A Bloodless Coup

News of innovations in drug and medical research including those affecting women's health make for interesting reading. While I do not take an academic interest in all pharmaceutical R&D, I do pay a fair amount of attention to what is reported in the popular news outlets. A story on the front page of Houston Chronicle this morning, caught me by extreme surprise - both because I had never heard about this new trend and for its possible implications. 

I have known for a long time that women athletes who train very hard for strenuous competitive sports and experience drastic loss of body fat, often stop menstruating ( as also do some anorexics). Most resume their regular menstrual rhythm once they gain back a "normal" feminine physique.  The cessation of the natural periodic cycle, known as " Athletic-induced amenorrhea" is considered a very significant physiological change and is believed to put affected young women at increased risk of heart disease, osteoperosis and infertility. What I learnt in today's report is that young, non-athlete women are choosing to eliminate menstruation altogether from their lives by means of certain birth control medications.

"For young women with a world of choices, even that monthly curse, the menstrual period, is optional.  Thanks to birth control pills and other hormonal contraceptives, a growing number of women are taking the path chosen by 22-year-old Stephanie Sardinha. She hasn't had a period since she was 17.

"It's really one of the best things I've ever done," she says.

A college student and retail worker in Lisbon Falls, Maine, Sardinha uses Nuvaring, a vaginal contraceptive ring. After the hormones run out in three weeks, she replaces the ring right away instead of following instructions to leave the ring out for a week to allow bleeding. She says it has been great for her marriage, preventing monthly crankiness and improving her sex life.

"I would never go back," said Sardinha, who got the idea from her aunt, a nurse practitioner.

Using the pill or other contraceptives to block periods is becoming more popular, particularly among young women and those entering menopause, doctors say.

"I have a ton of young girls in college who are doing this," says Dr. Mindy Wiser-Estin, a gynecologist in Little Silver, N.J., who did it herself for years. "There's no reason you need a period."

Such medical jury rigging soon will be unneeded. Already, the Seasonale birth control pill limits periods to four a year. The first continuous-use birth control pill, Lybrel, likely will soon be on the U.S. market.  The idea gained momentum after Barr Pharmaceuticals launched Seasonale in November 2003. It's a standard birth control pill taken for 12 weeks, with a break for withdrawal bleeding every three months. Amid wide acceptance by doctors, sales shot up 62 percent last year, to $110 million.

Publicity for Seasonale made women wonder, if just four periods a year are OK, why have any at all?

Users of Pfizer Inc.'s Depo-Provera, a progestin-only contraceptive shot lasting three months, usually are period-free after a year or two. And many women have been getting extra prescriptions so they could continuously stay on birth control pills, the Ortho Evra patch or the vaginal ring, rather than bleeding every fourth week to mimic normal menstrual cycles. But the extra prescriptions have led to insurance company hassles.

"What Seasonale did is get rid of that nuisance," says Dr. Peter McGovern of University of Medicine and Dentistry of New Jersey. New extended-cycle contraceptives will do the same. Wyeth is hoping by late June to get Food and Drug Administration approval to sell Lybrel, its low-dose, continuous birth control pill.

Dr. Patricia Sulak, who researches extended contraception at Texas A&M College of Medicine, applauds this new trend. "This redesign is way overdue," she says. "It's going to be the demise of 21-7." Most doctors say they don't think suppressing menstruation is riskier than regular long-term birth control use, and one survey found a majority have prescribed contraception to prevent periods."

I can understand pre-menopausal women who often go into irregular and spotty menstrual cycles, using the drugs for a short time. I can also understand that for younger women with busy lives, menstruation is a nuisance with its accompanying physical and mental discomforts of cramps, PMS and other symptoms. But is the choice of totally eliminating an inconvenient but natural physical process completely safe?  I am usually for any innovation that makes women's lives healthier, safer and hassle free. However unlike Dr. Sulak, I will hold my applause on this one until there are enough studies to show what the long term effects are on women's heart, bone, uterine and ovarian health.

Comments

[Anna]

Playing with drugs or, worse yet, hormones (with their complicated short and long term effects on the body) for convenience's sake does seem like a bad idea, as a general matter. In my case-- I don't know if you're influenced by this-- there's also an undefinable "ick" factor to overcome, a feeling that menstrual suppression is unnatural and even (perhaps counter-intuitively to some) unclean.

I've had to get over this aversion because of the utility of menstrual suppression as a treatment for ovarian cysts and endometriosis, two conditions for which there are few non-invasive treatments and both of which, unfortunately, are nearly universal among the women in my family, which has some seriously bad news reproductive system genes (for a separate medical reason-- a history of seizures, which are provoked by estrogen-- I don't do this).

A NY Times article on this subject from a few years ago includes the provocative argument of some clinicians that having monthly cycles over a course of years is what is "unnatural":

"Elsimar M. Coutinho and Sheldon J. Segal say that historically, women had very few periods, giving birth earlier and more frequently and nursing their babies longer.

''Regular and recurrent menstruation throughout most of a woman's reproductive years is a fairly recent phenomenon,'' the authors wrote.

...

Some doctors say they believe that the more frequent periods experienced by modern women pose significant health risks.

In a letter quoted on the Museum of Menstruation Web site, Dr. Patricia J. Sulak, an obstetrician and gynecologist at Texas A&M, wrote, ''Incessant ovulation and menses, month after month after month, is associated with many health problems, including a proven increased risk of ovarian cancer, anemia associated with heavy menses, ovarian cysts and endometriosis.''

http://query.nytimes.com/gst/fullpage.html?res=9C03EED8103FF937A25753C1A9659C8B63&sec=health&pagewanted=print

[Sujatha]

"Some doctors say they believe that the more frequent periods experienced by modern women pose significant health risks."

Longer lives mean more health risks to be experienced.
Women don't have to fear death by childbirth as much as they used to, so obviously the body has to find other mechanisms to limit the lifespan of the females in the species.
Just as people in general are now able to survive heart disease through medication/life style changes/surgery and move into their 70s and 80s, other forms of disease such as cancer start to catch up with heart disease as the biggest killer.
So now some OB/Gyns are hawking medicated amenorrhea- just as they pushed unneeded episiotomies, scheduled for convenience C-sections, HRT with attendant risks for menopausal women.
Me, I'll go by the advice of my much respected OB/Gyn aunt- don't mess with the natural hormone balance in your body- you'll never figure out the harmful side effects over the long term until it's too late to do anything about them.

[DevanJedi]

A while ago there was an article in the New Yorker, which made the point that the only reason the 3-week-on, 1-week-off cycle of the modern pill was introduced was to appease the church:

If it was lawful to suppress ovulation to achieve a regularity necessary for successfully sterile intercourse, why was it not lawful to suppress ovulation without appeal to rhythm? If pregnancy could be prevented by pill plus rhythm, why not by pill alone? In each case suppression of ovulation was used as a means. How was a moral difference made by the addition of rhythm?

These arguments, as arcane as they may seem, were central to the development of oral contraception. It was John Rock and Gregory Pincus who decided that the Pill ought to be taken over a four-week cycle--a woman would spend three weeks on the Pill and the fourth week off the drug (or on a placebo), to allow for menstruation. There was and is no medical reason for this.

While I do not know how true the assumptions of this article are, it is a great article and written by a respectable author (Malcolm Gladwell of "Blink" fame).

He goes on:

Today, the Pill is still often sold in dial packs and taken in twenty-eight-day cycles. It remains, in other words, a drug shaped by the dictates of the Catholic Church--by John Rock's desire to make this new method of birth control seem as natural as possible. This was John Rock's error. He was consumed by the idea of the natural. But what he thought was natural wasn't so natural after all, and the Pill he ushered into the world turned out to be something other than what he thought it was. In John Rock's mind the dictates of religion and the principles of science got mixed up, and only now are we beginning to untangle them.

[Ruchira Paul]

Anna, Sujatha and Devan:
Thanks for the thoughtful and informative comments.

Dr. Patricia Sulak of Texas A&M appears to be the most aggressive proponent of drug induced amenorrhea - she is referenced in all the three articles cited here by Anna, Devan and me.

As I said, this is a huge conundrum. Evolutionary pressures may have designed women's bodies for early and repeated child bearing. But social pressures no longer demand that.

It is important to remember that childbirth is not very kind to women's health either. Early and frequent pregnancies (women are believed to become fully physically mature around the age of 22) take a huge toll in the form of weaker bones, loss of muscle strength and yes anemia - the culprit associated also with excessive menstruation. Add to that the mental stress of child rearing and motherhood begins to look like a disease. Early menopause brought on by several pregnancies increased the risk of early onset of heart disease and brittle bones. The modern woman with fewer children and late menopause is protected in these areas for a longer time.

I guess what the doctors are proposing to do here is to create a state of perpetual faux pregnancy without the ravages of childbirth in order to protect against the ill effects of prolonged and regular periods. Early menarche and late menopause have been long associated with certain forms of cancer. What I would like to know is what percentage of those occur at a later age. As Sujatha points out, incidence of cancer increases dramatically with aging when the body starts to misfire at several levels, including cell division. Since our fecund and infrequently menstruating foremothers did not for the most part, live very long lives, there is no epidemiological study to compare the occurance of these cancers among them at an advanced age.

If the discomforts of menstrual periods can be eliminated without grave long term harm and if women can safely choose when to have periods just like they do for childbirth, I say good riddance to bad rubbish. But do we really know what awaits them at the end of this extreme and "prolonged" hormonal tinkering?

Let me be clear. I am not the vegan/yogic/natural type. I have a lot of respect for modern medicine and appropriate chemical intervention to cure and prevent disease. I don't equate "natural" with "always good." I also recognize that mother nature is the most complex chemical lab whose workings are still not fully known to us. And as is evident from cancer and autoimmune diseases, sometimes our own bodies become our worst enemies. But I am extremely leery of long term drug regimens which interfere with metabolic and endocrinal pathways. Which is why I am also very alarmed by the aggressive redefining of "safe" cholesterol numbers and the wide dispensation of newer and newer cholesterol lowering drugs to prevent heart disease without too much attention being paid to their devastating effects on the liver, muscles and some suspect even neural pathways. These women are starting to eliminate menstrual periods very early in life (seventeen in one case cited in the article). This is a bit alarming to me only because I don't know what they will face in their forties, fifties or later.

Devan, thanks for the link to the fantastic Malcolm Gladwell article from the New Yorker. I was mostly familiar with the health facts and studies about menstruation, pregnancy and birth control. What interested me much more was how much influence John Rock's church had on his research. It was rather ironic that at the end of his life he rejected the church's teachings but spent all his productive scientific life trying to accommodate them. Another lesson for scientists not to play the dangerous game of struggling to reconcile scientific truth with religious faith. It did not work for Galileo (who was a devout Catholic) and it won't work for anyone else!

[Ruchira Paul]

Anna:
I forgot to add that I find nothing wrong with induced amenorrhea for the treatment of endometriosis, ovarian cysts or irregular premenopausal bleeding.