Today’s Dreams, Tomorrow’s Reality? Contraceptives that Reliably Eliminate Menses
Menarche—the onset of menstruation—is a rite of passage for young girls everywhere. In many cultures, this milestone of womanhood comes with celebrations steeped in tradition. But following the ritual comes the reality of having to manage this aspect of being female for 40 or more years.
Worldwide, women refer to menstruation in various ways, reflecting their many attitudes toward it. Where I grew up in northeastern Pennsylvania, my family and friends called it the “curse” (in my opinion, for good reason). And, as much as many women dread “Aunt Flo’s” monthly visit, they have come to rely on their “friend” as a confirmation they are not pregnant. Others see it as affirmation of womanhood or view it as a natural and necessary means of cleansing to remove accumulated blood.
For many women, family planning (FP) methods that alter this monthly routine are unacceptable. Methods that cause irregular spotting, heavier flows, or even amenorrhea (no bleeding) are deal breakers. As contraceptive researchers, we wrestle with how best to address the potential impact a new FP method has on bleeding patterns and whether women will find this acceptable.
Before I offer up my own thoughts on amenorrhea as a target characteristic of new FP methods, let’s review a bit of physiology and history. During a normal menstrual cycle, sequenced hormonal changes prepare the uterine lining for pregnancy. If, following ovulation, a pregnancy is not established, the uterine lining breaks down and sheds (the process of menstruation); the cycle then begins anew. Natural states of amenorrhea occur during pregnancy and breastfeeding. Indeed, one FP method is called the Lactational Amenorrhea Method or LAM.
Until just a few generations ago, women typically had many pregnancies and often breastfed each child for one to two years. That meant they had far fewer menstrual cycles than contemporary women. One might contend that back then, monthly bleeding was less the norm than amenorrhea! Today, monthly menstruation is the normative state in most societies—this despite the fact that we now have contraception options (e.g., oral contraceptive pills used continuously and the LNG-IUS hormonal intrauterine system) that can minimize the frequency and duration of menstrual cycles without safety concerns, while even providing health benefits. Unfortunately, these methods do not work predictably or consistently to reduce or eliminate menstrual bleeding for all women.
Menstruation places an unnecessarily heavy burden on far too many women. Every woman alive has an embarrassing story or two about her periods. At some point, every woman has experienced menses-associated issues, such as pain (dysmenorrhea), emotional swings, bloating, breast tenderness, and hormone-related headaches. Some women suffer from menorrhagia (heavy bleeding) and are at risk of anemia. While these challenges exact a high personal and economic toll, their impact is magnified in resource-constrained areas where women who can’t afford hygiene products refrain from work and community activities…and too many young girls miss out on school.
It is important to acknowledge all the good work currently being done in the field of menstrual hygiene management to reduce stigma and to ensure that girls and women in resource-poor areas have reliable access to affordable menstrual hygiene products and safe places to manage their menses. Nothing that follows is meant to challenge those outstanding efforts.
That said, it has become increasingly clear to me that monthly bleeding not only is unnecessary from a biological perspective, it can stand in the way of true gender equality. Over the span of her reproductive life, a woman is burdened with managing her menses up to one quarter of her days. When societies deem that a "need to bleed" honors womanhood, they impose an additional hurdle in women’s path to achievement.
As contraceptive product developers, we should support development of contraceptive options that rapidly and reliably eliminate bleeding to offer women a liberating choice. How would method acceptability considerations change if absence of bleeding was the expectation and an amenorrhoeic state was a standard product design characteristic?
Research has documented that contraceptive-induced elimination of menstrual bleeding is increasingly accepted and sought out among women in the Western world. And, my FHI 360 colleagues, currently working on acceptability research in sub-Saharan Africa, are finding that a substantial proportion of women there also find the prospect appealing.
I dream of the day when advances in reproductive health technology provide women multiple, excellent tools to quickly and predictably stop their menses. I dream of the day when women are not limited by the burdens associated with having menses for a substantial fraction of their reproductive life. I dream of a day when the perception that women "need to bleed" is removed from any woman’s decision about which contraceptive to use.
It may take decades to achieve this dream, but I look forward to the day when women and girls are empowered not only to decide the timing and spacing of their children but also to say “no” to monthly visits from their “friend.”