not having periods because you’re taking birth control pills, that’s very different. The progesterone in the birth control pill thins the uterine lining, so there’s nothing for your uterus to shed.

Medical advantages
There are several advantages to suppressing periods in this way. By decreasing the number of periods you have, you decrease any period-related physical or emotional discomfort. By eliminating periods, I am also able to help my patients who have a painful condition called endometriosis control their condition. Endometriosis is caused by and made progressively worse by menstruation.

"I do not, however, suggest that all women should be taking birth control pills to control their periods."

Reducing the number of periods with birth control pills is no riskier than taking pills in the normally prescribed way. The major drawback of this method for some women is the development of annoying irregular vaginal bleeding that can occur after a while. Spotting is not particularly common, but it’s the main reason I generally do not keep patients on continuous birth control pill regimens for more than three or four months at a time.

A note of caution
I do not, however, suggest that all women should be taking birth control pills to control their periods. There are risks associated with their use; and these risks can be dangerous particularly for women over 35 who smoke cigarettes and for women with a history of blood clots in the lungs or legs.

If you do have heavy, painful periods or are plagued with menstrual migraines, then you might consider having a conversation with your physician or midwife about whether a regimen of continuous birth control pills might benefit you.

Dr. Silidker is an attending gynecologist/obstetrician at Yale-New Haven Hospital and associate clinical professor in obstetrics and gynecology at the Yale School of Medicine. He is a partner of Obstetrics- Gynecology & Infertility Group with offices in New Haven, Cheshire, Madison, Branford and Milford.


2002 Best Hospital--U.S. News Online

For the 12th year in a row, Yale-New Haven has been highly ranked by U.S. News & World Report for its programs in gynecology.


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