Contraceptive sparks debate on role of menstrual period

THE BALTIMORE SUN

Could a woman's period become a thing of the past?

In coming weeks, the Food and Drug Administration is expected to decide whether to approve the first oral contraceptive designed specifically to reduce the number of annual menstrual cycles a woman has. Seasonale, developed by Barr Laboratories, would reduce menstruation to four times a year instead of the typical 13.

Gynecologists say that suppressing the monthly period would mean fewer women would have to worry about bad biological timing spoiling a honeymoon or vacation. More important, they say, it could spare women from pounding headaches, wrenching cramps and other menstruation-related medical troubles.

A growing number of physicians are questioning the necessity of menstruation, sparking fierce debate around the country - from gynecologists' offices to women's studies departments - about its biological role.

"It is a needless loss of blood," concludes Elsimar Coutinho, a Brazilian reproductive biologist, in his provocative book Is Menstruation Obsolete? A few gynecologists go further, arguing that menstruation should be eliminated.

Other experts on women's health disagree and are concerned that not enough is known about the long-term biological effects on the body of menstrual suppression.

"Women very frequently are the targets for things to make their lives better that turn out to be extraordinarily unhealthy," says gynecologist Dr. Justina Trott, director of the Women's Health Services Family Care and Counseling Center in Santa Fe, N.M.

But for now, some women are thrilled at the prospect of fewer periods.

"I'm not going into work every day and worrying, 'Do I have a stain on my skirt or my dress or my pants?' " said Charlene Howard, a North Carolina real estate agent who has been taking part in a clinical trial of Seasonale for more than two years.

The origins and purpose of menstruation have been debated for centuries. In ancient Persia, women whose periods lasted longer than four days were deemed possessed and subjected to 100 lashes to purge the invading demon.

The Roman naturalist Pliny the Elder preached that menstrual blood was a deadly poison, with the power to sour wine, wither crops, rust metal, foul the air and drive dogs mad, among other things.

Not all of the ancient world was so horrified. Galen, an influential Roman physician, often pointed to menstruation as the best argument for bloodletting, a practice once thought to cure a wide variety of ailments.

"Menstruation was seen as nature's way to ... relieve the periodic ills from which some women suffered," Coutinho writes.

But thousands of years later, scientists are no closer to explaining why this monthly bleeding mechanism evolved, although they have determined that it is fairly rare. Only primates, bats and the elephant shrew, an odd, rodent-like creature, are known to experience a monthly bleed akin to that of human females.

A typical woman's cycle begins with a cascade of hormones flooding her uterus and lasts 28 days. The hormones - first estrogen and later progesterone - cause the lining of the pear-shaped organ to plump up in preparation for a fertilized egg. If no egg is fertilized, the flow of progesterone gradually ceases, causing contractions to ripple through the organ.

These contractions, the source of the cramping of which many women complain, rupture tiny blood vessels and cause the newly formed lining to shred and disintegrate. This cast-off tissue, egg and blood make up the period. It lasts three to seven days and can result in the loss of up to 100 milliliters - about seven tablespoons - of blood.

Physical changes

At the heart of the medical debate over menstrual suppression is the question of what number of periods is natural.

Some proponents of suppression point to evidence that modern woman experience far more menstrual cycles than their ancestors. One study estimates that women living in African hunter-gatherer societies had 160 lifetime periods vs. 450 for Western women. The reason is that bush women, unlike their urban counterparts, raise large broods and spend years pregnant or breast-feeding, both of which suppress menstruation.

"It's really not natural to have so many uninterrupted cycles without childbearing," argues Dr. Richard S. Legro, associate professor of obstetrics and gynecology at Penn State College of Medicine. "The human body was not designed to function that way."

The history of the birth control pill also figures into the debate. In The Pill, historian Bernard Asbell notes that the company contracted to supply synthetic hormones to the drug's inventors wanted no part of any medication that interfered with the menstrual cycle.

As a result, the contraceptive was designed to provide a steady supply of hormones for 21 days, followed by a hormone-free week to trigger a period. By providing a monthly period, scientists also hoped that the pill would be more palatable to the Roman Catholic Church, which forbids unnatural birth control.

Another reason to induce a period is to reassure women each month that they are not pregnant.

"Birth control pills were designed to have a period because men thought women needed it, and women thought women needed it," says Dr. Teresa Ann Hoffman, a Catonsville gynecologist.

Old idea, new form

Hoffman notes that the idea of menstrual suppression is not new. Since at least the 1970s, gynecologists have quietly advised their patients on ways to postpone their periods or stop them entirely by taking the active pills in their birth control packets every day. It's something Hoffman has been doing for more than a decade, starting when she was a first-year resident at Franklin Square Hospital Center.

"You're working 120 hours a week, and you really don't have time to bleed," she says. Today, many of her patients are blocking their periods, too. "I don't think the tampon people are going to be too happy with us," Hoffman says.

They are likely to be less happy if Seasonale is approved. Studies have shown that many women would be eager to put their periods behind them, mostly for medical reasons such as headaches, intense cramping and heavy menstrual flows.

A 1999 study determined that women with heavy menstrual flows lost an average of $1,692 in annual wages from missed work. Menstruation can also cause problems ranging from severe migraines to anemia to endometriosis, an intensely painful condition that results from the growth of endometrial tissue in abnormal locations. Studies have also linked ovarian cancer to the number of menstrual cycles a woman experiences during her life, although it's unclear why.

Seasonale, which should be available by Christmas if approved, contains the same mix of hormones found in standard birth control pills. The difference is that women take it for 84 consecutive days before seven pill-free days. As a result, women would experience a period once every three months (or once a season, hence the name).

"This is basically about convenience. It's not rocket science," says Dr. William E Gibbons, director of the Jones Institute for Reproductive Medicine in Norfolk, Va., which helped develop and test the contraceptive.

Long-term studies

Gibbons says Seasonale was formulated to allow four periods instead of none because surveys showed that is the number women would prefer.

Clinical studies also found that having a period once every three months reduced instances of spotting and "breakthrough" bleeding, one of the most common side effects of menstrual suppression.

Some experts on women's health say there haven't been enough long-term studies of menstrual suppression to know whether breakthrough bleeding is the only thing about which women have to worry. The few studies that have been conducted have ended too soon for subtle health problems to emerge, they say.

Justina Trott of the Women's Health Services Family Care and Counseling Center in Santa Fe points to the recent evidence that long-term hormone-replacement therapy, long promoted as beneficial, might increase a woman's risk of heart disease, breast cancer and dementia.

Last month, the Society for Menstrual Cycle Research, an interdisciplinary group of women's health advocates, expressed concern over whether long-term menstrual suppression might affect a woman's ability to get pregnant.

Such fears crossed Amanda Nemec's mind last year when her doctor suggested that she take the pill nonstop to prevent severe headaches and cramps.

"I asked her about once a week, 'Are you sure this is OK to do? Are you sure this is OK to do?'" says the 24-year-old Owings Mills resident.

Hoffman says it's a concern women often initially have about menstrual suppression. "They might say, 'Oh, it's not natural,' " she says. "Well, birth control pills are not natural. The fact is, you don't need to bleed."

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