Death of the pe­riod

THE NUMBER OF WOMEN WHO ARE DE­FY­ING THE LAWS OF NA­TURE AND DE­CID­ING WHEN TO HAVE THEIR PE­RI­ODS – IF AT ALL – IS ON THE RISE. SIXTY-THREE PER CENT OF WOMEN IN AUSTRALIA NOW USE CON­TRA­CEP­TIVES TO MAN­AGE THEIR MEN­STRUAL CY­CLE, WITH ONE IN FIVE OF THOSE CHOOS

Women's Health Australia - - NOVEMBER 2017 - By Lau­ren Clark

What hap­pens when you don’t have time for that time of the month

Sat at my desk, I look com­posed, but I’m about to pass out. Or at least, that’s how it feels. Pain from my lower torso is paralysing ev­ery inch of my body. A col­league asks me a ques­tion, but I can’t work out what her lips are say­ing – my brain has turned to mush and I have a des­per­ate urge to vomit, cry and curl up for a nap. I take a few deep breaths and start to feel hu­man again, un­til the next wave of agony.

What’s happening? Chalk it up to that time of the month. And yet this painful episode – and the week of suf­fer­ing that sur­rounds it – re­minds me why it’s my first pe­riod in six months. Like a grow­ing number of women, I de­cide exactly when I have my pe­riod – and for me, that’s not very of­ten. I con­trol mine by run­ning sev­eral com­bined oral con­tra­cep­tive pill packs to­gether in a row, stop­ping only to al­low for in­fre­quent with­drawal bleed­ing that forces me to scram­ble at the back of the bath­room cab­i­net for a tam­pon. Oth­ers choose the pro­gestogenonly pill or a long-act­ing reversible con­tra­cep­tive (LARC) such as the im­plant, in­jec­tion or in­tra-uter­ine de­vice (IUD), all of which can make pe­ri­ods less heavy or less fre­quent, or stop them al­to­gether.

I started tak­ing hor­mones ev­ery day nine years ago, at the age of

15, to ease ex­cru­ci­at­ing, heavy bleeds. As a re­sult, I’ve had far fewer pe­ri­ods than my peers in that time. “That’s un­nat­u­ral,” and, “It’s not good for you,” are just some of the com­ments peo­ple have made. But I’ve only felt the ben­e­fits: free­dom, con­trol and lack of dis­trac­tion.

And I’m not alone. “Word has def­i­nitely got out that it’s safe to run pill packs to­gether, al­though women have been do­ing it for decades,” ex­plains Dr Deb­o­rah Bate­son, med­i­cal di­rec­tor at Fam­ily Plan­ning NSW and clin­i­cal as­so­ci­ate pro­fes­sor at the Univer­sity of Syd­ney. “We have good data about the safety of it and cer­tainly there’s an in­creased aware­ness that it’s a use­ful thing to do.

We’re also seeing in the data, as well as in our prac­tice, that in­creas­ing

num­bers of women are ask­ing for a LARC, like a hor­monal IUD, as well as a con­tra­cep­tive im­plant.”

NAT­U­RAL WO­MAN

But, while it’s cer­tain that few women en­joy hav­ing pe­ri­ods, there’s a pre­vail­ing be­lief that putting up with them month after month is the nat­u­ral thing to do. As well as be­ing an in­di­ca­tor you’re not preg­nant, they’re a sig­ni­fier of health, right?

“Pe­ri­ods are a strong sig­nal that your body is func­tion­ing as it should,” says Dr Ul­rike

Sauer, a con­sul­tant in sex­ual and re­pro­duc­tive health. “Aside from preg­nancy, the most com­mon rea­sons women don’t get pe­ri­ods are that they’re un­der-eat­ing or over-ex­er­cis­ing. If a wo­man who [isn’t on] con­tra­cep­tion doesn’t bleed, it’s a sign that the womb lin­ing might have changed and that some­thing more se­ri­ous could be going on.” Katie Ann Has­son, as­sis­tant pro­fes­sor of so­ci­ol­ogy and gen­der stud­ies at the Univer­sity of South­ern Cal­i­for­nia, agrees that it’s a psy­cho­log­i­cal re­as­sur­ance and adds, “To some women, hav­ing a pe­riod is also an important part of their sense of fem­i­nin­ity.”

But, what if I told you that it’s not actually nat­u­ral for you to have reg­u­lar pe­ri­ods? “Our bod­ies evolved to be al­most con­stantly preg­nant or breast­feed­ing once we hit pu­berty,” says Sauer. “Cen­turies ago, women would rarely bleed, and most of our fe­male an­ces­tors died be­fore the menopause.” In­deed, re­search has found that to­day, mod­ern West­ern women will have four times as many pe­ri­ods through­out the course of their lives.

So, what does ‘nat­u­ral’ even mean? The ‘pe­riod’ you have when you take a break from the pill ev­ery three weeks isn’t nat­u­ral. “A with­drawal bleed oc­curs when the lin­ing of the uterus sheds in re­sponse to the pill’s ar­ti­fi­cial hor­mones be­ing taken away, while a pe­riod is the lin­ing of the uterus re­spond­ing to the changes in nat­u­ral hor­mone lev­els that oc­cur when a wo­man is not preg­nant,” says gy­nae­col­o­gist Dr Kate

Guthrie. “If you run packs to­gether, even­tu­ally you’ll get a ‘break­through bleed’, where the lin­ing builds up to a point where it needs to shed. This can be after a cou­ple of weeks or up to sev­eral months de­pend­ing on the per­son, and can be­come less fre­quent as your body adapts.”

I’ve seen my body adapt from last­ing just two con­sec­u­tive pill packs be­fore spot­ting, to hav­ing nothing be­fore six months. Bate­son points out, however, that if you’re con­cerned about un­usual bleed­ing, you should visit your doc­tor to see if there’s any­thing else going on.

There’s also a mis­con­cep­tion that reg­u­lar bleeds on the pill con­firm you’re not ex­pect­ing. “You can’t rely on that – in the same way you

21 THE PER­CENT­AGE OF WOMEN IN AUSTRALIA WHO SAY THEY’D LIKE A METHOD OF CON­TRA­CEP­TION SPECIF­I­CALLY DESIGNED TO HELP THEM SKIP PE­RI­ODS Source: Teva Pharma Australia

can’t even if you’re not on the pill, as some women have pe­ri­ods when they’re preg­nant,” says Guthrie. “The ab­sence of your with­drawal bleed could be ei­ther that you’re preg­nant, or that there isn’t enough of a re­duc­tion in hor­mones to trig­ger a break­through bleed.”

TURN BACK TIME

So, if a monthly bleed while on the pill is nei­ther real nor re­as­sur­ing, well, what’s the point? “It’s all set in his­tory and tra­di­tion,” says Dr Jane Dick­son, a con­sul­tant in sex­ual and re­pro­duc­tive health­care. “The cre­ators of the pill designed it to be taken with a seven-day monthly break, even though they knew it wasn’t med­i­cally nec­es­sary. By mim­ick­ing a monthly pe­riod, they be­lieved it might be bet­ter ac­cepted by the church and other re­li­gious in­sti­tu­tions.”

Gy­nae­col­o­gist – and de­vout Catholic – John Rock, along with bi­ol­o­gist Gre­gory Good­win Pin­cus, tried to main­tain as much men­strual ‘nor­mal­ity’ in their in­ven­tion as pos­si­ble to en­sure it would se­cure US Food and Drug Ad­min­is­tra­tion (FDA) ap­proval, which it did – ini­tially in 1957 as pain re­lief, then in 1960 for con­tra­cep­tive use.

To­day, when fem­i­nism has never felt stronger, many women re­main be­holden to a monthly bleed. But what if you knew the wage and pro­mo­tion gap would be 15 per cent smaller, ac­cord­ing to Ital­ian re­searchers, if your men­strual symp­toms and pe­riod-re­lated ab­sen­teeism weren’t fac­tors? In a Yougov sur­vey in the UK, 52 per cent of women said pe­ri­ods af­fected their abil­ity to work, and one-third of those said they’d had to take a sick day. In the West­ern world, men­strual symp­toms are one of the main rea­sons girls miss school.

“Sup­press­ing your pe­riod means you can skip the mood swings, headaches, bloat­ing, PMS and dis­rup­tion to your life – many women per­form less well dur­ing ex­ams and in sports – and for those with en­dometrio­sis it can make life far more man­age­able,” says Guthrie. I no­tice my pro­duc­tiv­ity dips at work, thanks to dis­rupted sleep and the fact that I spend chunks of the day keeled over in a toi­let cu­bi­cle.

IS IT SAFE?

But now, 57 years after the pill changed ev­ery­thing for women, there’s still con­fu­sion sur­round­ing its long-term safety. “Hor­monal con­tra­cep­tion has pros and cons,” says Sauer. A 2014 study pub­lished in the jour­nal Can­cer Re­search dis­cov­ered that re­cent use of the com­bined oral pill in­creased the risk of de­vel­op­ing breast can­cer by 50 per cent, while a 2007 study pub­lished in The Lancet found that be­ing on it for five years or more dou­bled your risk of cer­vi­cal can­cer. Should we be wor­ried? “You are slightly more likely to de­velop breast can­cer, but only when you’re on the pill, not once you stop – there’s no lin­ger­ing ef­fect 10 years after or into your 50s and 60s,” says John Guille­baud, emer­i­tus pro­fes­sor of fam­ily plan­ning and re­pro­duc­tive health at Univer­sity Col­lege London. “Most pill-tak­ers are un­der 35, the age when breast can­cer is very rare any­way, so a 50 per cent in­crease on top of ex­tremely small num­bers leaves total cases in this sce­nario still very low.”

The hor­mone doses in the present-day pill are much smaller than they used to be. “When it was first in­vented it con­tained 100mg of oe­stro­gen, which is what past re­search on in­creased breast can­cer risk has been based on,” ex­plains Guthrie. “Now it only con­tains 20mg, so fu­ture stud­ies may find there’s even less of a link or none at all.” This lower dose of oe­stro­gen also means blood clot risk has been low­ered even fur­ther.

There’s also ev­i­dence that the pill can in fact be pro­tec­tive against can­cer. “A wo­man tak­ing it is less likely to get can­cer than a wo­man whose part­ner uses con­doms be­cause it re­duces risk of ovar­ian, en­dome­trial, large bowel and rec­tal can­cer while in use and for 10 years after,” says Guille­baud. A 2008 study pub­lished in The Lancet es­ti­mated that the pill may have stopped around 100,000 women dy­ing from ovar­ian can­cer, as it sup­presses ac­tiv­ity and dis­rup­tion to the sur­face of the ovaries – this number out­weighs the in­creased risk for other types of can­cer linked to tak­ing the con­tra­cep­tive pill. Dick­son agrees, point­ing out that other fac­tors can play a much more sig­nif­i­cant role in can­cer risk. “Be­ing over­weight, smok­ing and fam­ily his­tory pose a much greater risk to your health than tak­ing the pill,” she says.

Then there were last year’s head­lines claim­ing that the pill has psy­cho­log­i­cal as well as phys­i­cal ef­fects, up­ping de­pres­sion by

23 per cent. “In a small mi­nor­ity it can lead to de­pres­sion or se­vere mood changes,” ac­cord­ing to Guille­baud. “But de­pres­sion is very com­mon, and what the study found was that out of ev­ery 123 pill-tak­ers with de­pres­sion, only 23 could truly blame their con­tra­cep­tive. The other 100 would have ex­pected to be di­ag­nosed any­way.” In­ter­est­ing.

OH, BABY

But what does switch­ing off your ovaries mean for fer­til­ity? While at 24 I’m not look­ing to have chil­dren right away, it’s a con­cern that does cross my mind. “It won’t make you in­fer­tile, but you can’t be sure how long it’ll take for your nat­u­ral cy­cle to re­turn,” says Dr Shazia Ma­lik, con­sul­tant ob­ste­tri­cian and gy­nae­col­o­gist. She sug­gests com­ing off the pill or LARCS and us­ing con­doms six months be­fore you start trying for a baby, to al­low ovu­la­tion to get back to normal.

But not ev­ery wo­man will need that long. “With the ex­cep­tion of the in­jec­tion, which can take up to a year to wear off, your cy­cle should re­turn to normal al­most straight away when you stop tak­ing con­tra­cep­tion,” says Guille­baud.

“In fact, it could even make you more fer­tile. A 2002 study* found that ex-pill-tak­ers were more likely to fall preg­nant in the six months after com­ing off the pill than those who’ve never used it.”

And if you don’t want to get preg­nant just yet, run­ning your pill packs to­gether can actually make it more ef­fec­tive as a con­tra­cep­tive. “All the time you take the pill, your ovaries are asleep, but in the seven days you stop tak­ing it, your ovaries start to wake up again and be­gin ovu­lat­ing,” ex­plains Dick­son. Tak­ing it ev­ery day keeps your ovaries on snooze for weeks, if not months. You’re also less likely to for­get to restart a pill pack and fall preg­nant. Bate­son agrees, but points out it’s still OK to take the break if you want to. “Some women pre­fer to have that bleed­ing, they might find it re­as­sur­ing – and that’s their choice.”

She adds that hav­ing a pill with a re­duced-hor­mone break can be an­other option. “With the traditional seven-day hor­mone break, if women miss the first tablets in the first week, it puts them at risk of preg­nancy. So it makes sense to re­duce or get rid of that break in this case. Com­bined pills with shorter breaks of four or [fewer] days may also re­sult in no with­drawal bleed be­cause the lin­ing of the uterus is thin, which can be ben­e­fi­cial.”

THE FU­TURE

Part of the prob­lem? That so­ci­ety is anti-bleed­ing. “Our cul­tural at­ti­tude is that men­stru­a­tion is dirty and shame­ful, and that we should avoid it at all costs. We don’t talk openly in so­ci­ety about the nitty-gritty of our bleeds, and we don’t have any ref­er­ence points for com­par­i­son,” says Has­son. “Tak­ing hor­mones to get away from it means that we of­ten don’t know our own healthy base­line.” Con­tra­cep­tion and painful bleeds are rea­sons enough to stop pe­ri­ods, but we shouldn’t be stop­ping them for the sake of it, points out Sauer.

That said, con­tra­cep­tion is start­ing to re­flect a pe­riod-less life­style. “As doc­tors, we’re be­ing more proac­tive when women start on the pill about in­form­ing them that it’s some­thing they can do,” says Bate­son. “We’ve also got a new pill on the mar­ket that runs three months to­gether, up to 91 pills. It has seven days of lower-dose oe­stro­gen in that break instead. Hav­ing a pack that runs the pills to­gether for you may make it eas­ier for some women.” If you’d pre­fer to stick with your cur­rent pill and run it to­gether, al­ways check with your doc­tor to make sure you’re able to do this with your par­tic­u­lar pre­scrip­tion and learn how best to man­age it.

If be­ing on an equal foot­ing with men is the ideal, ditch­ing our pe­ri­ods might just al­low us to catch up in the work­place – and to be free to spend our cash on items other than painkillers and san­i­tary wear. The ‘tam­pon tax’ is yet to be scrapped, after all.

“Women should be able to con­trol their own lives – their bleeds should fit in with them, not the other way around,” adds Guthrie. It’s not black and white – but as I con­tinue not dread­ing ev­ery fourth work­ing week and re­main anx­i­ety-free about div­ing into a pool this sum­mer (OK, my beach body might be a dif­fer­ent mat­ter), for me, it kind of is.

48 THE PER­CENT­AGE OF AUSSIE WOMEN MAN­AG­ING THEIR CY­CLES WITH CON­TRA­CEP­TIVES WHO ARE CON­CERNED ABOUT THE HEALTH IM­PLI­CA­TIONS Source: Teva Pharma Australia

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