Would More Women Use a Family Planning Method That Stops Monthly Bleeding?
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Seasonale is an oral contraceptive formulation consisting of 84 hormonal pills followed by 7 nonhormonal pills. This extended use regimen is packaged specifically to reduce monthly bleeding to once every three months, an option that appeals to more and more women. Photo: © 2004 Take Control of Your Period
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Women in developing countries may be more open to using contraception that stops monthly bleeding than in the past. For example, in 2001 a survey of women in three developing countries found that 73% of women in Nigeria and 52% to 64% of women in South Africa would be willing to try a contraceptive that stopped monthly bleeding (59). In Hong Kong and Shanghai, China, more women would be willing to try such a contraceptive than would not, but some women were undecided.
Women who are willing to accept no monthly bleeding or prefer it appear to be younger, more educated, and to live in urban areas—a pattern that suggests the attitude will spread. A recent survey of 2,000 Indian women found that 80% of women living in urban areas preferred to bleed infrequently or not at all (16). A smaller percentage of women living in rural areas (30%) preferred such bleeding patterns. In São Paulo, Brazil, most women interviewed did not want to prevent menstruation, but some of the younger women considered menstruation an unnecessary nuisance (43). They would be willing to try a contraceptive method that caused no monthly bleeding as long as it did not cause other problems.
The recent findings contrast with findings of surveys in the 1980s and early 1990s that most women would not be willing to try a contraceptive method that stopped monthly bleeding (125, 154). Many women thought that not bleeding would damage their health or else indicated pregnancy. Also, they worried that the absence of monthly bleeding would reveal secret use of contraception.
At the same time, however, the DMPA injectable, which eventually stops monthly bleeding for many users, became one of the most popular contraceptive methods in some places. For example, in 1992 in Rwanda 40% of married women using contraception were using injectables, making it the most popular method at that time (100). Injectables now have become the fourth most commonly used contraceptive method worldwide. (See forthcoming Population Reports issue on Injectable Contraceptives.) Some women stop using injectables because of the lack of monthly bleeding (34, 113), but many others continue the method either despite the absence of monthly bleeding or because they welcome it (2).
In developed countries manufacturers of contraceptives have identified enough women who do not want to bleed every month that they are now marketing special oral contraceptives for this purpose. Available in the United States since the fall of 2003, a formulation called Seasonale® is packaged specifically for use that limits bleeding to once every three months. The regimen consists of 84 uninterrupted days of hormonal pills followed by 7 days of nonhormonal pills, when bleeding occurs. This is known as extended use. Only 10 months after Seasonale became available, providers had written more than 260,000 prescriptions for it (135). Its manufacturer plans to apply for regulatory approval in other countries. After Seasonale became available, a survey found that 59% of the U.S. women questioned would be interested in avoiding bleeding each month. One-third would choose never to bleed (10). A combined oral contraceptive formulation called LybrelTM is currently awaiting approval by the U.S. Food and Drug Administration (FDA). Women would take a combined hormonal pill continuously 365 days a year without a nonhormonal pill phase or pill-free interval and thus they would avoid monthly bleeding altogether (157). Short-term studies and clinical review data from the FDA suggest that the safety of extended and continuous use are similar to that of conventional regimens (41). There are no studies on the long-term safety of these regimens.
Meanwhile, some women have already been avoiding monthly bleeding while using conventional combined oral contraceptives. They take the active, hormonal pills (the first 21 pills in a pack), one every day. Then they skip the inactive, nonhormonal pills (the last 7 pills in a 28-pill pack) or the 7-day hormone-free interval (with 21-pill packs) and start a new pill pack the next day. Women often use this approach to avoid bleeding during special events, such as vacations and athletic competitions (132). Some women also use this approach to avoid social and religious restrictions. For instance, some Muslim women skip the inactive, nonhormonal pills during Ramadan (the month of fasting) or during hajj (pilgrimage to Mecca) to avoid interrupting fasting or religious rituals as required during monthly bleeding (37, 57, 68).
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See companion INFO Reports, "Key Facts About the Menstrual Cycle