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Menstrual Suppression and Extended Cycling


A review of the literature on Menstrual Suppression and Extended Cycling
by me

The suppression of menses or imposition of an extended cycle is increasingly being sold to modern women as a "lifestyle choice" that can increase quality of life as well as providing contraception. Granted, it is convenient not to have menses, not to have any of the symptoms or hassles involved in a regular cycle. The cons are not so obvious, perhaps because they haven't been researched. There is no doubt that long term tampering with hormones causes unintended effects that may not be evidenced for years. But what will the long term effects be? A brief survey of the literature tells us that we don't really know yet. Several methods of menstrual suppression have been FDA approved since 2003, so the experiment on the general population has begun. The three main methods of menstrual suppression are depot injections, hormone-releasing IUDs, and oral contraceptives.

CONCERNS: FERTILITY, BONE DENSITY, AND THE UNKNOWN

Reduced bone mass density and decreased fertility after a period of suppressed menses have been briefly examined as possible negative effects of extended cycling. A study released in 2009 examined bone density in teen women who were on three different hormonal contraceptives for 5 years. The effects of depot medroxyprogesterone acetate (DMPA), norethisterone enanthate (NET-EN) and combined oral contraceptives (COCs) were compared. Women on NET-EN and COC gained significantly less bone mass density during that period than women on DMPA or no contraceptive. A small sample was followed after the study and the authors claim that the bone mass reduction was made up in those women after discontinuation of the contraceptive.

(Bekinska ME et al, Bone mineral density in a cohort of adolescents during use of norethisterone enanthate, depot-medroxyprogesterone acetate or combined oral contraceptives and after discontinuation of norethisterone enanthate. Contraception. 2009 May;79(5):345-9. Epub 2009 Jan 17.)

Decreased fertility after cessation of menstrual suppression is a serious concern. So far the studies have not revealed a longterm effect. Studies on resumption of cycling have for the most part been on women in their teens and 20's who are likely to be quite fertile. One 1995 study in China included 14 women ranging in age from 19 to 40. Extrapolating from the data I suspect that the number of perimenopausal women so far evaluated for return to fertility after menstrual suppression numbers less than 10.

A 2009 study in Pennsylvania found than of 34 women who discontinued a trial of continuous levonorgestral and ethinyl estradiol to get pregnant, 81% of the ones who were "at risk for pregnancy" were successful in conceiving within a year, and 86% were pregnant by 13 months. Women who were not "at risk" were either pregnant when they discontinued the continuous regimen, or initiated another form of birth control. The authors conclude that their findings suggest "a continuous oral contraceptive with levonorgestrel 90 μg and ethinyl E2 20 μg does not delay the return to fertility."

(Barnhart K et al, Return to fertility after cessation of a continuous oral contraceptive, 2009, Reprint requests: Kurt Barnhart, M.D., M.S.C.E., 3701 Market St., Ste. 801, Philadelphia, PA 19104 (FAX: 215-615-4200))

One of the primary findings of studies that look at ovarian function is the suppression of follicles in women who take continuous hormonal regiments. There are a number of clinically relevant questions that have not yet been investigated. How long can you suppress the follicles before they degrade or stop forming? How does age impact the recovery of fertility? What is the risk of infertility relative to populations that are not consuming exogenous hormones (at least not intentionally)?

So far the research has not turned up any significant negative effects of menstrual suppression. The positive effects, most centrally the reduction in PMS and dysmenorrhea, are trumpeted in many studies. The research appears to have a pro-pharmaceutical bias, based on the choices of outcome measures and the lack of longterm followup, which is time consuming. So we must wait for answers until the longterm experimentation is performed with the FDA's blessing on a great many unsuspecting women who may decide that for convenience and comfort's sake they'd like to stop menstruating altogether.

WHO IS AT RISK

A survey of the research reveals what groups the pharmaceutical companies plan to target with their marketing. There has be very little research that includes women past the age of 40, possibly because as contraceptive consumers perimenopausal women are a limited market. It appears that the groups most likely to be studied and potentially targeted by advertising are women who are obese, teen aged, deployed in the military or mentally incompetent. Women who have used COCs with cycling have also been identified as a group more likely to consider menstrual suppression. Therapeutic amenorrhea is also indicated for thrombocytopenia,

((Martin-Johnston MK, Okoji OY, Armstrong A., Therapeutic amenorrhea in patients at risk for thrombocytopenia., Obstet Gynecol Surv. 2008 Jun;63(6):395-402; quiz 405.

but because it is a rare condition, the research on sufferers of this disease is clinical in emphasis and not as concerned with "attitudes" about menses.

I do not mean to imply that the suppression of menses is never clinically indicated. A great many physicians prescribe menses-stopping hormones for women with iron deficiency anemia due to menorrhagia. As long as these applications are short term and well indicated, science and good clinical outcomes support their use.

OBESITY

A 2006 survey of sexual behaviors in a large group in France discovered that obese women are 4.3 times more likely to have unintended pregnancies, even though they are more likely to be celibate than normal weight women. Hot on the heels of this finding the suggestion was made that "long acting reversible contraceptives are suitable for obese women" because they require fewer physician visits, have less problems with weight-related dosing, and cause less DVT.

((Bajos, N et al., Obesity Linked to Lower Number of Sexual Partners and Increased Unwanted Pregnancies, BMJ. 2010;340:c2573.)) Medical practitioners are encouraged to consider depot and IUD methods of hormonal delivery in such cases.

In 2004 a study comparing three different hormonal combinations in combined oral contraceptives noted that overweight women had less follicular suppression and higher estrogen levels than normal weight women. They also noted that there was less follicular suppression in women who took 7 day breaks from the hormone regimen.

((Schlaff WD, Lynch AM, Hughes HD, Cedars MI, Smith DL., Manipulation of the pill-free interval in oral contraceptive pill users: the effect on follicular suppression., Am J Obstet Gynecol. 2004 Apr;190(4):943-51.

A 2010 study examined blood pressure and body weight effects of a vaginal ring releasing approximately 120mcg of etonorgestrel and 15mcg ethinyl estradiol per day. It was a one year study with a sample size of 75, and the regimen was 84 days on and 7 days off. The findings relative to the vaginal ring were that there was no change in blood pressure, symptoms were decreased, and body weight increased but "within the expected biological variation range".

((Barreiros FA, Guazzelli CA, Barbosa R, de Assis F, de Araújo FF., Extended regimens of the contraceptive vaginal ring: evaluation of clinical aspects., Contraception. 2010 Mar;81(3):223-5. Epub 2009 Nov 14.

The correlation between weight gain and assorted birth control alternatives is an area that is well worth examining in future research, even though these authors dismissed the finding.

ADOLESCENTS

In 2009 a study in Pittsburg found that adolescents could use extended cycling or continuous regimens for "successful menstrual suppression". The found that it decreased symptoms associated with menses and that the main reason women discontinued the regimen was breakthrough bleeding. The abstract advises that women with breakthrough bleeding might consider intermittent estrogen supplementation, or taking a 4 day break from the hormones, when spotting occurs. The number of prescriptions to adolescents is increasing.

((Gold, MA et al, Extended cycling or continuous use of hormonal contraceptives for female adolescents. Curr Opin Obstet Gynecol. 2009 Oct;21(5):407-11.))

MILITARY

Also in 2009 a study of 62 female US Naval aviators found that 93% of the women were aware that menses can be suppressed, and 66% wanted it for deployment. Only 33% were using oral contraceptives and 15% were on a continuous regimen, so another market was identified. Among the aviators 44% said they had a hard time taking a daily pill, again suggesting that a non-daily dosage would be a preferred delivery system. This study specifically noted that "flight surgeons should provide further education and consider continuous OCP dosing", elucidating the pharmaceutical industry strategy for delivery to this population.

((Powell-Dunford N et al, Menstrual suppression using oral contraceptives: survey of deployed female aviation personnel. Aviat Space Environ Med. 2009 Nov;80(11):971-5.))

MENTAL INCOMPETENCE

Females who are mentally incompetent and institutionalized are likely to have their menses suppressed. The reasons given are hygiene, and the potential disturbance caused by the appearance of menstrual blood should it be evident to any psychologically imbalanced inpatients. Menstrual suppression was suggested for mentally retarded patients in 1967 in a report published in JAMA. The study recommends the new (at the time) 19-nor-progestogens as a "safe and efficient method of suppressing menstruation as a hygienic measure in the care of mentally retarded patients". This report relies on research by Kistner proving "that a state of pseudopregnancy can be maintained for long periods without deleterious effects".

((Shropshire L, Morris WM, Foote EL., Suppression of menstruation. A hygienic measure in the care of mentally retarded patients. JAMA. 1967 May 1;200(5):414-5. PMID: 6071518))

The discussion was sidelined, and the practice is most likely prevalent. A 2007 review of the literature revealed that little has been published on the subject. The authors push on to consider the therapeutic options available for the suppression of menstruation in adolescents with severe learning disabilities, and report on current clinical practices at one hospital in London.

((Assunta Albanese, Neil W Hopper, Suppression of menstruation in adolescents with severe learning disabilities, Arch Dis Child 2007;92:629-632 doi:10.1136/adc.2007.115709))

The physicians at a residential school in Cheshire (also in the UK) responded to that study with comments regarding their female population with severe learning disabilities and epilepsy. Their management of menstruating females is a good example of the customized and informed care that can be applied in such situations. Their cohort included 21 women aged 12-20 who displayed normal pubertal development. Two of the epileptics had worsening of their siezures around the menses. One third of the group had no problems with menses and were not medicated for menstrual control. In seven of the girls "dysmenorrhoea and other menstrual disturbances such as menorrhagia were well managed with combinations of paracetamol and mefenamic acid" and COCs were used cyclically in another seven, but discontinued in most for the usual reasons including weight gain and concerns about bone density. There did not appear to be benefits surrounding siezure frequency. These practitioners do not use depo-provera in conjunction with anticonvulsant use because of the concern over decreased bone density acquisition. They did use norethiesterone to postpone the menses if requested. Surgical management of menses had been considered by two families but not pursued.

((Mel M McMahon, Neurodiability SpR Margaret Huyton, Dan Hindley, Management of menstruation in severe learning disability, response to the Hopper study at http://adc.bmj.com/content/92/7/629.abstract/reply#archdischild_el_3503

MARKETING: EFFECTS OF PRIMING AND ATTITUDES OF ITALIAN WOMEN

Two 2008 studies found on pubmed appear more like marketing research than pharmacology. One study considered the effect of "priming" women by putting them in one of two groups, one that supported the idea that menstruation is normal and natural, and one that did not. The abstract leads us to believe that the emphasis was promenstrual, but I suspect that the object was to examine ways in which women might be brought around to the idea that suppression of menses is fine. The important finding was that higher scores on the menstrual joy questionaire (MJQ) and previous oral contraceptive use were "predictors of women's willingness to suppress menstruation". The women's primary concern about suppression was "safety" and their main source of information was "media".

((Rose JG, Chrisler JC, Couture S., Young women's attitudes toward continuous use of oral contraceptives: the effect of priming positive attitudes toward menstruation on women's willingness to suppress menstruation., Health Care Women Int. 2008 Aug;29(7):688-701.))

A second 2008 survey on women's attitudes was performed in Italy. They found that 32% of Italian women prefer to bleed monthly and 58% considered an extended cycle oral contraceptive regimen acceptable.

((Fruzzetti F, Paoletti AM, Lombardo M, Carmignani A, Genazzani AR., Attitudes of Italian women concerning suppression of menstruation with oral contraceptives., Eur J Contracept Reprod Health Care. 2008 Jun;13(2):153-7.))

A 2010 study looked at a 91 day extended regimen of ethinyl estradiol with the stated goal "to demonstrate the efficacy and safety" of the therapy. They found what they were looking for: an absence effects and reduction in menstrual symptoms in the short term. It was a larger group (n = 1249) including women aged 19-40, but the duration was still only a year (or less). Ovulatory function and bone mass were not assessed. The intention to verify the marketability of the product is clear in the abstract.

((Kroll R, Reape KZ, Margolis M., The efficacy and safety of a low-dose, 91-day, extended-regimen oral contraceptive with continuous ethinyl estradiol., Contraception. 2010 Jan;81(1):41-8.))

This marketing research parading as science does not provide useful information about the safety of the therapy, rather, it illuminates potential markets. Through studies like this the pharmaceutical industry is monitoring the effects of "educational" campaigns about birth control options that halt menses.

Western women are being gradually desensitized to the concept of menstrual suppression. This is in preparation for the marketing barrage that is waiting in the wings. Women who adopt this therapy before its long term effects are known are taking their chances.

A FEW MORE STUDIES WITH USEFUL MEDICAL FINDINGS

A 2007 study (n = 62) looked at medical outcome measures for a continuous regimen of 20mcg ethinyl estradiol and 1mg norethindrone acetate. In short they found that the total bleeding days was the same for women taking the hormones or not, but the women not on hormones had heavier menstrual bleeding, whereas the women taking hormones had breakthrough spotting. The continuous group had lower estrogen levels, lower ovarian volume, smaller lead follicles and "improved" premenstrual behavior, in addition to the "improved patient symptomatology".

((Legro RS, Pauli JG, Kunselman AR, Meadows JW, Kesner JS, Zaino RJ, Demers LM, Gnatuk CL, Dodson WC., Effects of continuous versus cyclical oral contraception: a randomized controlled trial., J Clin Endocrinol Metab. 2008 Feb;93(2):420-9. Epub 2007 Dec 4.))

A 2005 study found that many adolescents would like to menstruate less frequently (more marketing research), and that the metabolic changes associated with extended cycling were the same as with regular birth control pills. This study suggested that the increased ovarian suppression of extended cycling might make the therapy more effected as a contraceptive. Most of the young women in this experiment were found to have atrophic endometriums. A 4 day break from birth control pills to manage breakthrough bleeding is suggested here too.

((Sucato GS, Gerschultz KL., Extended cycle hormonal contraception in adolescents., Curr Opin Obstet Gynecol. 2005 Oct;17(5):461-5.))

In 1995 a study on a small group (n = 14) of Chinese women looked at levonorgestrel delivered via IUD after six years. Outcome measures included changes in luteinizing hormone, progesterone, estradiol, prolactin and sex hormone binding globulin. After six years of use 78.5% of the women resumed ovarian cycling and had normal hormones. Two women had suppression of LH and progesterone and high E2 levels associated with follicular hyperactivity, and one woman had a luteal phase defect.

((Xiao B, Zeng T, Wu S, Sun H, Xiao N., Effect of levonorgestrel-releasing intrauterine device on hormonal profile and menstrual pattern after long-term use., Contraception. 1995 Jun;51(6):359-65.

It was in 1995 that the hormone-releasing IUD (to become Mirena) was first marketed in Scandinavia, the UK and Denmark. The claim was that unlike the copper IUD, the "failure rate" was not dependent on age, and that it was protective against ectopic pregnancy and PID.

((Luukkainen T, Toivonen J., Levonorgestrel-releasing IUD as a method of contraception with therapeutic properties., Contraception. 1995 Nov;52(5):269-76.

WHY BLEED

An assortment of values have been attached to menstruation that the majority of modern women seem quite willing to give up. There is the connection to one's animal nature, the connection with self as woman that is celebrated with the menses in some cultures. In our culture the value of nature and our own animal nature is largely submerged or denied. There is also the multi-culturally recognized phenomenon of increased spiritual sensitivity or connection which occurs during the menses. Some native American groups still celebrate this opportunity, but for the most part Western women lack a regular spiritual practice and certainly don't associate spirituality with their menses.

Even lacking the animal and spirit reasons, there are medical reasons why one might be glad to bleed, most predominantly the regular loss of excess iron. This benefit is especially notable in women with the genetic variation causing hemochromatosis, which ironically occurs more in the Scandinavian populations who appear to be willing to adopt menstrual suppression.

Another reason to enjoy your periods is the natural increase in testosterone that occurs during the sloughing part of the menstrual cycle. During this time women may have increased libido and a high energy level, once the symptoms commonly associated with onset have passed.

A naturopathic indication for allowing regular menstrual release is function as an emunctory organ. Eliminating the lining of the uterus reduces the potential for pelvic infection and may serve to release toxins or other unwanted substances from the body. According to Chinese medicine liver qi builds up every month, and becomes stagnant until it is released with the menstrual flow. This blocked qi is seen as the cause of premenstrual irritability and frustration. It would be interesting to scientifically evaluate contents of the menses relative to women's health status.

Another persuasive indication for natural cycling has to do with mate selection. Whether we know it or not, scent is paramount in importance in sexual attraction. The most attractive pheromones are formed by potential mates who have MHC (major histocompatibility complexes) on their cells that are substantially different, but not altogether alien from one's own. When women have altered hormonal status, their attractions based on pheromones are altered, potentially altering mate selection. It is possible that altered perception of pheromones may have immunological effects, since the MHC molecules are central in our ability to distinguish "self" from "other" cells. One PhD researcher recommends that women who are using hormonal contraceptives and considering marriage stop the contraceptive and re-evaluate their feelings about the potential mate before tying the knot. This is fertile ground for yet another scientific inquiry. The "disruption of women's natural hormonal cycle through the use of oral contraceptives has consequences to their personal lives and potential implications for the future well-being of the human species." A review of the research on this topic (with references) can be found in Susan Rako's book, The Blessings of the Curse.

((Rako, Susan, M.D., The Blessings of the Curse, pp39-41, iUniverse Inc publisher, 2006.

IN CONCLUSION

There is one argument made in support of menstrual cessation that invites a whole new set of questions. The argument is based on evolution and goes like this: Primitive human women must have been either pregnant or nursing pretty much continuously, from the time that they become fertile to the time their fertility waned. In the modern era we have many options for preventing pregnancy, and we choose to have fewer children. Women are not continuously using our reproductive facilities, and this change radically alters each woman's hormonal, nutritional, and anatomical condition. It is possible that suppressing the menses could mitigate some of the effects of this change in human reproductive patterns. A careful comparison of women on birth control with pregnant and breast feeding women with an eye on this change could reveal interesting new information.

In practical application, menstrual suppression is on the increase. Extended cycling is very appealing to many women, and negative effects appear minimal at this time. There are steady media mentions of the subject, and increasingly prevalent medical practitioner suggestion of menstrual suppression and extended cycling in women. The short term benefits are obvious. The long term costs are not yet clear. It will be incumbent upon medical professionals to continue to monitor the research and make decisions that are not based solely on the marketing, even when such marketing is disguised as science.



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below here resource material used for research


TYPES
depot medroxyprogesterone acetate (DMPA)
norethisterone enanthate (NET-EN)
combined oral contraceptives (COCs)
levonorgestrel (binds prog receptor with 323$ more affinity than prog)
ethinyl estradiol

LNg 90mcg & E2 20mcg studied, n=34, 81% who stopped to get preg were preg within a year


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THE CONTROVERSY
biological normal vs cultural normal
bio: pregnant while fertile
cultural: preg only 1-3x/life
changes in reproduction in last century

PROS
convenience
cleanliness
military: living with men but no special needs

CONS including Health Risks
tampering with hormones
loss of connection with self, with nature
may reduce future fertility

INDICATIONS
military
mental retardation

CONTRAINDICATIONS


METHODS


RETURN TO FERTILITY
after cessation of continuous levonorgestrel and ethinyl
trying to get full article from http://www.fertstert.org/search/
90mcg, 20mcg respectively
2009 phase 3 trial, U of Pennsylvania, lead researcher K Barnhart
analyzed pregnancy outcomes after contraceptive trial
looked at participants who discontinued birth control to become pregnant
women contacted at 3 and 12 mo after d/c
n = 34 women who d/c bcs they wanted to get pregnant
of these:
4 already preg before stopping tx
4 initiated other contraception
5 lost to followup
21 left "at risk" of pregnancy
preg rate 57% at 3 months
81% at 12 months
86% (18-21) at 13 mo
"CONCLUSION(S): These findings suggest that a continuous oral contraceptive with levonorgestrel 90 microg and ethinyl E(2) 20 microg does not delay the return to fertility."
my questions: how old were these women and how long were they on the continuous hormones?

LEVONORGESTREL
used in mono and biphasic pills, progestin only and combined pills, Mirena IUD, norplant and jadelle
a hormonally active levorotatory enantiomer of the racemic mixture norgestrel
a gonane progestin derived from 19-nortestosterone
relative binding affinities (in humans):
323% that of progesterone at the progesterone receptor
58% that of testosterone at the androgen receptor
17% that of aldosterone at the mineralocorticoid receptor
7.5% that of cortisol at the glucocorticoid receptor
<0.02% that of estradiol at the estrogen receptor
SE: n/v/d, gi pain, dizz, breast tenderness, tired/weak, headache, menstrual changes
Decr total and free testosterone, androstenedione, dehydroepiandrosterone sulfate (DHEAS), dihydrotestosterone (DHT) and sex hormone–binding globulin (SHBG)
"has no effect on sexual function or markers of androgen bioactivity" (wiki)

ETHINYL



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ABSTRACTS OF STUDIES USED

Fertil Steril. 2009 May;91(5):1654-6. Epub 2008 May 7.
Return to fertility after cessation of a continuous oral contraceptive.
Barnhart K, Mirkin S, Grubb G, Constantine G.

Department of Obstetrics and Gynecology, PENN Fertility Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA. kbarnhart@obgyn.upenn.edu
Comment in:

Fertil Steril. 2009 Oct;92(4):e47; author reply e48.
Abstract
OBJECTIVE: To evaluate the return to fertility among women planning to become pregnant after the use of a continuous regimen of levonorgestrel 90 microg and ethinyl E(2) 20 microg. DESIGN: Descriptive analysis of pregnancy outcomes after participation in a contraceptive trial. SETTING: Multicenter trial. SUBJECT(S): Participants in a phase 3 contraceptive trial who discontinued to become pregnant. INTERVENTION(S): Eligible subjects were contacted at 3 and 12 months after treatment discontinuation to determine if and when they had conceived. MAIN OUTCOME MEASURE(S): Kaplan-Meier analysis displaying the time until conception after oral contraceptive discontinuation. RESULT(S): In the phase 3 trial, 34 of 2,134 subjects cited a desire for pregnancy as a reason for discontinuation. Of these, 4 were already pregnant before stopping treatment, 4 initiated other contraception, and 5 were lost to follow-up. Of the remaining 21 subjects at risk of pregnancy, the pregnancy rate was 57% at 3 months, 81% at 12 months, and 86% (18 of 21) (95% confidence interval 64% to 97%) at 13 months after discontinuation of treatment. CONCLUSION(S): These findings suggest that a continuous oral contraceptive with levonorgestrel 90 microg and ethinyl E(2) 20 microg does not delay the return to fertility.

PMID: 18462723 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/18462723

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Contraception. 2009 May;79(5):345-9. Epub 2009 Jan 17.
Bone mineral density in a cohort of adolescents during use of norethisterone enanthate, depot-medroxyprogesterone acetate or combined oral contraceptives and after discontinuation of norethisterone enanthate.
Beksinska ME, Kleinschmidt I, Smit JA, Farley TM.

Department of Obstetrics and Gynaecology, Reproductive Health and HIV Research Unit, University of the Witwatersrand, Mayville, South Africa.
Abstract
BACKGROUND: Depot medroxyprogesterone acetate (DMPA), norethisterone enanthate (NET-EN) and combined oral contraceptives (COCs) have been shown to have a negative effect on bone mineral density (BMD) in adolescents. The aim of this study was to investigate BMD in 15- to 19-year-old new users of DMPA, NET-EN and COCs. STUDY DESIGN: This 5-year longitudinal study followed up new users of DMPA (n=115), NET-EN (n=115) and COCs (n=116) and 144 nonuser controls. BMD was measured at the distal radius using dual-energy X-ray absorptiometry. RESULTS: BMD increased in all groups (annual percent increase: nonusers, 1.49%; DMPA, 1.39%; NET-EN, 1.03%; COCs, 0.84%) during follow-up (p<.001). There was evidence for lower BMD increases per annum in NET-EN (p=.050) and COC (p=.010) users compared to nonusers but no difference between DMPA and nonusers (p=.76). In 14 NET-EN discontinuers, an overall reduction of 0.61% per year BMD was followed upon cessation by an increase of 0.69% per year (p=.066). CONCLUSION: This study suggests that BMD increases in adolescents may be less in NET-EN and COC users; however, recovery of BMD in NET-EN users was found in the small sample of adolescents followed post-discontinuation.

PMID: 19341845 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/19341845

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Aviat Space Environ Med. 2009 Nov;80(11):971-5.
Menstrual suppression using oral contraceptives: survey of deployed female aviation personnel.
Powell-Dunford N, Cuda AS, Moore JL, Crago MS, Deuster PA.

Naval Operational Medicine Institute, NAS Pensacola, Pensacola, FL, USA. dunford.powell@us.army.mil
Abstract
INTRODUCTION: Increasing numbers of women perform aviation duties in the combat flight environment. Oral contraceptive pills (OCPs) afford numerous health and operational benefits, including prevention of anemia and suddenly incapacitating conditions, as well as menstrual suppression when taken continuously. Until now, the use of OCPs in the combat flight environment has not been examined. METHODS: An anonymous, voluntary questionnaire was distributed to 62 female U.S. Army aviation personnel who had recently deployed in support of combat flight operations to characterize continuous OCP use and perceived barriers to this practice, as well as to determine associations with menstrual burden. RESULTS: There were 81% (N=50) of the women who had personal experiences using OCPs and 93% (N=58) were aware that continuous use can suppress menstruation. For deployment, 66% (N=41) desired menstrual suppression, yet only 33% (N=20) reported any OCP use. Even fewer (15%; N=10) reported using continuously. Of the women who did not use OCPs continuously, 35% had insufficient knowledge about OCPs and 44% of women reported difficulty in remembering to take a daily pill. Continuous OCP users were more compliant (P = 0.019), reported less spotting (P = 0.007) and fewer unexpected menstrual cycles (P = 0.03) than conventional OCP users. A trend toward reduced cramping was noted (P = 0.064). Most women (60%) desired standardized entry-level education about menstrual suppression through OCPs. CONCLUSIONS: The use of continuous OCPs is low in deployed women with aviation-related duties, yet a majority desires menstrual suppression. Continuous OCP use in this setting is associated with significantly improved compliance and significant reductions in specific menstrual burdens. Entry-level education is desirable and may reduce barriers to continuous OCP use by addressing risks, side effects, and daily pill adherence strategies. Flight surgeons should provide further education and consider continuous OCP dosing in the austere environment of combat flight.

PMID: 19911522 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/19911522

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Curr Opin Obstet Gynecol. 2009 Oct;21(5):407-11.
Extended cycling or continuous use of hormonal contraceptives for female adolescents.
Gold MA, Duffy K.

Division of Adolescent Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA. magold@pitt.edu
Abstract
PURPOSE OF REVIEW: The purpose of this review is to present the most recent data on extended cycling and continuous use of hormonal contraception for female adolescents. RECENT FINDINGS: Since 2003, several new products have been US Food and Drug Administration approved to provide extended cycling or continuous use of hormonal contraception. Clinical trials have been conducted with adult women of 18 years and older and not with adolescents under age of 18 years. Studies find successful menstrual suppression using extended cycling and continuous-use regimens that are safe and effective without negative effects on the endometrium or hemostasis. Extended cycling and continuous use improves menstrual symptoms attributed to the hormone-free interval in traditional cyclic regimens. Adolescent health providers report prescribing extended cycles of contraception with increasing frequency to adolescents. It is unknown how well female adolescents tolerate breakthrough bleeding, but data suggest that bleeding is the main reason for discontinuing. Supplementation with intermittent estrogen or instituting a 4-day hormone-free interval in response to persistent bleeding may decrease this side effect; adolescents should be counseled about these options. SUMMARY: Extended cycling or continuous use of hormonal contraception offers adolescents an opportunity to decrease, delay or suppress monthly menstruation for health or personal reasons.

PMID: 19528798 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/19528798

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Health Care Women Int. 2008 Aug;29(7):688-701.
Young women's attitudes toward continuous use of oral contraceptives: the effect of priming positive attitudes toward menstruation on women's willingness to suppress menstruation.
Rose JG, Chrisler JC, Couture S.

Department of Psychology, Connecticut College, New London, Connecticut 06320, USA. Jennifer.rose@conncoll.edu
Abstract
The present study investigated American women's attitudes toward menstrual suppression and the effect of priming attitudes toward menstruation on women's willingness to suppress menstruation. One hundred college women randomly were assigned to either a positive priming group or a negative priming group. The positive priming group first completed the menstrual joy questionnaire (MJQ) followed by a willingness to suppress menstruation (WSM) questionnaire, the beliefs and attitudes toward menstruation (BATM) questionnaire, the menstrual distress questionnaire (MDQ), and a demographic questionnaire. The negative priming group completed, in the following order: the MDQ, WSM, BATM, MJQ, and demographics. Priming affected women's reports of positive cycle-related changes on the MDQ, but not women's willingness to suppress menstruation. Higher scores on the MJQ, positive attitudes toward menstrual suppression, and previous oral contraceptive (OC) use were predictors of women's willingness to suppress menstruation. Women's primary source of information about menstrual suppression was "media," and their primary concern was "safety." Thus, researchers should continue to investigate the long-term effects of continuous OC use and to analyze information about menstrual suppression in the popular press.

PMID: 18663629 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/18663629

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Nurs Womens Health. 2008 Jun;12(3):243-8.
Menstrual suppression: benefits and risks of continuous combined oral contraceptives.
Dougherty PL.

Reproductive Medicine and Surgery Division, Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, VA, USA. dougherty@virginia.edu
PMID: 18557855 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/18557855
(CAN'T SEEM TO GET AN ABSTRACT FOR THIS ONE)

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Eur J Contracept Reprod Health Care. 2008 Jun;13(2):153-7.
Attitudes of Italian women concerning suppression of menstruation with oral contraceptives.
Fruzzetti F, Paoletti AM, Lombardo M, Carmignani A, Genazzani AR.

Department of Obstetrics and Gynaecology, University of Pisa, Pisa, Italy. ffruzzi@tin.it
Abstract
OBJECTIVES: Perceptions of menstruation vary according to culture and religion. This study addresses attitudes of Italian women towards changes in menstrual frequency induced by oral contraceptives (OCs) administered in an extended regimen. METHODS: Three-hundred-and-fifty healthy women of reproductive age were enrolled in three test areas in Italy. Participants completed a standardized questionnaire. One-hundred-and-ten men, aged 21-54 years, accompanying their partners to the gynaecological consultation were also given a questionnaire to get to know their opinion about the extended use of OCs by their partner. RESULTS: Only 32% of Italian women prefer to bleed monthly. The preferred frequencies in all age groups were 3-monthly (23.7%) or never (26%). Of the OC-users, 57.2% preferred to bleed less than once a month: 26% wished to bleed every 3 months, and 21.2% once a year. Among men, 58.1% considered an extended OC regimen to be acceptable. CONCLUSIONS: About 60% of Italian women with spontaneous or OC-driven cycles prefer to bleed less than monthly. This fact should be kept in mind by physicians when prescribing OCs.

PMID: 18465477 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/18465477

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2243231/?tool=docline
J Clin Endocrinol Metab. 2008 Feb;93(2):420-9. Epub 2007 Dec 4.
Effects of continuous versus cyclical oral contraception: a randomized controlled trial.
Legro RS, Pauli JG, Kunselman AR, Meadows JW, Kesner JS, Zaino RJ, Demers LM, Gnatuk CL, Dodson WC.

Department of Obstetrics and Gynecology, Pennsylvania State University College of Medicine, M.S. Hershey Medical Center, 500 University Drive, H103, Hershey, Pennsylvania 17033, USA. RSL1@PSU.EDU.
Abstract
CONTEXT: Continuous oral contraception may better suppress the ovary and endometrium, lending itself to the treatment of other medical conditions. OBJECTIVE: Our objective was to determine the effects of continuous vs. cyclical oral contraception. DESIGN: This was a randomized double-blind trial. SETTING: This trial was performed at an academic medical center in Pennsylvania. PATIENTS: A total of 62 healthy women with regular menses were included in the study. INTERVENTION: Cyclical oral contraception (21-d active/7-d placebo given for six consecutive 28-d cycles) vs. continuous (168-d active pill) therapy using a monophasic pill (20 microg ethinyl estradiol and 1 mg norethindrone acetate) was examined. MAIN OUTCOME MEASURES: The primary outcome was vaginal bleeding, and secondary outcomes included hormonal, pelvic ultrasound, quality of life, and safety measures. RESULTS: There was no statistically significant difference in the number of total bleeding days between groups, but moderate/heavy bleeding was significantly greater with the cyclical regimen [mean 11.0 d (sd 8.5) vs. continuous 5.2 d (sd 6.8); P = 0.005], with both groups decreasing over time. Endogenous serum and urinary estrogens measured over six cycles were significantly lower (P = 0.02 and 0.04, respectively) in the continuous group than the cyclical group. Women in the continuous group also had a smaller ovarian volume and lead follicle size over the course of the trial by serial ultrasound examinations. The Moos Menstrual Distress Questionnaire showed that women on continuous therapy had less associated menstrual pain (P = 0.01) and favorable improvements in behavior (P = 0.04) during the premenstrual period. CONCLUSIONS: Continuous oral contraception does not result in a reduction of bleeding days over a 168-d period of observation but provides greater suppression of the ovary and endometrium. These effects are associated with improved patient symptomatology.

PMID: 18056769 [PubMed - indexed for MEDLINE]PMCID: PMC2243231Free PMC Article
http://www.ncbi.nlm.nih.gov/pubmed/18056769

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Curr Opin Obstet Gynecol. 2005 Oct;17(5):461-5.
Extended cycle hormonal contraception in adolescents.
Sucato GS, Gerschultz KL.

Division of Adolescent Medicine, Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA. Gina.Sucato@chp.edu
Abstract
PURPOSE OF REVIEW: There is increasing interest in the use of extended cycles of hormonal contraception to manage menstrual cycle-related complaints in adolescents and to accommodate the menstrual preferences of patients using hormonal contraception. This review summarizes recent findings related to the use of extended cycles and highlights their relevance to adolescents. RECENT FINDINGS: Many adolescents would prefer to menstruate less frequently. Among health care providers who prescribe hormonal contraceptives, the majority believe suppressing withdrawal bleeding is well tolerated and prescribe extended cycling regimens to their patients. Shortening or eliminating the hormone-free interval results in greater ovarian suppression and thus may increase contraceptive efficacy. Studies in adult women have not identified changes in metabolic parameters beyond what would be expected from traditional cyclic use. New endometrial biopsy data have found no pathologic changes; most women using an extended cycle had atrophic endometriums. Extended cycling is frequently associated with breakthrough bleeding. In some women, this can be managed with a brief hormone-free interval. SUMMARY: Recent findings demonstrate high levels of interest in extended cycling among adolescents and providers, and continue to add to the growing body of literature supporting the safety and improved contraceptive efficacy of extended regimens. Further research is warranted to focus on issues including cancer, thrombotic disease and fertility, and should enroll a sufficient adolescent sample.

PMID: 16141758 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/16141758

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Obstet Gynecol Surv. 2008 Jun;63(6):395-402; quiz 405.
Therapeutic amenorrhea in patients at risk for thrombocytopenia.
Martin-Johnston MK, Okoji OY, Armstrong A.

Illinois Masonic Medical Center, Chicago, Illinois, USA.
Abstract
To examine the need for and evaluate the method of menses suppression in women at risk for thrombocytopenia. A systematic review of the published literature in MEDLINE using the search terms thrombocytopenia, menorrhagia, therapeutic amenorrhea, progestin intrauterine device, combination oral contraceptive--extended and cyclic, gonadotropin releasing hormone agonist, danazol, and progestins. There are an increased number of reproductive age women at risk for thrombocytopenia who would benefit from menses suppression. A number of effective medical regimens are available. In patients who fail medical therapy, endometrial ablation appears to be effective in women with thrombocytopenia. As a result of the increased number of women at risk for thrombocytopenia, there is a need for therapeutic amenorrhea. The type of regimen selected depends upon the patients need for contraception and the ability to tolerate estrogen-containing medications. For women who fail medical therapy, there are surgical options, which are associated with less morbidity than hysterectomy.

PMID: 18492296 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/18492296

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Am J Obstet Gynecol. 2004 Apr;190(4):943-51.
Manipulation of the pill-free interval in oral contraceptive pill users: the effect on follicular suppression.
Schlaff WD, Lynch AM, Hughes HD, Cedars MI, Smith DL.

Department of Obstetrics and Gynecology, Section of Reproductive Endocrinology, University of Colorado Health Sciences Center, Denver, 80010, USA. Willaim.Schlaff@uchsc.edu
Abstract
OBJECTIVE: The purpose of this study was to compare follicular suppression that was produced by 3 different oral contraceptive regimens that differ by treatment in the pill-free interval. STUDY DESIGN: In a university setting, 54 women were assigned randomly to receive either 20 microg ethinyl estradiol+100 microg levonorgestrel followed by 7 pill-free days, 20 microg ethinyl estradiol+150 microg desogestrel followed by 2 days of placebo then 10 microg ethinyl estradiol for 5 days, or 28 days of 20 microg ethinyl estradiol plus 150 microg desogestrel. Follicular suppression was evaluated by serial ultrasound scans and by serum and urinary hormone levels during a 2-month study period. Data were analyzed by nonparametric statistical tests. RESULTS: There was a significant difference in follicle count among the 3 groups (P=.005). Women who were treated with a 7-day pill-free interval experienced the least suppression. Estrogen levels were more variable and led to an observation that overweight (body mass index, >25 kg/m(2)) was associated with reduced follicle suppression (relative risk, 1.6; 95% CI, 1.0, 2.7) and higher estrogen levels (relative risk, 5.3; 95% CI, 1.3, 21). CONCLUSION: Contraceptive pill users who were treated with a 7-day pill-free interval demonstrated less follicular suppression than women who were supplemented with either estrogen alone or estrogen plus progestin. Overweight women were less suppressed than women of normal weight.

PMID: 15118618 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/15118618

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Contraception. 1995 Nov;52(5):269-76.
Levonorgestrel-releasing IUD as a method of contraception with therapeutic properties.
Luukkainen T, Toivonen J.

Family Health International, Research Triangle Park, NC 27709, USA.
Abstract
The levonorgestrel-releasing intrauterine device LNg IUD is a new contraceptive method that combines the advantages of both hormonal and intrauterine contraception. It gives users non-contraceptive health benefits and can also be used as an effective therapy for menorrhagia. The local release of LNg within the endometrial cavity results in strong suppression of endometrial growth as the endometrium becomes insensitive to ovarian estradiol. The endometrial suppression is the reason for a significant reduction of menstrual blood loss or amenorrhea, and for the disappearance of dysmenorrhea. The bleeding pattern during the use of the LNg IUD is characterized by reduction of the blood loss and in the number of bleeding days per cycle. During the first two to three months of use, however, irregular spotting is common. The removal of the device results in a quick return of menstrual bleeding and fertility. The failure rate of copper-releasing IUDs, as with other methods of fertility regulation, is higher in young women and decreases with age. The LNg IUD, on the other hand, has the same low pregnancy rate in every age group of the users. The LNg IUD also gives protection against ectopic pregnancy and pelvic inflammatory disease and, by reducing menstrual blood loss, increases the body iron stores. The LNg IUD can be used to effectively treat menorrhagia. This has been demonstrated in studies with quantitative determination of menstrual blood loss. During the first year of use, the LNg IUD reduced menstrual blood loss by 90% from pretreatment levels. Comparative clinical trials with the LNg IUD cover more than 10,000 women-years of follow-up during use over five to seven years. The Pearl pregnancy rate in studies has been 0.0-0.2 per 100 women-years. The overall ectopic Pearl pregnancy rate is 0.02 per 100 woman-years. The LNg IUD is marketed in Denmark, Finland, Norway, Sweden and in the United Kingdom.

PIP: The levonorgestrel-releasing intrauterine device (LNg IUD) is a new contraceptive method which combines the advantages of both hormonal and intrauterine contraception. It confers noncontraceptive health benefits and can also be used as an effective therapy for menorrhagia. The new device is currently being marketed in Denmark, Finland, Norway, Sweden, and the UK. Comparative clinical trials with the LNg IUD cover more than 10,000 women-years of follow-up during use over 5-7 years. The Pearl pregnancy rate has been 0.0-0.2 per 100 women-years and the overall ectopic Pearl pregnancy rate is 0.02 per 100 woman-years. The local release of LNg in the endometrial cavity results in the strong suppression of endometrial growth as the endometrium becomes insensitive to ovarian estradiol. The endometrial suppression is the reason for a significant reduction of menstrual blood loss or amenorrhea, and for the disappearance of dysmenorrhea. Use of the LNg IUD results in the reduction of blood loss and in the number of bleeding days per cycle. Irregular spotting is, however, common during the first two-three months of use. The reduction in menstrual blood loss results in an increased storage of iron in the body. Menstrual bleeding and fertility are quickly restored following removal of the device. Finally, unlike copper-releasing IUDs, the failure rate of the LNg IUD is not dependent upon the user's age, and it protects against ectopic pregnancy and pelvic inflammatory disease.

PMID: 8585882 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/8585882

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Contraception. 1995 Jun;51(6):359-65.
Effect of levonorgestrel-releasing intrauterine device on hormonal profile and menstrual pattern after long-term use.
Xiao B, Zeng T, Wu S, Sun H, Xiao N.

National Research Institute for Family Planning, WHO Collaborating Centre for Research in Human Reproduction, Haidian District, Beijing, People's Republic of China.
Abstract
In the present study 14 women after 6 years' use of levonorgestrel-releasing IUD were investigated for the changes of LH, progesterone (P), estradiol (E2), prolactin (PRL) and serum binding globulin (SHBG) in relation to the levonorgestrel levels throughout a segment of 26-40 days with the aim of comparing the hormonal profiles with those during the first year of use of Lng-IUD. Ultrasound scanning was used to follow the development of follicles along with the RIA measurement of hormones. The results of serum LH, P and E2 showed ovulation in 11 cases with either normal menstrual cycles (5 cases), prolonged or irregular cycles (4 cases) or with amenorrhea for 2-3 years (2 cases). One case showed insufficiency of luteal function and 2 cases showed anovulation but with follicular hyperactivity. Higher percentages of ovulatory cycles (78.5%) were found after 6 years of use. No case of complete suppression of ovulation was found. Anovulatory cycles only constituted 14.3%. Clinically, the development of follicles followed by ultrasound scanning further confirmed the hormonal findings. The persistent enlargement of follicles coincided with high levels of E2. After 6 years of use, the serum levels of levonorgestrel were still maintained at mean levels of 314.26 pmol/L and 470.63 pmol/L in the ovulatory and anovulatory groups, respectively. It is concluded that over two-thirds of the cases have ovulatory cycles after long-term use of Lng-IUD; the contraceptive effect is mainly due to its local action on the endometrium, with much less effect on the ovarian function.

PIP: In 1993 in China, 14 women who had used a levonorgestrel [LNG]-releasing (20 mcg/day) IUD since 1987 underwent a medical check-up so that the National Research Institute for Family Planning in Beijing could study their hormonal profile along with their menstrual pattern and their follicular cyclic changes. Health workers drew blood samples three times/week, beginning with the fifth day of the menstrual cycle or, in cases of amenorrhea, after recruitment. They were followed for 26-40 days. Ultrasound recorded cyclic changes of ovarian follicles. The women recorded days of vaginal bleeding or spotting on a menstrual diary card. The serum levels of luteinizing hormone (LH), estradiol (E2), and progesterone (P) of 11 women were normal, indicating that they had ovulatory cycles. Three women (14.3%) did not ovulate. One anovulatory woman exhibited an insufficiency in luteal function. LH and P were suppressed and E2 levels were very high in the other two women, indicating follicular hyperactivity. Ultrasound confirmed the development of follicles as indicated by hormone levels. High levels of E2 were associated with persistent enlargement of follicles. Serum levels of LNG were still at a stable level after six years of use, with anovulatory women having higher levels than ovulatory women (470.63 vs. 314.26 pmol/L; p 0.001). These stable levels after six years' use suggest that the LNG-IUD could be effectively used for another 2-3 years. These findings suggest that the LNG-IUD has a minimal effect on ovarian function since 78.5% of users have ovulatory cycles after six years' use. Local action on the endometrium is largely responsible for its contraceptive effect.

PMID: 7554977 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/7554977

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Contraception. 2010 Mar;81(3):223-5. Epub 2009 Nov 14.
Extended regimens of the contraceptive vaginal ring: evaluation of clinical aspects.
Barreiros FA, Guazzelli CA, Barbosa R, de Assis F, de Araújo FF.

Department of Obstetrics and Gynecology, Sao Paulo Federal University Family Planning Clinic/UNIFESP, São Paulo, Brazil.
Abstract
BACKGROUND: Oral contraceptives used for extended periods of time have been extensively studied because of their potential benefits; however, there have been few publications on extended regimens of vaginal contraceptive rings. The aim of this study was to evaluate the clinical symptoms, body weight and blood pressure changes in women using the vaginal ring continuously over a 1-year period. STUDY DESIGN: This prospective cohort evaluated clinical aspects (dysmenorrhea, headache, breast tenderness, leg pain and irritability), body weight and blood pressure changes in 75 women (18-37 years of age) using a vaginal ring releasing 120 mcg of etonogestrel and 15 mcg of ethinyl estradiol daily, over a continuous period of 84 days, followed by a 7-day ring-free interval, during 1 year. The chi-square, Wilcoxon and paired t tests were used to analyze differences in the outcomes of interest. RESULTS: Compared to pre-enrollment status, at the end of the study period, the patients reported significantly less dysmenorrhea and irritability, a nonsignificant decrease in breast tenderness, leg pain and headaches. Blood pressure measurements remained unchanged. Although weight and body mass index increased significantly among users, they remained within the expected biological variation range. CONCLUSION: The vaginal ring used on an extended regimen is a well-tolerated contraceptive method and also offers noncontraceptive benefits. Copyright (c) 2010 Elsevier Inc. All rights reserved.

PMID: 20159178 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/20159178

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PTS USING DMPA DURING LEEP MORE LIKELY TO DEVELOP CERVICAL STENOSIS

J Low Genit Tract Dis. 2010 Jan;14(1):37-42.
Depot medroxyprogesterone acetate: a risk factor for cervical stenosis after loop electrosurgical excisional procedure management of cervical intraepithelial neoplasia?
Martirosian TE, Smith SC, Baras AS, Darracott MM.

Department of Obstetrics and Gynecology, UVA Health System, Charlottesville, VA 22908, USA. tem2p@virginia.edu
Abstract
OBJECTIVES: In our anecdotal experience and sporadically in the literature, gynecologists have observed a connection between patient's use of depot medroxyprogesterone acetate (DMPA) and increased occurrence of cervical stenosis during follow-up after loop electrosurgical excisional procedure (LEEP). We decided to formally examine this association in our clinic population. MATERIALS AND METHODS: We performed a chart review, enrolling 257 patients and tabulating data on demography, use of hormonal contraceptives, characteristics of the LEEP, and presence or absence of cervical stenosis at 1- and 6-month follow-up evaluations. Univariate tests of association between the independent variables and the dependent variable of cervical stenosis were examined via the chi and Student t tests for discrete and continuous variables, respectively. To characterize the relative importance of independent variables significantly associated with cervical stenosis, logistic regression was performed. RESULTS: Of the 257 charts reviewed, 127 patients (49.4%) completed 1 and 6 months after LEEP follow-up appointments, providing adequate data for analysis. In this population, we observed 25 cases of cervical stenosis, or an overall rate of 19.7%. Of patients using DMPA at the time of LEEP or during the follow-up period, 9 (41.0%) of 22 developed stenosis, whereas of those who did not use DMPA, 16 (15.2%) of 105 developed stenosis, indicating a significant difference (odds ratio = 3.85, 95% CI = 1.41-10.50). CONCLUSIONS: In our clinic population, use of DMPA was associated with higher rates of development of cervical stenosis, calling for larger studies of the association of DMPA in this LEEP complication.

PMID: 20040834 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/20040834

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Contraception. 2010 Jan;81(1):41-8.
The efficacy and safety of a low-dose, 91-day, extended-regimen oral contraceptive with continuous ethinyl estradiol.
Kroll R, Reape KZ, Margolis M.

Women's Clinical Research Center, Seattle, WA 98105, USA.
Abstract
BACKGROUND: This clinical trial was conducted to demonstrate the efficacy and safety of a 91-day extended-regimen, low-dose combination oral contraceptive (OC) consisting of 84 days of ethinyl estradiol (EE) 20 mcg/levonorgestrel (LNG) 100 mcg, followed by 7 days of 10 mcg EE in place of placebo. STUDY DESIGN: A multicenter open-label, single-treatment, Phase 3 study evaluated women aged 18 through 40 years over a treatment period of up to 1 year (four 91-day extended cycles). All subjects completed daily paper diaries to monitor compliance, bleeding and additional forms of contraception used during the course of the study. RESULTS: A total of 1249 subjects completed the study. The Pearl Index was 2.74 (95% confidence interval, 1.92-3.78), based on 36 pregnancies that occurred after the onset of treatment and within 14 days after the last combination tablet in women aged 18-35 years. Among compliant-use subjects 18-35 years old, the Pearl Index was 1.73 based on 22 on-treatment pregnancies. The life table pregnancy rate for subjects 18-35 years of age was 2.39%. Cycle control and adverse events reported with this regimen were similar to those reported with other low-dose OCs. CONCLUSIONS: This study demonstrated effective prevention of pregnancy with a 20-mcg EE, 91-day extended-regimen OC. In addition, the regimen was well tolerated and incidence of adverse events were consistent with what has been reported with other low-dose OCs.

PMID: 20004272 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/20004272

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GOOD
the debate
http://www.womensenews.org/story/medicine/060823/menstrual-suppression-too-risky-experiment
http://www.post-gazette.com/healthscience/20030624hcycle2.asp
and a response: http://www.mum.org/bothamen.htm
http://www.arhp.org/publications-and-resources/clinical-fact-sheets/menstrual-suppression
http://www.utdol.com/patients/content/topic.do?topicKey=~WWzlwKtB4dIBtd1
http://thewelltimedperiod.blogspot.com/2006/09/menstrual-suppression-interactive-tool.html
http://gynecological-health.suite101.com/article.cfm/menstrual_suppression
http://www.noperiod.com/
http://www.wellwomanblog.com/50226711/supressing_menstruation.php
http://awakeningcharlotte.com/content/2009/05/05/no-periods-pros-and-cons-of-menstrual-suppression/

periods as a lifestyle choice
http://www.webmd.com/sex/birth-control/features/no-more-periods

no research on teens
http://www.scarleteen.com/blog/heather_corinna/2010/04/01/a_very_important_note_on_menstrual_suppression

documentary: period
http://www.periodthemovie.com/ABOUT.html
http://www.springerlink.com/content/th650p283hp4365p/

townsend newsletter, for women with anemia
http://findarticles.com/p/articles/mi_m0ISW/is_256/ai_n6258827/

suppression of menses in adolescents with severe learning disabilities
http://adc.bmj.com/content/92/7/629.abstract
mentally retarded patients
http://jama.ama-assn.org/cgi/content/summary/200/5/414
http://www.ncbi.nlm.nih.gov/pubmed/6071518
proposed in 1967

fertility concerns with
http://www.fertilityfactor.com/infertility_periodsuppression.html

attitudes
among Italians: http://www.informaworld.com/smpp/content~db=all~content=a788631109
http://www.ingentaconnect.com/content/apl/ejc/2008/00000013/00000002/art00007

military women
special scale devised to consider their opinions about it
http://cat.inist.fr/?aModele=afficheN&cpsidt=18917495
http://oai.dtic.mil/oai/oai?verb=getRecord&metadataPrefix=html&identifier=ADB258545

OK
http://www.epigee.org/menstruation/suppression.html
http://www.medicalnewstoday.com/articles/84596.php

research IN MACAQUES
http://www.scienceblog.com/community/older/2001/B/200111952.html
http://humrep.oxfordjournals.org/cgi/content/abstract/16/8/1562
http://www.stormingmedia.us/96/9674/B967442.html

FORMS OF BC
the new pills: http://www.epigee.org/guide/anya.html

nuva ring
http://ehealthforum.com/health/suppression-of-menstruation-and-the-nuva-ring-t182704.html
depo provera
IUD: mirena Possible delay in return of fertility once Mirena is removed
Releases levonorgestrel (LNg), a synthetic progestin, just in uterus. Reduces menstrual volume in time but spotting can occur in initial 6–12 months
May cause benign ovarian cysts
Can rarely cause hormonal side effects similar to those seen with oral birth control pills, such as mood swings, breast tenderness, headaches, and acne.

SEASONIQUE
https://www.seasonique.com/about/what-is-seasonique/?gclid=CNWK98q1paECFR5rgwod3Ep4Ew

novasure
endometrial ablation for perimenopausal women with heavy periods
http://www.novasure.com/

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