The end of menstruation

Most women would agree that getting their period is a big drag. Now, a growing movement argues for reducing menstruation during child-bearing years, or even getting rid of it altogether — for the sake of women’s health.

By Julie Dulude

Elizabeth Strein hasn’t had her period since September. Although many women would view this as cause for alarm — a sign of unwanted pregnancy, or an indication of gynecological trouble — the 25-year-old hasn’t lost any sleep over Aunt Flo’s prolonged absence.

That’s because Strein, a flight attendant, is one of a growing number of women who are using birth-control pills to limit the frequency of their menstruation. After reading several articles in women’s magazines listing many pros and few cons to the practice of deliberately skipping periods, she was intrigued. She had a brief consultation with her father, a pharmacist, and then decided to give it a try. “I work out a lot so I don’t get much of a period anyway, and I just figured, why bother with it at all?” she says. “It’s great. I have no PMS. There’s less stuff I have to lug around with me on trips, less money I’m spending on that stuff.”

Forget conventional wisdom about menstruation. The monthly curse that women were told they had to put up with in order to experience the miracle of childbirth — it turns out they might not have to tolerate it after all. Women like Elizabeth Strein are discovering that regular monthly menstruation simply isn’t necessary — period.

A growing body of medical research supports the idea, too, arguing that incessant ovulation is a relatively recent and unnatural phenomenon. In their book Is Menstruation Obsolete?, for example, doctors Elsimar Coutinho and Sheldon Segal claim that menstruation isn’t meant to be a monthly event, and, after citing research linking fewer periods to decreased risk of modern-day diseases like ovarian and endometrial cancer, they advocate the seemingly radical position that menstruation should be suppressed.

“What we know,” says Dr. James Flaherty of Generations, a Portland obstetrics and gynecology center, and a practicing OB/GYN in the city since 1986, “is that with ovarian cancer there is, across the board, around a 40 percent reduction in ovarian cancer for women who have been on the pill for at least 10 years during

reproductive years. For women who have been on the pill for 15 years, the decrease in risk is even higher, around an 80 percent decrease in risk.”

For years, using birth-control pills to reduce the frequency of menstruation has been fairly standard in treating certain medical conditions, including painful periods, endometriosis, and recurring ovarian cysts. And doctors have routinely counseled women on how to use the pill to skip periods during special occasions — a honeymoon, say, or a beach vacation. But now, women are using these methods simply to avoid the hassle of getting their periods. To do it, they throw away the week of placebo pills in their monthly dial packs and immediately start on the active hormone pills of the next segment. Continuing this way, they can conceivably go for years without menstruating, although most choose to cut down to about four periods a year.

The pharmaceutical companies are catching on, too, and several companies have extended pill regimens in clinical trials right now. What’s surprising is that so many doctors seem to agree on the benefits of period suppression. In one survey, 56 percent of doctors said they do not think a monthly period is necessary to a woman’s health.

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Avoiding PMS, bloating, headaches, and bloodstained sheets, it seems, are all the reason one needs to keep periods at bay. Says Elizabeth Strein, the flight attendant who started taking the pill constantly, “I listen to my friends complain about their periods now and I say, ‘Look, why don’t you just not get it?’”

For someone who changed the world, John Rock had pretty conventional ideas about women. Before 1960, when the Harvard Medical School doctor co-invented the birth-control pill, the only way for pre-menopausal women to stop ovulating was to get pregnant. But though his invention opened the door to unprecedented sexual liberation, he hadn’t wanted to revolutionize nature — in fact, he’d wanted to create an idealized version of a woman’s natural cycle. Rock’s personal beliefs deeply influenced the way he thought about the pill and, consequently, the way we think about birth control today. The week’s worth of placebo pills, that allow a woman on birth-control pills to menstruate once a month, was in fact an arbitrary decision. The idea was that women would be more likely to use the pill if they had that reassurance they weren’t pregnant. And it was a societal perception at that point that a monthly menstruation was natural.

That perception still prevails, which accounts for much of the resistance to period suppression. But biologically speaking, fewer periods are more “natural” than monthly ones. Back in the caveman days, women menstruated about a hundred times in their lives (as compared to modern women, who average 350 to 400 times). Why? Because, according to Coutinho and Segal in Is Menstruation Obsolete?, “ancestral women were either pregnant or lactating almost continuously” until menopause or death, which usually came first. “During pregnancy and lactation they would remain free of menstruation,” the authors explain, and “even before the suckling baby was weaned, the mother would often become re-impregnated. Release from this repetitive chain of reproductive events would come only with secondary infertility . . . or the unlikely event of reaching menopause.”

In tribal societies, where pre-modern conditions prevail, monthly periods are still the exception rather than the rule. Scientist and anthropologist Beverly Strassman, for example, spent two and a half years tracking the menses of women in the Dogon tribe of Mali, Africa between 1986 to 1989. Strassman found that a Dogon woman, on average, reaches menarche — the onset of menstruation— at the age of 16. From her first period to the age of 20, she averages seven periods a year. From 20 to 34, she averages slightly more than one period per year. From 35 until menopause, a time of declining fertility, she averages four periods a year. She gives birth eight or nine times in her lifetime. During Strassman’s years with the Dogon tribe, the only women who made regular visits to Strassman’s menstrual hut were the village’s two sterile women.

Contemporary Western women, in contrast, menstruate many more times over the course of their lives for several reasons: they live longer, they reach menarche earlier, they are less likely to breastfeed (an activity that prolongs menstruation-free stretches), they have fewer children, and they begin bearing them later in life. Historically and anthropologically, the original, “natural” state for women is having fewer periods. Taking the pill continuously, then, induces a “natural” state in women. And this leads to a somewhat counter-intuitive conclusion: in today’s contemporary landscape, where women marry late and hold full-time jobs, a woman must engage in the “artificial” practice of oral contraception to return to her “natural” physiology of infrequent menstruation.

“It’s a pity that gynecologists think that women have to menstruate every month,” Strassman told the New Yorker earlier this year. “They just don’t understand the real biology of menstruation.”

Forty years after Rock’s invention, the use of long-term, uninterrupted oral-contraception use is increasing. Doctors, scientists, and drug companies are particularly interested in how the pill may help prevent certain cancers. According to American Cancer Society data, endometrial and ovarian cancer strike an estimated 62,600 women a year and prove fatal for approximately one-third of them. But many studies show that taking the pill even for one year dramatically reduces women’s risk of getting these cancers. The decrease is at least 40 percent, and could be as much as 60 or 70 percent, compared to women who have never taken the pill. In fact, the more time women spend in a state of pseudo-pregnancy or pseudo-breast feeding — that is to say, on the pill — the more their risk goes down.

Understanding how the pill can prevent reproductive cancer begins with an understanding of ovulation. When a woman ovulates, an egg pushes through the wall of one of her ovaries and implants itself in the uterine lining. To repair the rupture, a period of cell division and reproduction within the ovary walls must follow. Cancer occurs when cells – which are constantly dividing and reproducing — make mistakes that cripple the cells’ defenses against runaway growth. Older people, for instance, are more likely to develop some form of cancer because their cells have had more time to make mistakes. But any change leading to cell division, ovulation included, can increase cancer risk. The pill’s promise, at least with respect to ovarian and endometrial cancer, lies in its ability to disrupt a woman’s cycle, causing her to ovulate less frequently.

At the same time, however, some doctors theorize that progestin, the hormone in birth-control pills that suppresses ovulation, increases the risk of breast cancer. The theory is supported by the fact that women who have had their ovaries removed, and thus do not manufacture progestin, have a significantly decreased risk of the disease, which ills more than 40,000 women a year. Although there is absolutely no definite link between birth-control pills and breast cancer, this uncertainty causes some to caution women against taking oral contraceptives without interruption simply because they don’t want to be bothered with menstruation. Judy Norsigian, co-author of Our Bodies, Ourselves for the New Century, urges women to be concerned — young women and smokers especially. At least three studies document a small but statistically significant risk increase of breast cancer for women who begin taking birth control pills at an early age and continue long-term, she explains.

“This is a massive experiment,” says Norsigian. “Even though there was a time when women didn’t menstruate as much as they do now, that is not the same as using artificial hormones to prevent ovulation. There are benefits to doing this, but there ought to be a good reason for taking hormones to avoid one’s period because we don’t know what the long-term effects of this practice will be.”

Defenders of continuous oral contraception point out, among other things, that the higher hormone levels women ingest this way — 13 extra weeks a year, or 33 percent more in any given four-week interval — is still far lower than old birth-control pill dosages.

Doctors do caution that suppressed menstruation should not be confused with irregular menstruation. Professional athletes or dancers, for example, may not get their periods because they’re suffering from critically low levels of estrogen. This is a serious medical condition that must be treated.

But when it comes to suppressing menstruation with the pill, many doctors think the only real downside is spotting. Since the progestin in birth control acts to suppress ovulation, taking birth control without interruption means that the uterine lining doesn’t have a chance to build up and, therefore, doesn’t need to be shed. But the lining may build up a little or become atrophic, which can lead to irregular light bleeding. For this reason, many doctors recommend that women withdraw from the pill once every three or four months, and have their periods.

Another issue, at least as important, is not medical, but cultural and political. Is menstruation the essence of “femaleness” — the thing that sets women apart from men and defines their identity as women? Or is it simply a physical process that women should be able to control as they see fit?

Some women see menstruation as a hindrance to their lives and argue that objections to suppressing their periods are, like objections to abortion, expressions of a society that wants to deny women autonomous control over their bodies. “Our culture is very uncomfortable when women do anything that makes the visible differences between men and women less visible,” says Susan Reverby, a professor of women’s studies at Wellesley College in Massachusetts and a medical historian. “There’s nothing natural about Viagra,” she continues. “Are we uncomfortable with that? If you make a nature argument, why are we uncomfortable with things that are unnatural for women but not for men? Because there’s no such thing as Father Nature. Women are allowed to do something non-natural to increase our bust, but only because that’s for men. God forbid we stop menstruating.” Pointing to articles in women’s magazines ranging from Style to Redbook that bear headlines such as “Lifting the Curse” and “A Pill to Uncramp Women’s Style,” Reverby says most women see getting their period as a pain.

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On the other hand, she admits, some women see it as a wonderful reminder of the fact that their bodies are different from men’s. The onset of menstruation is a woman’s most important rite of passage, and the mystical connection between monthly menses, the phases of the moon, and Mother Nature as a whole is an important part of a woman’s identity.

Kathleen MacPherson, a recently retired professor emeritus of nursing at USM with degrees in nursing and a PhD in medical sociology, agrees on this point. “Some women love their periods,” she says. “They feel a sense of loss when they’re facing menopause. These researchers make the assumption that women find periods as a nuisance, time consuming, without looking at the possibility that all women don’t feel this way. This trend in research is trying to say, ideologically, that women don’t want their periods. I don’t think that’s necessarily the case.

“Many of the researches who have been studying the menstrual cycle and fertility have a narrow view. Many of them have a blind spot: that the male body is the model for the human body, it’s the ideal. This places women’s bodies as abnormal. They want to fix it or manipulate it. They have a history of wanting to control women’s cycles, this fantastically complex and beautiful system. If they’d listened to the women’s health movement, they would see how most women don’t think like that.”

Comments received by survey analysts underscore this idea: “Keep technology out of our wombs,” writes one woman. “To stop or inhibit [menstruation] would be to remove one important aspect of the intricate and glorious facet of a woman’s body and nature,” writes another.

Signaling that “the monthly” may soon become a thing of the past, there is now even a Museum of Menstruation in Maryland. Its Web site (www.mum.org) is full of informative and entertaining articles, including a complete list of code words and expressions women have used to refer to their periods: Old Faithful, the Dot, Bloody Mary, Closed for Maintenance, That Time of the Month, Surfing the Crimson Wave, and the Plague, to name a few. Still, it is an open question whether the tampon industry may be on its way out of business or the idea of putting an end to menstruation could be just the latest passing fad in women’s health.

“Why do women hate it?” Reverby asks. “That’s the biggest issue we have to think about. Do women still loathe their bodies?” She adds that in her mother’s generation, women referred to getting their periods as “being unwell.” “I think this goes back to women being taught to feel ashamed of their bodies,” she says. “There’s been some change, but [research shows that] the pressure on women to be taller and skinnier, that has gotten worse.”

Norsigian agrees that women stand to lose more than their periods if they begin taking the pill continuously. She fears that they also stand to lose their self-esteem and their identity. That’s why it’s important to draw a distinction between women who are doing this because their periods are so painful they get knocked out of commission, and women who are doing it because they just don’t want to get their periods.

“If you’re doing it because it’s a little messy and inconvenient, one has to wonder whether this feeds into an ongoing and insidious negative view of reproductive functioning,” Norsigian says. “The idea that women might start thinking about menstruation as a horrible thing to be avoided if at all possible — I don’t think that’s the thing we want to encourage.”

Sam Smith contributed reporting to this story.
Julie Dulude can be reached at jdulude@hotmail.com.