Menstrual Suppression
/Read the new ACOG Clinical Consensus! – General Approaches to Medical Management of Menstrual Suppression
Why menstrual suppression?
As an OB/GYN that might sound like a silly question – but for our patients, this is a serious concern!
A holdover of understanding (even with the design of OCPs) that a “natural cycle” is necessary for health – it’s not.
Goal overall is to:
Reduce menstrual flow, by amount and total days while
Find a strategy based on patients preferences and goals, balancing any risk factors.
Which method is best?
Combined Hormonal Contraception
Can achieve menstrual suppression by skipping the placebo week.
Some packs designed for this - 84/7 regimens, 24/4 regimens.
This can be done indefinitely!
Studies have found these extended cycle and continuous use regimens to be safe and effective
Patients should be counseled that over time, breakthrough bleeding is more likely to occur. In a recent RCT comparing OCPs to an LNG-IUD for menstrual suppression, folks in the OCP group had BTB:
50% at pill pack 3;
69% at pill pack 7;
79% at pill pack 13.
Bleeding overall tends to decrease with successive cycles.
Breakthrough happens less with higher doses of estrogen (i.e., more bleeding on a 20mcg pill than a 30mcg pill).
BTB will decrease with each successive cycle – so it’s not unreasonable to consider monthly cycles for 3-6 months, then transition to more extended cycles.
Intermittent estrogen can also be used to help prevent BTB.
The patch and vaginal ring can also be used for menstrual suppression, and have advantage of not requiring daily medication.
Patch has no difference in frequency of BTB compared to pills.
Ring is well tolerated for extended cycles and seems to be effective in reducing/minimizing bleeding.
Progestin-Only Methods
These can be of particular importance to patients where estrogen is contraindicated (cardiovascular disease, migraine with aura, hypertension, hypercoagulability) or undesired (trans-men, patient preference).
POPs
The mini-pill (norethindrone 0.35mg) has to be taken in a tight window, and has low rates of amenorrhea, so is generally not a great choice for menstrual suppression.
Norethindrone acetate 5mg can be used for menstrual suppression with better success compared to the minipill, with amenorrhea rates of up to 76% at 2 years of use.
However, this formulation is not approved as a contraceptive so can’t be used for this.
Drosperinone 4mg is a new progestin only pill on the market; data is limited, but it is likely more promising than the minipill for menstrual suppression and also has contraceptive effect.
That said, likely not a first line choice for this indication specifically.
DMPA (depot medroxyprogesterone acetate)
The DMPA shot is given roughly every 3 months.
Amenorrhea rates are good, especially with more prolonged use – 68-71% at 2 years.
However, unscheduled bleeding is a common side effect.
Loss of bone mineral density and weight gain are other common concerns; the loss of BMD is reversible with discontinuation.
LNG-IUD
Excellent at amenorrhea - 50% at 1 year, 60% at 5 years; highest with the 52mg varieties.
BTB can be managed by offering a trial of NSAIDs, POPs/OCPs, or doxycycline before discontinuing the IUD.
Not a good choice for patients where ovulation suppression is also desired (ie, PCOS) – the IUD has unclear/unpredictable effects on ovulation suppression.
Etonogestrel implant (nexplanon)
Can be continued up to 5 years for contraception, FDA approved for 3 years.
For menstrual suppression, use past 3 years may not be effective.
22% achieve amenorrhea, but breakthrough bleeding and spotting are common, especially shortly after insertion.
BTB can be managed with OCPs or norethindrone.
The ACOG document contains a very helpful but large table on the different types of hormonal contraception and their relative success, advantages, and disadvantages with menstrual suppression. Definitely worth keeping a bookmark on or a snapshot on your phone!
How do I go about selecting a method?
Counsel your patient with shared-decision making in mind:
Be aware of inequities in provision of menstrual suppression methods and your own biases
Share with patients realistic expectations of what each method might offer in the way of menstrual suppression
No method can guarantee amenorrhea
Take into account patient’s preferences and values
Be aware of medical history / medical eligibility criteria that might contraindicate certain methods
CDC Contraception App – super helpful to have the MEC handy!
By patient population:
Adolescents:
Hormone therapies are safe for adolescents
Initiation of menstrual suppression is safe anytime after menarche!
Need to have at least one menstrual period to be certain of normal pubertal development.
Pelvic exam is not needed for routine prescription of contraception, unless needed for the actual insertion (i.e., IUD)
IUD insertion has been shown to not be any more difficult in adolescents compared to older individuals, nor more difficult in nulliparas compared to parous patients.
Other tenets of adolescent reproductive healthcare counseling should be applied:
Discuss concerns about any side effects that are common / common concerns - fertility, weight, development, bone health, STIs
Use the opportunity to establish healthy alignment with adolescent at the OB/GYN office to establish as a safe place for current & future care
Transgender / Gender Diverse Patients
Menstrual suppression can help reduce feelings of gender dysphoria associated with menstruation
Testosterone use for gender-affirming care is associated with amenorrhea, often within a few months of starting therapy.
GnRH is also capable of pubertal blockade and suppression of menses for gender-affirming therapy, with amenorrhea rates nearing 100%.
Testosterone and GnRH are not contraceptives, though - so if they are at risk of pregnancy, contraception should be discussed
GnRH also cannot be used long term given concerns for bone density effects.
Patients with physical or cognitive disabilities, or both
Particularly for patients with cognitive disability, menstruation is a significant source of anxiety for caregivers and is a common reason for visit for pediatric gynecology clinics, even among premenarchal patients
Adolescents and adults with disabilities are also often assumed (erroneously) to be asexual and do not receive sexuality and contraceptive counseling on par with their peers
These individuals are also at increased risk of sexual abuse and unintended pregnancy
Assist families with developmentally-appropriate education and family assistance with hygiene concerns, contraception, STIs, and abuse prevention
Menstrual suppression methods can follow the patient’s needs, preferences, and values.
Consider in these patients their mobility and presence of contractures; swallowing ability for pills; and presence of other interacting drugs (i.e., antiepileptics).
If plan for LARC and anesthesia required, it can be considered to “bundle” together services like dental work to minimize patient exposures to anesthetics
If patient doesn’t have capacity to make independent decision, menstrual suppression discussions should be made with the caregiver in patient’s best insterest.
Ethical and prudent choice is reversible and low-risk options.
Populations with challenges affecting hygiene/privacy
Military deployment
Incarceration
Houselessness
Patients in war zones or difficulty with care access
Athletes
Obviously hard to think about all of the potentials here, but consider patient access to medical services, sanitary products, restrooms or private areas, in making shared-decision making on menstrual suppression
How do I manage breakthrough bleeding?
One of the most common challenges in menstrual suppression
Anticipatory counseling that this is common is helpful in reducing method discontinuation rates and improving method satisfaction, as well as reassuring that BTB is benign and common.
Reassure that with some methods BTB decreases or ceases after some time period of initial use