Blog of the Society for Menstrual Cycle Research

Coming off Depo-Provera can be a woman’s worst nightmare

April 4th, 2012 by Laura Wershler

Need proof that women are sometimes desperate for information and support when it comes to quitting hormonal contraception? You need look no further than the 100 plus comments in reply to an old blog posting at Our Bodies OurselvesQuestions About Side Effects of Stopping Contraceptive Injections.  The comment stream – a litany of woes concerning women’s discontinuation of Depo-Provera – has been active since Nov. 2, 2009.

On March 29, 2012, Rachel, author of the post, wrote a follow-up piece in which she laments: “Although a quick internet search finds many women complaining of or asking about post-Depo symptoms, there isn’t much published scientific evidence on the topic.” Beyond research about bone density and length of time to return to fertility, little is known about the withdrawal symptoms women have been commenting about.

Depo-Provera is the 4-times-a-year birth control injection that carries an FDA “black box” warning that long-term use is associated with significant bone mineral density loss.  Never a fan, I made a case against this contraceptive in a paper for Canadian Woman Studies, published in 2005. The comments on the OBOS post indicate that many women took Depo-Provera without full knowledge of the potential for serious side effects while taking it, or of what to expect while coming off the drug.

Considering that Depo-Provera completely suppresses normal reproductive endocrine function, it is not surprising that many women experience extreme or confusing symptoms once stopping it. Take Lissa’s comment for example, posted on February 21, 2011:

Omg I thought I was tripping. I have been on depo for a year and stopped in jan. My breasts constantly hurt, I put on weight, have hot flashes, and sleeping problems. I pray everyday my cycle returns and stops playing with me. I only spot lightly.

Two and a half years after publication, the original article continues to garner monthly comments. I’ve read most of them and have yet to see one that offers concrete advice or a referral to resources that provide information and support to women looking for both. One such resource is Coming Off The Pill, the Patch, the Shot and Other Hormonal Contraceptives, a comprehensive, clinical-based guide to assist women transition back to menstruation and fertility, written by Megan Lalonde and Geraldine Matus.

Lalonde, a Holistic Reproductive Health Practitioner, and Certified Professional Midwife, helps women establish healthy, ovulatory cycles after using hormonal contraception. She says that women who’ve used Depo-Provera generally experience the most obvious symptoms and have the hardest time returning to fertility.  She finds that every client’s experience is different and will be affected by the status of their cycles before taking the drug, and their overall health. “It can take time to regain normal menstrual cycles, from a few months to 18 months, in my experience,” says Lalonde. “Some women have minimal symptoms while their own cycles resume, while others might have significant symptoms, including mood changes, unusual spotting and breast tenderness.”

The comments to the Our Bodies Ourselves blog post demonstrate that many women are not finding the acknowledgement and support they need to understand and manage the post-Depo transition. Some are disheartening to read, like this comment by Judy from April 12, 2011, and this recent one posted by Melani on March 21, 2012.

In my last re: Cycling post, I asked for input on the Coming Off the Pill Mind Map I created. I’ll be making a few revisions thanks to the thoughtful feedback readers have provided. I had assumed that this guide would be applicable to all methods of hormonal birth control but, after reading these women’s comments about their Depo-Provera experiences, it appears this contraceptive may require its own branch on the mind map.

Misogyny, Medicine, or Menstrual Madness?

February 29th, 2012 by Elizabeth Kissling

Guest Post by Lydia Aponte — Marymount Manhattan College

In Professor David Linton’s Social Construction and Images of Menstruation course, our class watched two documentaries involving menstruation and menstrual suppression. Both Period: The End of Menstruation? and Red Moon addressed what is becoming an increasingly concerning topic: now that menstrual suppression in the form of birth control is becoming more and more readily available – and is even being promoted to specifically stop or slow the menstrual cycle – is menstruation necessary?

Many women, including myself, have asked themselves this very question – some because of the monthly cramps that have reduced us to a fetal position, some because of the awkward situations that menstrual stigma has put us in. Yet, many women still do not question it because menstruation is believed to be a natural occurrence that must happen because, well, that’s just life. What happens, on the other hand, when a man questions the necessity of menstruation? Or even further, does something about it? Meet Dr. Elsimar Coutinho.

From São Paulo, Brazil, Dr. Coutinho appeared briefly in Red Moon avidly disputing the necessity of menstruation. He believes that it is not necessary, because “what is the use of an ovulation if it does not result in a pregnancy?” I was initially stunned by his intensity when it came to the subject, not only because of his stance against menstruation, but because of the role he seemed to be playing. It seemed as if Dr. Coutinho were playing the “mad scientist,” distributing birth control to women and spreading the word that menstruation was “unnecessary” and “unnatural.” So I decided to look up this “character,” and came upon Dr. Coutinho’s biography page. Of course, the first paragraph of his bio was nothing but praise: “Dr. Elsimar Coutinho is, unquestionably, a man born to make history. For more than 50 years, his research and discoveries in the fields of human health and reproduction have broken paradigms and brought down millenary concepts.” (For a man who made history, I had never heard his name before Red Moon.)

Yet, I was more taken aback by how he had been quoted regarding menstruation. “My greatest contribution to humanity was to realize that menstruation was unnecessary, a disposable phenomena.” (Coutinho, E.M.) Not only is a doctor refuting the biological necessity of menstruation, which alone is jarring, but a man is refuting the necessity of a cycle highly regarded by many women, including myself, as a symbol of womanhood and deeming it “disposable.” Not only is Dr. Coutinho refuting it, he is actively taking measures to suppress menstruation through his research and practices.

If menstruation equals womanhood to so many, and Dr. Coutinho believes that menstruation is unnecessary, what is he saying about the beliefs and values that many people hold in regards to femininity? According to his philosophy, those,too, would be disposable. Dr. Coutinho’s suggestions — although questionable — have caused me to ask these questions: has something I regarded a natural part of my female biology been unnecessary this entire time? Is the human body wrong, and is Coutinho seeking to correct it with medicine? Or is misogyny still a key player in the menstrual realm?

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The pill, reduced period pain and the ongoing delusion

January 20th, 2012 by Laura Wershler

Is there a woman over the age of 18 anywhere who doesn’t know that taking the birth control pill can make her periods lighter and less painful? Most women know this, but not many know why. The news stories swirling around a new study about the pill and period pain will not enlighten them.

Photo credit: Ceridwen, Creative Commons 2.0

A 30-year longitudinal Swedish study has finally proved the worth of what is accepted practice in North America and Europe: the prescribing of combined oral contraceptives (COCs), or birth control pills with synthetic estrogen and progestin, to treat painful periods known clinically as dysmenorrhea.

Of course, pharmaceutical companies that manufacture COCs are probably eager for this research, as prescribing the pill for dysmenorrhea is still an off-label use in the U.S. (unlicensed use in the U.K.). Pill manufacturers may be able to use this finding to lobby the FDA (or equivalent agencies in other nations) to approve the pill as treatment for menstrual pain, leading to increased sales and insurance coverage. Perhaps that’s why news media have been treating this discovery as breaking news.

Take this headline: Yes, the Pill CAN ease the agony of period pain: Scientists confirm what millions of women already know, or this one: The pill ‘does ease period pain’, or this one: Combination oral contraception pills cut menstruation pain, or, really, any of these.

You can read the abstract of the study by Swedish researchers Ingela Lindh, Agneta Andersson Ellström and Ian Milsom, published this week in the journal Human Reproduction, here: The effect of combined oral contraceptives and age on dysmenorrhoea: an epidemiological study. The conclusions are simple: “COC use and increasing age, independent of each other, reduced the severity of dysmenorrhoea. COC use reduced the severity of dysmenorrhea more than increasing age and childbirth.”

Forget the age factor for the purposes of this discussion. The fact that COC use reduces the severity of dysmenorrhea is not astounding. This is old news. So says Dr. Steven Goldstein, an obstetrician/gynecologist at NYU Langone Medical Center in New York City, quoted in a USA Today story:

“The study results are not surprising. It’s gratifying to see researchers documenting scientifically what practitioners have been seeing for a very long time. The amount of discomfort from a woman’s period with a combination birth control pill is a fraction of what it is without the Pill. There is a diminution of pain from the Pill.”

What is astounding is what Dr. Goldstein, and other OBGYNs, didn’t say in responding to the study. That the reason the pill reduces menstrual pain is because the synthetic hormones in the pill shut down a woman’s own menstrual cycle. The “period” women experience when on the pill is technically known as a “withdrawal bleed,” brought on by seven days of placebo pills. While it feels like a period to menstruators, it is not the same physiologically as the period they experience when NOT on the pill. That’s why it doesn’t hurt as much.

The point is, the pill is too often credited with regulating the menstrual cycle. It does no such thing. The pill does not regulate any woman’s menstrual cycle; it supercedes it. This research, and the many news stories that reported it, once again ascribe power to the pill – this time the power to cut menstrual pain. This is an incomplete truth.

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New versions of menstrual suppression drugs on the way?

August 4th, 2011 by Elizabeth Kissling

Successful tests on rhesus monkeys are a long way from clinical trials on women, but this is interesting to those of us following the conversations and debates about cycle-stopping contraceptives: new research testing progestin antagonists indicates that the drug can be successful in suppressing menstruation without necessarily suppressing ovulation. Another variant of the drug can suppress both menstruation and ovulation.

Dr. Robert Brenner, who is the lead researcher conducting these studies in the Division of Reproductive Sciences at Oregon Regional Primate Research Center, notes that this has potential beyond just a new lifestyle drug:

I would emphasize that we are not talking here only about lifestyle choices but also about the potential to bring relief to the many women who suffer years of misery from distressing complaints such as endometriosis, and painful and excessive monthly bleeding. In fact, excessive bleeding is one of the major reasons that women undergo hysterectomy, and this treatment may also reduce the need for this surgical procedure, with all its attendant risks and costs.

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Don’t Ask, Don’t Smell

January 27th, 2011 by Elizabeth Kissling

female-minority-happy-military-wide-horizontalGuest Post by Emily Swan, Marymount Manhattan College

With the military’s history of suppressing minority groups, its new effort to conceal and terminate menstruation comes as no surprise. Hopefully, the menses will be able to come out of the closet soon enough.

I recently wrote a paper about menstruation in the military and was excited to see this recent post at re:Cycling. Researchers have suddenly become sensitive to the “devastating” effects of menstruation on women in combat and training, citing a potential link to iron-deficiency, among other things. (Might I add that, while the article identifies menses as the culprit, the actual data suggest no correlation between the loss of menstrual blood and the low iron levels of the participants.) Researchers have also conducted studies and interviews to determine the level of difficulty menstruation adds to a variety of physical activities and expose reported difficulty in obtaining, storing, transporting, changing, and disposing of “sanitary products” (Note the hygiene-promoting terminology). These reports have indicated a significant struggle with menstrual management, giving grounds to the military’s new encouragement for women to use continuous oral contraceptive pills (OCPs) to “temporarily” induce amenorrhea.

What’s happening here is not simply a conquering of the menses but an overpowering of women as a whole. The article about iron deficiency says it best, with its opening paragraph explaining the biological disadvantages of women: women’s lower levels of physical strength, inferior aerobic performance, and a number of other physical and mental “shortcomings” that include the ability to menstruate. It states, “the physical differences between genders in the military setting should be minimized as much as possible” (866). They’re not trying to make women more comfortable by stopping their periods; they’re using men to set the physical and mental performance standard for which women must strive. The failure of women to meet this standard lies in their very biology; the study directly blamed their femaleness as the source of this imbalance. It’s not, “Stop menstruating because it will help you.” It’s, “Stop menstruating because it will get you that much closer to being a man.” Oh joy.

The misogyny embedded within this move toward menstrual suppression does not discount the results of the studies; menstrual management poses a serious issue for most military women! In addition to the difficulty reported in transporting, obtaining, and storing products, another article relayed the troubling results of interviews from women of the Air Force, Army, and Navy regarding personal hygiene and field menstrual management.4 These interviews told of highly unsanitary bathroom facilities in combat environments, lack of privacy for the use and changing of menstrual products, and bathrooms that rarely contained receptacles for disposing of the products. The women reported collecting used products in Ziploc bags to either bury them in the secrecy of night or to keep them in their luggage until they returned to the U.S. Because of the hot, moist climates inhabited during deployment; the heavy, reused, and unwashed clothing; and the frequent lack of water or time to wash up, the interviewees reported constant awareness and humiliation surrounding menstrual odor. Most of the women also admitted hesitancy toward utilizing the clinic for menstrual health issues because they were made to feel that their menstrual symptoms were not worthy of care. They also reported that gynecological exams were excluded from their general deployment health examinations.

Menstrual Suppression for Military Women

January 13th, 2011 by Elizabeth Kissling

One of the arguments for using hormonal contraception to suppress the menstrual cycle is that it mitigates the logistical challenges menstruation can present in high-stress occupations in harsh settings — such as military service in a combat theatre. Given how  compelling the argument is, it’s surprising that birth control pills/patches aren’t used in these settings more frequently.

A new study in Women’s Health Issues indicates that although service women are eager to learn more about the option of menstrual suppression, education about it is lacking. A survey of U.S. women serving in Iraq, Afghanistan, and other combat operations indicates that the number of lost duty days due to menstrual pain would likely decrease with better education about suppression options and compliance regimens.

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How the Birth Control Pill Works: An Illustrated Guide

November 17th, 2010 by Elizabeth Kissling

tumblr_pill_500


[Source: Jackie, Let's Be Honest]

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Blood on Screen: Red Moon

August 2nd, 2010 by Giovanna Chesler



Red Moon: Menstruation, Culture and the Politics of Gender may have crossed your path as The Moon Inside You (its original title prior to 2010 its current distribution through Media Education Foundation). It is a film that has enjoyed wide release, with exhibition on French television and inclusion in an EU showcase of films that circulated last year. The broad exhibition strategy of Red Moon is fitting; it has a casual, heartfelt and humorous style that should appeal to many.

The purpose of Red Moon, as articulated by the filmmaker Diana Fabianova in voice over, is to answer this question: “At any given time, 25% of the female population is menstruating. Invisible. Discreet. Why is this normal, biological function taboo? There must be some deeper meaning.” There are problems with this statistical framing device – 25% is an over inflated number that eliminates girls and post-menopausal women as “females”. It also glosses over females that do not menstruate because of gender transformations and amenorrhea. Outside of this statistical malfunction, there are a few other facts provided through voice over which are not supported by specific research or attributed directly to any menstrual researchers. However, beyond these slights, Red Moon has great potential to make a taboo subject approachable.

As it begins with man-on-the-street interviews, the film seems to have interest in addressing men as equally as women. Through interviews with researchers who have written about menstruation in the 80’s and 90’s, the film attends to menstrual taboo historically and highlights menstrual suppression as an issue to address within patriarchy. There is a fantastically creepy interview with Elsimar Couthino, famous for inventing Depo Provera, Norplant and for writing Is Menstruation Obsolete (the book that launched millions of suppressed periods.) In his interview Couthino believes that women should have no more than one period in her lifetime and he likens menstruation to pending death: “First of all, menstruation is incompatible with life and nature, because an animal cannot survive bleeding longer than a few minutes in the forest. Blood, the smell of blood (he sniffs) attracts the predators. This one is bleeding. She is going to die.” Fabianova comically cuts to a hooting owl, waiting for your blood.

Fabianova is critical of pill-popping mentality and finds it better to challenge the negative view of menstruation, and silence around it, rather than do away with the period altogether. While she provides some examples of solutions to painful PMS (a belly dancing class delights, for example) the film does not directly address dysmenorrhea and severe menstrual challenges which have become justification for suppression in the first place. It does however, remind menstruators on hormonal birth control that the blood you see is a fake-period.

In fellow Re:Cycling blogger Chris Bobel’s recently released book New Blood: Third Wave Feminism and the Politics of Menstruation, she focuses on the type of menstrual activist stylings akin to Red Moon. In short, feminist spiritualism, according to Bobel, is a narrowly focused mode of menstrual positivism that essentializes the idea of womanhood through menstruation. The movement typically appeals to middle class white women and identifies menstrual change through the self. In feminist spiritualism, political action is limited to the individual menstruator or to the girls the menstruator is encouraged to educate. Red Moon treads in this territory throughout as interviewees speak to menstrual energy, the preciousness of menstruation, and the spiritualism in bleeding. The film ends with this logic as a nude woman walks through city streets, dropping red blobs that spring new trees to life through CGI effects. In voice over we hear about the filmmaker’s changed subject position: “I no longer fight with my hormonal clock, because it is she that reminds me once a month that I have a personal, intimate connection to nature and the universe.” It’s too bad the film narrows its final message to the individual, rather than reflecting on some of the broader work done throughout, like connecting negative menstrual associations to patriarchy, and demonstrating how certain menstrual practices harm the environment and our wallets. Overall, Red Moon is a conversation starter that requires additional reading to supplement its message.

How to overcome resistance to Cycle-Stopping Contraception (a physician’s guide)

May 12th, 2010 by Chris Hitchcock

If you’re wondering why your doctor might not take you seriously when you question taking the pill to abolish your periods, you might want to look at this piece of advice.

I had a look at the Clinical Advisor magazine information – it looks like they pay for articles, help to massage them into shape, but as far as I can tell the articles are not peer-reviewed, and the editorial staff do not have any credentials after their names, so they look like non-medical people. But it is freely available on the web, and apparently gets sent to many practicing physicians and nurses. And it’s a lot more readable than other sources of medical education.

The article is framed as a doctor-to-doctor question:

What can I do to overcome patient resistance to continuous use of oral contraceptives (OCs)? So many women say it’s not natural.—SHERRY HILL, ARNP, Bothell, Wash.

And, the answer? Explain the physiology, explain that there is no build up of old blood, that menstrual flow doesn’t have any effect on infections or toxins. And, for talking points, use the educational materials about cycle-stopping contraceptives on the Association of Reproductive Health Professionals web page (coincidentally funded with unrestricted educational funds from companies who happen to make cycle-stopping contraceptive products). And use Malcolm Gladwell’s 2000 article, John Rock’s Error, to reframe monthly menstrual flow as a historic anomaly (“you don’t need that old-fashioned thing”) and help women to see their regular menstrual flow as unnatural, so that the synthetic drugs you are suggesting will seem less unnatural by comparison.

But, ultimately, “if a patient feels that a monthly withdrawal bleed suits her best, many OCs containing 21 active pills and seven inert pills are available.”

I guess the option of using non-hormonal contraception just won’t come up.

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What’s Up with Yaz?

April 3rd, 2010 by Elizabeth Kissling

Yaz box and pill pack.We’ve mentioned Yaz and its sister drug Yasmin before, and our friend Holly Grigg-Spall tracks the progress of complaints against them and other oral contraceptives. Yaz and Yasmin were Bayer’s top-selling drugs in 2008, bringing in about $1.8 billion, a 17 percent increase from 2007. The key element that makes them different from other OCs is drospirenone, a new form of synthetic progestin which has a pharmacological profile that is reported to be closer to the human body’s own progesterone but a safety profile that has come under scrutiny since the FDA approval of Yaz/Yasmin. Last fall, Bayer revealed that they were fighting 129 lawsuits over side effects and marketing of Yaz and Yasmin. More suits have since been filed.

So with this context in mind, it was with great interest that I noticed this study in my periodic searching of menstruation research literature: Bleeding patterns and menstrual-related symptoms with the continuous use of a contraceptive combination of ethinylestradiol and drospirenone: a randomized study, published in last month in Contraception. It’s a small study, only 78 women over six months time, but the researchers conclude: “Continuous use was associated with amenorrhea and fewer menstrual-related symptoms compared to cyclic use.”

It looks like Yaz and/or its analogues are being tested for marketing as menstrual suppression drugs. Time to put in an interlibrary loan request to get my hands on the full study. Anyone want to place bets on how the study was funded?

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What’s Sick?

March 31st, 2010 by Chris Bobel

crestorToday, there’s a front page story in the New York Times about Astra-Zeneca’s move to market their cholesterol pills (known as statins, and as the NYT reports, already the most prescribed drugs in the US)  at healthy people in spite of unresolved concerns about risks, namely an elevated risk of developing Type 2 diabetes.

Gee. This sure sounds familiar: a  product aimed at healthy people, approved by the FDA, even before there’s ample evidence of safety.

I am imagining the new ad campaign…”Why let cholesterol worries slow you down? Choosing healthy foods and getting adequate exercise is sooooooo 20th century.Take a pill. Done.”

Of course, the comparison I am hinting at here is flawed. High levels of cholesterol ARE a genuine hazard. Heart disease is deadly.  Conversely, menstruation is NOT a disease and under most conditions, need not be treated.

But my point here is to call attention to Big Pharma’s too-quick impulse to sell drugs of questionable safety to healthy people and FDA collusion in this.  Marketing cycle-stopping contraception (a.k.a. menstrual suppressive contraception a la brands Lybrel and Seasonique, for example) to healthy women is not an isolated incidence of the premature and high-risk mainstreaming of prescription medications. See recent critiques here and here (and the official Society for Menstrual Cycle Research position statement on cycle-stopping contraception here).

In the eyes of Big Pharma, if we aren’t sick, we will be soon. If we aren’t dosing  The. Next. New. Drug, we aren’t taking charge of our health.

Sick? I think THAT’S sick.

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So the pill won’t kill me; what’s the point?

March 18th, 2010 by Laura Wershler

Women on the pill live longer. So touts a March 12, 2010 Reuters news story out of London, England reporting on a study published March 11 in the British Medical Journal (BMJ). A misleading headline if ever there was one.

The study followed 46, 000 women for up to 40 years, to see if the mortality risk among women sho have used oral contraceptives differs from that of never users. What the study actually found, according to the public release issued by BMJ on March 12 is this: “Women in the UK who have ever used oral contraceptives are less likely to die from any cause, including all cancers and heart disease, compared with never users.”

The study also found a slightly higher risk (of death, I presume) in women under 45 years old who are current or recent users of the pill.  As such, the authors assert:

Many women, especially those who used the first generation of oral contaceptives many years ago, are likely to be reassured by our results.  However, our findings might not reflect the experience of women using oral contraceptives today, if currently available preparations have a different risk than earlier products.

I’m 56 years old. I didn’t take the pill in the UK. But I did take it in Canada in the early to late seventies, back when it was much stronger than it is today. And back when it was NOT common for women to start the pill at 15 and take it for a decade or longer.  Am I reassured by these findings? Sort of. Although years of hard-fought-for healthy, ovulatory menstruation, subsequent to my year long post-pill amenorrhea, are more likely responsible for my good health than having  been an “ever user” of oral contraceptives. And more likely to protect me from heart disease and cancer than whatever benefits I may have derived from my on again, off again pill-taking history.

As for women under 45, it’s not just the “currently available preparations” I’d be concerned about. And there are tons of them: multiple variations of standard pills, continuous use pills like Seasonale and Lybrel, and cycle-stopping contraceptives like Depo-Provera and the Mirena IUD. The other concern is that the contraceptive use of young women today is much different than it was in my youth. They start using oral and other hormonal contraception at younger ages, before their reproductive systems have fully matured and their fertility (regular, ovulatory menstrual cycles) is well established. And they tend to take it for longer. The verdict on the long-term effects of this kind of contraceptive use is yet to be determined.

I’m not going to debate the merits or faults of this study or the unanswered questions it raises. The question I really want to ask is “What’s the point?”

The cynic in me believes that this study, and misleading headlines like Women on the pill live longer, will be used to compel women of all ages to ‘shut up already’ about their growing concerns with hormonal contraception. It will be dragged out as “scientific evidence” that taking the pill saves lives, as is implied in this article published by the Daily Mail:

The contraceptive Pill can extend your life and may even save 1,500 lives a year, a study has suggested.

Women who have taken the Pill at any stage in their life are less likely to die from any cause – including heart disease and all types of cancer – than those who have never taken the oral contraceptive.

But wait, here’s the next paragraph:

However, the positive effects may only be enjoyed by women who have taken older-style pills rather than those on newer drugs.

Readers should note that statements published in re: Cycling are those of individual authors and do not necessarily reflect the positions of the Society as a whole.