With the advent of extended cycle contraception (continuous birth control pills such as Seasonale), lots of women are talking about whether or not to have periods. 72% of women surveyed say they don’t like having periods, and 40% would prefer to never have one.  But 50% said they would never consider suppressing menstruation with hormones.  In fact, I was just interviewed by Body & Soul magazine regarding this very issue, and it’s such a juicy topic, I wanted to share with you some thoughts, in case you’re one of those women trying to figure out whether to bleed or not to bleed.

The History of Menstrual Frequency

First, a history lesson.  Back when we were cave people, women didn’t bleed much. Sure, they menstruated, but not very often. They started getting periods late (as we have evolved, the age of first menstruation has gotten younger and younger- we suspect as a result of environmental estrogens found in pesticides, plastics and other toxic substances). They spent the majority of their reproductive life either pregnant or nursing, thus no periods. And they died long before menopause.

The Average Number of Menstrual Cycles a Woman Will Have In Her Lifetime

But the advent of birth control in modern life means women bleed more than they ever have because they can choose how many pregnancies they will have. On average, a woman will have two pregnancies and breastfeed for about 6 months. As recently as the 1900’s, a woman was statistically only likely to have 1-2 menses/year. Now, things have changed. In modern life, women experience an average of 450 menstrual cycles in their lifetime, compared to only 160 cycles for the pre–Industrial Revolution woman.

Are Periods Good or Bad?

So what’s the deal? Is it good or bad to get periods? Should we have more? Less? Well, it depends. If you’re not on any type of hormonal birth control and you’re not pregnant, nursing or menopausal, it’s not good to skip periods.  But if you’re skipping periods because you’re taking hormones, that can be good- or bad, depending on how you look at it.

Is it Natural To Skip Periods With Hormones?

Well, no. There’s nothing natural about the birth control pill, the Depo-Provera shot, or the Mirena IUD.  Menstrual cycles while on birth control are not the same as non-hormonal cycles the body has naturally.  If you’re not taking birth control, skipping periods can cause overgrowth of the lining of the uterus and lead to problems.  But while taking continuous hormones such as Seasonale, skipping periods results from shrinkage of the uterine lining, rather than unshed overgrowth, so there is no need for a monthly period. 

Why Do You Have Periods When You’re on The Pill?

The only reason you get a period when you’re on the Pill is because those who developed it back in the 1960’s assumed women would prefer to have periods. Why? So they would know they weren’t pregnant. So they would feel “natural.”  Now, pharmaceutical companies are rethinking things, since many women surveyed say they would love to skip periods.

How Does it Work?

When you’re taking the Pill, the period that comes during the placebo week of birth control is the body’s natural withdrawal from taking the hormones.  By continuing to take the hormones instead of the placebo, the body does not withdraw from the hormones and no period occurs.  This is different than missing menses when not taking birth control.  While taking continuous birth control, the lining of the uterus gets thin and periods, when they do occur, are often very light. 

Why Would I Choose to Suppress My Menses?

Most patients choose this regimen purely for convenience, to avoid the nuisance of menses and to fit with their lifestyles.  However, OB/GYNs have been recommending this regimen for many years for the treatment of endometriosis, PMS, menstrual migraines, anemia, painful periods, mittelschmerz (painful ovulation), ovarian cysts, and heavy periods. 

Is Extended Cycle Birth Control As Effective as Regular Birth Control Pills?

Yes.  Like traditional birth control, extended cycle birth control is >99% effective if taken correctly and may even be more effective.

What’s the Down Side to Skipping Periods With Extended Cycle Contraception?

Well, it depends how you do it. Birth control pills, the Patch, and the Ring all contain synthetic hormones that may increase the risk of estrogen sensitive problems, such as blood clots and, potentially, breast cancer. Some women are also very sensitive to synthetic hormones and have mood issues, irritability or exacerbation of other health conditions. Using bio-identical hormones instead may help, but they have not been tested for use as birth control, so there is no bio-identical birth control pill.

Also, because you are skipping the placebo week, you’re getting 25% more hormones in your body, which may pose some risk. Although studies to date have demonstrated safety in using extended cycle regimens, we don’t have long term data yet.

In addition, menstrual cycles give a lot of information about the health of the body, and skipping them may rob you of this useful barometer of health. For example, an anorexic or competitive athlete will often skip periods, a signal that the body is unfit for pregnancy. If you’re taking extended cycle contraception, you’re masking this signal. You may also blunt the natural ebb and flow of emotions and intuition that comes with a natural cycle, but this is the case for anyone on hormonal birth control.

What about the Mirena IUD or Depo-Provera. Is it okay that I don’t get my period with these methods?

Yes. Like other hormonal birth controls, it’s important to understand that these hormones are synthetic. However, because these contraceptives don’t contain estrogen, they are much safer and do not contain many of the risk of the Pill, the Patch, and the Ring. 

If I’m on hormonal birth control and I want to skip periods, how do I do it?

First, talk to your doctor to make sure you’re a good candidate. If he or she agrees, you can use any monophasic pill, Ortho Evra, or Nuvaring.  Monophasic pills include things like Yasmin, Yaz, Ortho-Cyclen, Lo-Ovral, Ovcon, Nordette, Ovral, Desogen, Mircette, Demulen, Alesse and many others.  Patients taking triphasic pills should not try to use their pills for extended cycle contraception (this includes OrthoTri-Cyclen and Ortho Tri-Cyclen Lo, Estrostep, Triphasil, Tri-Levlen, Ortho Novum 7/7/7 and others).

To use these methods, skip the placebo pills at the end of the packet and start another packet the next day after the first three weeks are done.  When you finish taking all the active pills in four packets (12 weeks worth of pills), stop the pills for one week and you will get your period.  For Ortho-Evra and Nuvaring, just skip the patch/ring-free week and continue for 12 weeks in a row, then don’t use the patch or ring for a week.  Because you will use more pills/patches/rings, your insurance may not cover as many as you need to take them continuously, so you may have to pay out of pocket for one month out of every four.  The reason to have a period every 3 months is to reduce the risk of breakthrough bleeding.

What if I start to bleed when I’m not supposed to?

The most common side effect of extended cycle contraception is breakthrough bleeding, especially in the beginning.  Most women’s bodies will get used to the new regimen over time, but breakthrough bleeding can persist intermittently for up to a year.  Often, when you first start taking birth control in this manner, you will have spotting or even a full period sometime during the second or third month.  When taking extended cycle birth control, it is particularly important to try to take your pills at the same time every day and to make sure you don’t skip pills.

If you have spotting, you should continue to take your pills every day unless the bleeding is persistent or heavy. If you continue to bleed and have been taking your pill continuously for at least 3 weeks, you may stop your pills for 5 days and expect a full period, then restart a new 12-week cycle.  Some people can only go 6-9 weeks without their bodies bleeding, so to some degree, you can adjust the pill cycle to meet the needs of your body.  Some patients simply cannot extend beyond the traditional 4 week cycle without bleeding. Extended cycle contraception is not for everyone.  The key is to keep taking pills daily unless you decide to induce a period.  If you start randomly skipping pills, you will bleed irregularly- and you might get pregnant.

If I don’t get a monthly period, how will I know I’m not pregnant?

If you take your pill as prescribed, your chance of pregnancy is extremely low.  If you have symptoms of pregnancy, have missed pills, or need reassurance, take a home pregnancy test.

What if I don’t get my period during the week I’m supposed to bleed?

The uterine linings of some women using extended cycle contraception become so thin that they don’t bleed at all.  If you don’t get a period, check a pregnancy test and if it’s negative, don’t be concerned. Just keep taking your birth control.

Tips for taking extended cycle contraception:

• Always do this under the care of a physician.
• If you’re using pills, take your pills at the same time every day.  If using the patch or ring, don’t forget to replace it when it’s time (every week with the patch and every 3 weeks with the ring).
• If you miss one pill, take two pills the next day. 
• If you miss two or more pills, stop the pills for 5 days and expect a period.
• If you have persistent breakthrough bleeding, stop the pill for 5 days and expect a period, then restart another 12-week cycle. 
• If your body routinely bleeds at a specific time (for example, you always have spotting on week 8), plan your extended cycle accordingly and schedule a week off pills at week 8.
• If you’re confused or uncertain how to take your pills, make an appointment to discuss this with your OB/GYN

What Do I Think?

Well, I have mixed feelings. I always hated having periods. I know- it’s not very Pink of me, but it’s true. I was a ballerina, and then I would be scrubbed into these 8 hour surgeries with no breaks for tampon changes. So I was never particularly moon goddessy about my menstrual cycle.

Personally, I went 9 years using an extended cycle contraception regimen during my medical training and didn’t have a single period until I decided to get pregnant, which happened very quickly once I quit. I never had any side effects and felt perfectly happy not to deal with it. Then I was pregnant- and after that, I was nursing, when I had a Mirena IUD inserted, which also suppressed menstruation.

So now I’ve had my IUD in for 4 years, and I’ve never once had a period. Which works for me. But it doesn’t work for many of my patients. I’m a big believer in listening to your body, tuning into your intuition, listening to your yoni, and going with your gut. My job as a doctor is to educate you about your options, but ultimately, the choice must be yours.

Trusting that you’ll know what’s right for you,

Dr. Lissa