Menstrual suppression refers to the practice of using

hormonal management Hormone therapy or hormonal therapy is the use of hormones in medical treatment. Treatment with hormone antagonists may also be referred to as hormonal therapy or antihormone therapy. The most general classes of hormone therapy are hormonal therap ...

to stop or reduce

menstrual bleeding The menstrual cycle is a series of natural changes in hormone production and the structures of the uterus and ovaries of the female reproductive system that make pregnancy possible. The ovarian cycle controls the production and release of eggs a ...

. In contrast to surgical options for this purpose, such as

hysterectomy Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovaries (oophorectomy), Fallopian tubes (salpingectomy), and other surrounding structures. Usually performed by a gynecologist, a hysterectomy may b ...

or endometrial ablation, hormonal methods to manipulate menstruation are reversible. There are a number of medical conditions for which fewer menstrual periods and less

blood loss Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...

may be beneficial. In addition, suppression of hormonal cyclicity may benefit menstrual-related mood swings or other conditions which increase in frequency with menses. Management of menstruation may be a challenge for those with

developmental delay Global developmental delay is an umbrella term used when children are significantly delayed in their cognitive and physical development. It can be diagnosed when a child is delayed in one or more milestones, categorised into motor skills, speech, c ...

or intellectual disability, and menstrual suppression can benefit individuals with specific job- or activity-related needs. There is increasing attention being given to menstrual suppression for

transgender men A trans man is a man who was assigned female at birth. The label of transgender man is not always interchangeable with that of transsexual man, although the two labels are often used in this way. ''Transgender'' is an umbrella term that inclu ...

and non-binary transmasculine people who may experience dysphoria with menstruation. Menstrual suppression is also being used by individuals with a variety of personal reasons to have less frequent or no menses, including honeymoon, vacations, travel, or other specific reasons. Options for menstrual suppression include hormonal medications like

extended cycle combined hormonal contraceptive pill Extended or continuous cycle combined oral contraceptive pills are a packaging of combined oral contraceptive pills (COCPs) that reduce or eliminate the withdrawal bleeding that would occur once every 28 days in traditionally packaged COCPs. It w ...

s, progestogen-only contraceptives (including

progestogen-only pill Progestogen-only pills or progestin-only pills (POP) are contraceptive pills that contain only synthetic progestogens (progestins) and do not contain estrogen (medication), estrogen. They are colloquially known as mini pills. Although such pills ...

s, progestogen-containing implants, progestogen-containing intrauterine devices, and progestogen-only injectable contraceptives), gonadotropin-releasing hormone modulators, and

testosterone Testosterone is the primary sex hormone and anabolic steroid in males. In humans, testosterone plays a key role in the development of Male reproductive system, male reproductive tissues such as testes and prostate, as well as promoting secondar ...

, as well as the surgical options of

(removal of the

uterus The uterus (from Latin ''uterus'', plural ''uteri'') or womb () is the organ in the reproductive system of most female mammals, including humans that accommodates the embryonic and fetal development of one or more embryos until birth. The uter ...

) and endometrial ablation (removal of the

endometrium The endometrium is the inner epithelial layer, along with its mucous membrane, of the mammalian uterus. It has a basal layer and a functional layer: the basal layer contains stem cells which regenerate the functional layer. The functional laye ...

). Most options for the suppression of menstrual bleeding are not immediately 100% effective, and with many options, unscheduled bleeding (termed "

breakthrough bleeding Intermenstrual bleeding, previously known as metrorrhagia, is uterine bleeding at irregular intervals, particularly between the expected menstrual periods. It is a cause of vaginal bleeding. In some women, menstrual spotting between periods occ ...

") can occur; for many options for menstrual suppression, breakthrough bleeding becomes less frequent with time.

Medical uses

Hormonal therapies to reduce or stop

have long been used to manage a number of

gynecologic condition Gynaecology or gynecology (see spelling differences) is the area of medicine that involves the treatment of women's diseases, especially those of the reproductive organs. It is often paired with the field of obstetrics, forming the combined ar ...

s including

menstrual cramp Dysmenorrhea, also known as period pain, painful periods or menstrual cramps, is pain during menstruation. Its usual onset occurs around the time that menstruation begins. Symptoms typically last less than three days. The pain is usually in th ...

s (

dysmenorrhea Dysmenorrhea, also known as period pain, painful periods or menstrual cramps, is pain during menstruation. Its usual onset occurs around the time that menstruation begins. Symptoms typically last less than three days. The pain is usually in the ...

heavy menstrual bleeding Heavy menstrual bleeding (HMB), previously known as menorrhagia or hypermenorrhea, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding (AUB). Abnormal uterine bleeding can be caused by structural abnorma ...

, irregular or other abnormal uterine bleeding, menstrual-related mood changes (

premenstrual syndrome Premenstrual syndrome (PMS) refers to emotional and physical symptoms that regularly occur in the one to two weeks before the start of each menstrual period. Symptoms resolve around the time menstrual bleeding begins. Different women experienc ...

premenstrual dysphoric disorder Premenstrual dysphoric disorder (PMDD) is a mood disorder characterized by emotional, cognitive, and physical symptoms that cause significant distress or impairment in menstruating women during the luteal phase of the menstrual cycle. The symptoms ...

), and

pelvic pain Pelvic pain is pain in the area of the pelvis. Acute pain is more common than chronic pain. If the pain lasts for more than six months, it is deemed to be chronic pelvic pain. It can affect both the male and female pelvis. Common causes in include ...

due to

endometriosis Endometriosis is a disease of the female reproductive system in which cells similar to those in the endometrium, the layer of tissue that normally covers the inside of the uterus, grow outside the uterus. Most often this is on the ovaries, f ...

uterine fibroid Uterine fibroids, also known as uterine leiomyomas or fibroids, are benign smooth muscle tumors of the uterus. Most women with fibroids have no symptoms while others may have painful or heavy periods. If large enough, they may push on the bl ...

s. Medical conditions that are associated with

anemia Anemia or anaemia (British English) is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, th ...

or excessive

, including sickle cell disease,

iron deficiency anemia Iron-deficiency anemia is anemia caused by a lack of iron. Anemia is defined as a decrease in the number of red blood cells or the amount of hemoglobin in the blood. When onset is slow, symptoms are often vague such as feeling tired, weak, shor ...

Fanconi anemia Fanconi anaemia (FA) is a rare genetic disease resulting in impaired response to DNA damage. Although it is a very rare disorder, study of this and other bone marrow failure syndromes has improved scientific understanding of the mechanisms of nor ...

, von Willebrand disease, low platelets (

thrombocytopenia Thrombocytopenia is a condition characterized by abnormally low levels of platelets, also known as thrombocytes, in the blood. It is the most common coagulation disorder among intensive care patients and is seen in a fifth of medical patients an ...

) from immune thrombocytopenia, or other blood/

hematologic disorder Hematologic diseases are disorders which primarily affect the blood & blood-forming organs. Hematologic diseases include rare genetic disorders, anemia, HIV, sickle cell disease & complications from chemotherapy or transfusions. Myeloid * Hemog ...

s such as clotting factor deficiencies could all benefit from menstrual suppression. In patients with

malignancies Malignancy () is the tendency of a medical condition to become progressively worse. Malignancy is most familiar as a characterization of cancer. A ''malignant'' tumor contrasts with a non-cancerous ''benign'' tumor in that a malignancy is not s ...

who will receive

chemotherapy Chemotherapy (often abbreviated to chemo and sometimes CTX or CTx) is a type of cancer treatment that uses one or more anti-cancer drugs (chemotherapeutic agents or alkylating agents) as part of a standardized chemotherapy regimen. Chemotherap ...

that could result in low blood counts or anemia, or individuals with recurrent malignancies who will receive a stem cell transplant, excessive menstrual bleeding during this treatment could be medically serious, and thus menstrual suppression might be indicated. In addition, there are a number of other medical conditions with menstrual exacerbation that may benefit from menstrual suppression, including catamenial seizures, menstrual

migraine headache Migraine (, ) is a common neurological disorder characterized by recurrent headaches. Typically, the associated headache affects one side of the head, is pulsating in nature, may be moderate to severe in intensity, and could last from a few hou ...

s, irritable bowel syndrome, and

asthma Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, cou ...

. Menstrual hygiene issues, as in those individuals with

or intellectual disability or other manual dexterity or mobility/wheelchair challenges such as spina bifida or

cerebral palsy Cerebral palsy (CP) is a group of movement disorders that appear in early childhood. Signs and symptoms vary among people and over time, but include poor coordination, stiff muscles, weak muscles, and tremors. There may be problems with sensa ...

may prompt an individual or caregiver to request menstrual suppression. Job- or activity-related indications for menstrual suppression may include deployed military as occurred during

Operation Desert Storm Operation or Operations may refer to: Arts, entertainment and media * ''Operation'' (game), a battery-operated board game that challenges dexterity * Operation (music), a term used in musical set theory * ''Operations'' (magazine), Multi-Man ...

, travel, wilderness camping, astronauts, or athletes with concerns about menses occurring during competition or training. There is also a growing recognition that

and non-binary transmasculine people may experience dysphoria with menses, and thus may request medical therapy for menstrual suppression.

Contraindications

The use of hormonal methods containing estrogen (

combined oral contraceptives The combined oral contraceptive pill (COCP), often referred to as the birth control pill or colloquially as "the pill", is a type of birth control that is designed to be taken orally by women. The pill contains two important hormones: proges ...

, the

contraceptive patch A contraceptive patch, also known as "the patch", is a transdermal patch applied to the skin that releases synthetic oestrogen and progestogen hormones to prevent pregnancy. They have been shown to be as effective as the combined oral contrac ...

or contraceptive ring), may be associated with risks that outweigh benefits for individuals with specific medical problems, such as migraine headaches with aura, a history of

breast cancer Breast cancer is cancer that develops from breast tissue. Signs of breast cancer may include a lump in the breast, a change in breast shape, dimpling of the skin, milk rejection, fluid coming from the nipple, a newly inverted nipple, or a re ...

, or a history of deep vein thrombosis. Thus these options would be contraindicated for menstrual suppression with such conditions. Progestin-only options (depot medroxyprogesterone acetate, oral progestins) are appropriate for these individuals. Drug-drug interactions are also important to consider, particularly with combined hormonal options.

Safety

Because extended cycle regimens of combined hormonal contraceptives provide a greater cumulative dose of steroid hormones, questions have been raised about their safety. Data currently provide reassurance that these options are safe.

Options

While some forms of

birth control Birth control, also known as contraception, anticonception, and fertility control, is the use of methods or devices to prevent unwanted pregnancy. Birth control has been used since ancient times, but effective and safe methods of birth contr ...

do not affect the menstrual cycle, hormonal contraceptives work by disrupting it.

Progestogen Progestogens, also sometimes written progestagens or gestagens, are a class of natural or synthetic steroid hormones that bind to and activate the progesterone receptors (PR). Progesterone is the major and most important progestogen in the body. ...

negative feedback decreases the pulse frequency of

gonadotropin-releasing hormone Gonadotropin-releasing hormone (GnRH) is a releasing hormone responsible for the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary. GnRH is a tropic peptide hormone synthesized and released ...

(GnRH) release by the

hypothalamus The hypothalamus () is a part of the brain that contains a number of small nuclei with a variety of functions. One of the most important functions is to link the nervous system to the endocrine system via the pituitary gland. The hypothalamu ...

, which decreases the release of

follicle-stimulating hormone Follicle-stimulating hormone (FSH) is a gonadotropin, a glycoprotein polypeptide hormone. FSH is synthesized and secreted by the gonadotropic cells of the anterior pituitary gland and regulates the development, growth, pubertal maturation, an ...

(FSH) and luteinizing hormone (LH) by the

anterior pituitary A major organ of the endocrine system, the anterior pituitary (also called the adenohypophysis or pars anterior) is the glandular, anterior lobe that together with the posterior lobe (posterior pituitary, or the neurohypophysis) makes up the p ...

. Decreased levels of FSH inhibit follicular development, preventing an increase in estradiol levels. Progestogen negative feedback and the lack of

estrogen Estrogen or oestrogen is a category of sex hormone responsible for the development and regulation of the female reproductive system and secondary sex characteristics. There are three major endogenous estrogens that have estrogenic hormonal acti ...

positive feedback on LH release prevent a mid-cycle

LH surge Luteinizing hormone (LH, also known as luteinising hormone, lutropin and sometimes lutrophin) is a hormone produced by gonadotropic cells in the anterior pituitary gland. The production of LH is regulated by gonadotropin-releasing hormone (GnRH) ...

. Inhibition of follicular development and the absence of an LH surge prevent ovulation.

Combined hormonal contraceptives

The use of

combined hormonal contraceptive Combined hormonal contraception (CHC), or combined birth control, is a form of hormonal contraception which combines both an estrogen and a progestogen in varying formulations. The different types available include the pill, the patch and the vag ...

s such as

the pill The combined oral contraceptive pill (COCP), often referred to as the birth control pill or colloquially as "the pill", is a type of birth control that is designed to be taken orally by women. The pill contains two important hormones: progesti ...

, the

patch Patch or Patches may refer to: Arts, entertainment and media * Patch Johnson, a fictional character from ''Days of Our Lives'' * Patch (''My Little Pony''), a toy * "Patches" (Dickey Lee song), 1962 * "Patches" (Chairmen of the Board song) ...

, and the

vaginal ring Vaginal rings (also known as intravaginal rings, or V-Rings) are polymeric drug delivery devices designed to provide controlled release of drugs for intravaginal administration over extended periods of time. The ring is inserted into the vagina a ...

are methods of contraception that contain both an

and

progestogen Progestogens, also sometimes written progestagens or gestagens, are a class of natural or synthetic steroid hormones that bind to and activate the progesterone receptors (PR). Progesterone is the major and most important progestogen in the body. ...

. These methods have traditionally been used in a cyclic fashion, with three weeks (21days) of hormones, followed by a 7-day hormone-free interval (with combined oral contraceptives, often with a week of

placebo A placebo ( ) is a substance or treatment which is designed to have no therapeutic value. Common placebos include inert tablets (like sugar pills), inert injections (like Saline (medicine), saline), sham surgery, and other procedures. In general ...

pills) during which time withdrawal bleeding or a hormonally-induced menstrual period occurs, mimicking an idealized spontaneous menstrual cycle. When these methods are taken without the hormone-free week, the withdrawal bleeding is reduced or eliminated. Thus

s are commonly used for menstrual suppression, although breakthrough bleeding is common in the initial months of use. The rate of amenorrhea (no bleeding) is in the range of 60% for users who are continuing to use combined hormonal contraceptive pills at the end of a year. Combined hormonal contraceptives include both an estrogen and a progestogen. Estrogen negative feedback on the

greatly decreases the release of FSH, which makes combined hormonal contraceptives more effective at inhibiting follicular development and preventing ovulation. Estrogen also reduces the incidence of irregular

. Several combined hormonal contraceptives—the pill, vaginal ring, and contraceptive patch—are usually used in a way that causes regular

withdrawal bleeding Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproduct ...

. In a normal cycle, menstruation occurs when estrogen and progesterone levels drop rapidly. Temporarily discontinuing use of combined hormonal contraceptives (a placebo week, not using patch or ring for a week) has a similar effect of causing the uterine lining to shed. If withdrawal bleeding is not desired, combined hormonal contraceptives may be taken continuously, although this increases the risk of breakthrough bleeding.

Progestogen-only contraceptives

-only medications, including

s and a slow-release (depot) injectable medication,

depot medroxyprogesterone acetate Medroxyprogesterone acetate (MPA), also known as depot medroxyprogesterone acetate (DMPA) in injectable form and sold under the brand name Depo-Provera among others, is a hormonal medication of the progestin type. It is used as a method of birt ...

(DMPA; Depo-Provera) do not contain an

. DMPA is given as an injection every 90days, and is typically associated with amenorrhea in about 50 to 60% of users at the end of one year. Progestogens that are not typically used for birth control, such as norethisterone acetate, may be used to induce amenorrhea. The degree of

ovulation suppression Controlled ovarian hyperstimulation is a technique used in assisted reproduction involving the use of fertility medications to induce ovulation by multiple ovarian follicles. These multiple follicles can be taken out by Transvaginal oocyte retrieval ...

in progestogen-only contraceptives depends on the

ic activity and dose of the formulation used. Low-dose progestogen-only contraceptives, including traditional progestogen-only pills (e.g.,

norethisterone Norethisterone, also known as norethindrone and sold under many brand names, is a progestin medication used in birth control pills, menopausal hormone therapy, and for the treatment of gynecological disorders. The medication is available in both ...

(Micronor, Nor-QD, Noriday)), levonorgestrel-releasing implants (Norplant, Jadelle), and

hormonal intrauterine device A hormonal intrauterine device (IUD), also known as a intrauterine system (IUS) with progestogen and sold under the brand name Mirena among others, is an intrauterine device that releases a progestogenic hormonal agent such as levonorgestrel ...

s (IUDs) (e.g.,

levonorgestrel Levonorgestrel is a hormonal medication which is used in a number of birth control methods. It is combined with an estrogen to make combination birth control pills. As an emergency birth control, sold under the brand name Plan B One-Step among ...

(Mirena)), inhibit ovulation in about 50% of cycles and rely mainly on other effects, such as thickening of cervical mucus, for their contraceptive effectiveness. Intermediate-dose progestogen-only contraceptives, including the progestogen-only pill desogestrel (Cerazette) and the subdermal implant etonogestrel (Nexplanon, Implanon), allow some follicular development but more consistently inhibit ovulation in 97 to 99% of cycles. The same cervical mucus changes occur as with very low-dose progestogens. High-dose progestogen-only contraceptives—the injectables DMPA (Depo-Provera) and

norethisterone enanthate Norethisterone enanthate (NETE), also known as norethindrone enanthate, is a form of hormonal birth control which is used to prevent pregnancy in women. It is used both as a form of progestogen-only injectable birth control and in combined inject ...

(Noristerat)—completely inhibit follicular development and ovulation. Injections such as DMPA became available in the 1960s and later became used to also achieve amenorrhea. A majority of patients will achieve amenorrhea within 1 year of initiating DMPA therapy. DMPA therapy is typically successful in achieving amenorrhea but also has side effects of decreased

bone mineral density Bone density, or bone mineral density, is the amount of bone mineral in bone tissue. The concept is of mass of mineral per volume of bone (relating to density in the physics sense), although clinically it is measured by proxy according to optica ...

that must be considered before beginning therapy. When using the subdermal progestogen-only implants, unpredictable bleeding continues and amenorrhea is not commonly achieved amongst patients. Progestogen-only contraceptive pills (sometimes called the "mini pill") are taken continuously without a 7-day span of using placebo pills, and therefore menstrual periods are less likely to occur than with the combined pill with placebo pills. However, disturbance of the menstrual cycle is common with the mini-pill; one-third to one-half of women taking it will experience prolonged periods, and up to 70% experience break-through bleeding (

metrorrhagia Intermenstrual bleeding, previously known as metrorrhagia, is uterine bleeding at irregular intervals, particularly between the expected menstrual periods. It is a cause of vaginal bleeding. In some women, menstrual spotting between periods occur ...

). Irregular and prolonged bleeding is the most common reason that women discontinue using the mini pill. Hormonal IUDs containing the progestogen levonorgestrel have the side effect of inducing amenorrhea, and some types of IUDs have been shown to markedly decrease menstrual blood loss, and thus are efficacious in treating heavy and abnormal menstrual bleeding. The rate of amenorrhea after one year of use is in the range of 20 to 50%, although most users of the hormonal IUDs Mirena and Liletta experience a marked decrease in menstrual bleeding, which is beneficial and has led to reported high rates of user satisfaction. Levonorgestrel IUDs have also been used been shown to induce amenorrhea. The lower dose device has a lower rate of achieving amenorrhea compared to the higher dose device where 50% of users have been found to achieve amenorrhea within 1year of use. A concern for usage of these devices is the invasive administration and initial breakthrough bleeding while utilizing these devices however they have the advantage of the most infrequent dosing schedule of every 5years. Use of IUDs have also shown to reduce menorrhagia and dysmenorrhea.

Others

Gonadotropin-releasing hormone Gonadotropin-releasing hormone (GnRH) is a releasing hormone responsible for the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary. GnRH is a tropic peptide hormone synthesized and released ...

(GnRH) modulators, including both GnRH agonists and

GnRH antagonist Gonadotropin-releasing hormone antagonists (GnRH antagonists) are a class of medications that receptor antagonist, antagonize the gonadotropin-releasing hormone receptor (GnRH receptor) and thus the action of gonadotropin-releasing hormone (GnRH ...

s, are associated with amenorrhea, and have been used to induce therapeutic amenorrhea. Among oncologists caring for adolescents with cancer, GnRH modulators were the most commonly recommended treatment for menstrual suppression to prevent or treat heavy bleeding during therapy. The hormonal agent danazol (Danocrine) was once used for the treatment of endometriosis, and was associated with amenorrhea, but its use was limited by androgenic side effects such as the potential for permanent lowering of the voice or

hair growth The growth of human hair occurs everywhere on the body except for the soles of the feet, the inside of the mouth, the lips, the backs of the ears, the palms of the hands, some external genital areas, the navel, scar tissue, and, apart from eyelas ...

. Because these side effects may be desired in

and non-binary transmasculine people, there has been some consideration of this option for menstrual population in this group of individuals.

Testosterone Testosterone is the primary sex hormone and anabolic steroid in males. In humans, testosterone plays a key role in the development of Male reproductive system, male reproductive tissues such as testes and prostate, as well as promoting secondar ...

and its

ester In chemistry, an ester is a compound derived from an oxoacid (organic or inorganic) in which at least one hydroxyl group () is replaced by an alkoxy group (), as in the substitution reaction of a carboxylic acid and an alcohol. Glycerides ar ...

s are effective as a form of menstrual suppression and help to suppress menstruation in transgender men and non-binary transmasculine people. Testosterone is not used in cisgender women due to its masculinizing effects at required doses. Other

anabolic–androgenic steroid Anabolic steroids, also known more properly as anabolic–androgenic steroids (AAS), are steroidal androgens that include natural androgens like testosterone as well as synthetic androgens that are structurally related and have similar effects t ...

s, such as nandrolone and oxandrolone, may also produce menstrual suppression at sufficiently high doses.

History

Historically, women and girls had far fewer menstrual periods throughout their lifetimes, a result of shorter life expectancies, as well as a greater length of time spent pregnant or breast-feeding, which reduced the number of periods they experienced. When the first birth control pill was being developed, the researchers were aware that they could use the contraceptive to space menstrual periods up to 90days apart, but they settled on a 28-day cycle that would mimic a natural menstrual cycle and produce monthly periods. The intention behind this decision was the hope of the inventor, John Rock, to win approval for his invention from the Roman Catholic Church. That attempt failed, but the 28-day cycle remained the standard when the pill became available to the public. Historically, the concept that menstruation did not have beneficial effects, and that menstruation could be controlled was raised in the 1990s, by Dr. Elsimar Coutinho. The English language version, title, "Is Menstruation Obsolete: How suppressing menstruation can help women who suffer from anemia, endometriosis, or PMS?" was published in 1999.

References

{{Menstrual cycle Menstrual cycle