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Reproductive Health

The Case for Bleeding: Think Twice Before Using the Pill to Skip Periods

package of birth control pills

Writing for the Guardian, Nicole Davis makes a strong claim: that there’s no need for women to get their periods. Pushing back against the recent wave of feminist authors and activists calling on women to embrace their periods, Davis points out that periods are inconvenient and cause pain and discomfort in some women. And further, having a period every month may not be as “natural” as it seems, because in earlier days women experienced far fewer periods due to more pregnancies and breastfeeding. 

And then Davis drops a bombshell: she quotes a couple of medical doctors who suggest that 99% of women do not need to bleed and there is no health benefit to doing so. The doctors she quotes argue that hormonal contraception can be taken continuously to prevent any bleeding, with no negative consequences.

These are glaring claims, and what’s missing is any evidence to support them. It seems it is the opinion of the few doctors interviewed that menstrual cycles are not necessary, but opinion does not equal fact. Especially when this opinion directly contravenes the endocrine society practice guidelines around amenorrhea[1].

Bleeding itself is not a health benefit, but it is evidence that ovulation is occurring. Why does it matter that ovulation is occurring? Because a large body of research demonstrates unequivocally that there are benefits to ovulation and the hormonal changes that accompany it. As a follicle grows and the egg inside matures, estrogen increases by about 10-fold[2]. This leads to a surge in luteinizing hormone (LH), which causes ovulation. After ovulation, progesterone levels increase by more than 25-fold over baseline[3]. There are many other hormones involved in the menstrual cycle[4] as well. 

What are the benefits of the hormonal changes associated with ovulation?

The best examples come from the health effects in women who have either undergone natural or surgical menopause[5] (where ovaries and uterus are removed for medical reasons). By far the most serious change after menopause is a sharp decline in bone density[6]. We know that both estrogen and progesterone[7] are heavily involved in increasing and maintaining bone density from puberty on, as well as a number of other hormones related to the menstrual cycle such as inhibins[8], IGF-1[9], and FSH[10]. We also know that women with amenorrhea[11] tend to have lower bone density. 

Women who have gone through menopause are more likely to experience cardiovascular disease[12], and there are even studies that show that in regularly cycling women, heart attacks are more likely during the follicular phase[13,14] when estradiol is lowered. Younger women with amenorrhea show impaired vascular function[15].

There are also suggestions of increases in dementia[16] and other neurodegeneration[17] after menopause, as well as increased rate of death due to neurological causes after surgical menopause[18].

The Guardian article goes on to discuss the virtues of hormonal birth control, with mentions of a few negative side effects such as anxiety and possibly elevated cancer risks, but overall little regard for the health implications of preventing natural ovulations, on which there simply is not sufficient data.

One area where studies have found detrimental effects of hormonal contraception, even in women who were cycling normally before contraception, is lower increases in bone density than expected as compared to controls[19, 20, 21]. In addition, use of oral contraceptives may lead to deficiencies[22] in various micronutrients[23]. There are also reports of increased anxiety and depression[24] with hormonal contraceptive use in some populations.

In women who are experiencing missing periods due to underfueling—known variously as hypothalamic amenorrhea, hypogonadotropic hypogonadism, female athlete triad, or relative energy deficiency in sport—the detrimental effects of absent periods[25] can be even more stark: abnormal thyroid function, abnormal growth hormone patterns, infertility (due to lack of ovulation), digestive effects, possibly alterations to the immune system, decreased bone density leading to stress fractures, being prone to other injuries …

Hormonal birth control provides exogenous estrogens and progestins, but these are not provided at the same level as physiological estrogen and progesterone during the menstrual cycle. Indeed hormonal birth control results in much lower levels of endogenous (physiological) estrogen and progesterone[26].

Not to mention there are around 20 different hormones, enzymes, and other molecules[27] that are involved in our cycles, including GnRH, FSH, LH, inhibins A and B, prostaglandins, IFG-1 and -2, EGF, estradiol, progesterone, 17-OH-progesterone, testosterone, HETE, and more. To argue that replacing just one or two with synthetic versions that may or may not activate receptors in exactly the same way as the natural form is going to fulfill all the same functions as those 20+ hormones is not logical.

It is irresponsible to ignore years of medical literature and make the claim that there is no need to bleed (and by extension, no need to ovulate). It is irresponsible to gloss over side effects of hormonal birth control and make it sound like a panacea, particularly if it is taken to correct a period issue with a treatable medical underpinning.

Of course, every woman has the right to make her own choices around reproductive health care, and for many women, the hormonal birth control pill or other options that prevent ovulation and bleeding may be the best option. For other women, a non-hormonal method of birth control that ovulation intact is preferable. Importantly, making the optimal choice given needs, desires, and health, requires accurate and complete information. Medical professionals and journalists should be presenting women with a summary of ALL the evidence so they can make truly informed decisions.


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[1]Catherine M. Gordon, Kathryn E. Ackerman, Sarah L. Berga, Jay R. Kaplan, George Mastorakos, Madhusmita Misra, M. Hassan Murad, Nanette F. Santoro, Michelle P. Warren “Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline” The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 5, 1 May 2017, Pages 1413–1439

[2]Mikael Häggström “Reference ranges for estradiol, progesterone, luteinizing hormone and follicle-stimulating hormone during the menstrual cycle” WikiJournal of Medicine

[3]ibid

[4]Beverly G Reed, MD and Bruce R Carr, MD. “The Normal Menstrual Cycle and the Control of Ovulation” 2018 Aug 5. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-.

[5]Google search, term="surgical menopause"

[6]Karlamangla AS, Burnett-Bowie SM, Crandall CJ. “Bone Health During the Menopause Transition and Beyond.” Obstet Gynecol Clin North Am. 2018 Dec;45(4):695-708.

[7]Sundeep Khosla, L Joseph Melton III, B Lawrence Riggs “The unitary model for estrogen deficiency and the pathogenesis of osteoporosis: Is a revision needed?” J Bone Miner Res. 2011 Mar;26(3):441-51.

[8]Daniel S. Perrien, Sara J. Achenbach, Samuel E. Bledsoe, Brandon Walser, Larry J. Suva, Sundeep Khosla, Dana Gaddy “Bone Turnover across the Menopause Transition: Correlations with Inhibins and Follicle-Stimulating Hormone” The Journal of Clinical Endocrinology & Metabolism, Volume 91, Issue 5, 1 May 2006, Pages 1848–1854

[9]Southmayd EA, De Souza MJ. “A summary of the influence of exogenous estrogen administration across the lifespan on the GH/IGF-1 axis and implications for bone health.” Growth Horm IGF Res. 2017 Feb;32:2-13.

[10]Daniel S. Perrien, Sara J. Achenbach, Samuel E. Bledsoe, Brandon Walser, Larry J. Suva, Sundeep Khosla, Dana Gaddy “Bone Turnover across the Menopause Transition: Correlations with Inhibins and Follicle-Stimulating Hormone” The Journal of Clinical Endocrinology & Metabolism, Volume 91, Issue 5, 1 May 2006, Pages 1848–1854

[11]Keen AD, Drinkwater BL “Irreversible bone loss in former amenorrheic athletes.” Osteoporos Int. 1997;7(4):311-5.

[12]TAVIA GORDON; WILLIAM B. KANNEL, M.D., F.A.C.P.; MARTHANA C. HJORTLAND, Ph.D.; PATRICIA M. McNAMARA, “Menopause and Coronary Heart Disease: The Framingham Study” Ann Intern Med. 1978;89(2):157-161.

[13]Hamelin, Bettina A et al. “Influence of the menstrual cycle on the timing of acute coronary events in premenopausal women.” The American Journal of Medicine, Volume 114, Issue 7, 599 - 602.

[14]G W Lloyd, N R Patel, E McGing, A F Cooper, D Brennand-Roper, G Jackson. “Does angina vary with the menstrual cycle in women with premenopausal coronary artery disease?” Heart 2000;84:189-192.

[15]W. A. Rocca, J. H. Bower, D. M. Maraganore, J. E. Ahlskog, B. R. Grossardt, M. de Andrade, L. J. Melton. “Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause.” Neurology Sep 2007, 69 (11) 1074-1083.

[16]Noriko Yoshida, Hisao Ikeda, Kenzo Sugi, and Tsutomu Imaizumi. “Impaired Endothelium-Dependent and -Independent Vasodilation in Young Female Athletes With Exercise-Associated Amenorrhea” Arteriosclerosis, Thrombosis, and Vascular Biology. 2006;26:231–232.

[17]W. A. Rocca, J. H. Bower, D. M. Maraganore, J. E. Ahlskog, B. R. Grossardt, M. de Andrade, L. J. Melton. “Increased risk of parkinsonism in women who underwent oophorectomy before menopause.” Neurology Jan 2008, 70 (3) 200-209.

[18]Rivera C.M.a · Grossardt B.R.b · Rhodes D.J.a · Rocca W.A., “Increased Mortality for Neurological and Mental Diseases following Early Bilateral Oophorectomy.” Neuroepidemiology 2009;33:32–40.

[19]Talita Poli Biason, Tamara Beres Lederer Goldberg,corresponding author Cilmery Suemi Kurokawa, Maria Regina Moretto, Altamir Santos Teixeira, and Hélio Rubens de Carvalho Nunes. “Low-dose combined oral contraceptive use is associated with lower bone mineral content variation in adolescents over a 1-year period.” BMC Endocr Disord. 2015; 15: 15.

[20]Rizzo ADCB, Goldberg TBL, Biason TP, Kurokawa CS, Silva CCD, Corrente JE, Nunes HRC. “One-year adolescent bone mineral density and bone formation marker changes through the use or lack of use of combined hormonal contraceptives.” J Pediatr (Rio J). 2018 Jun 28. pii: S0021-7557(18)30069-X.

[21]Gersten J, Hsieh J, Weiss H, Ricciotti NA. “Effect of Extended 30 μg Ethinyl Estradiol with Continuous Low-Dose Ethinyl Estradiol and Cyclic 20 μg Ethinyl Estradiol Oral Contraception on Adolescent Bone Density: A Randomized Trial.” J Pediatr Adolesc Gynecol. 2016 Dec;29(6):635-642.

[22]Prabhudas R.Palan, Amy T.Magneson, MoniqueCastillo, JamesDunne, Magdy S.Mikhail. “Effects of menstrual cycle and oral contraceptive use on serum levels of lipid-soluble antioxidants.” American Journal of Obstetrics and Gynecology Volume 194, Issue 5, May 2006, Pages e35-e38.

[23]M. PALMERY, A. SARACENO, A. VAIARELLI, G. CARLOMAGNO. “Oral contraceptives and changes in nutritional requirements.” Eur Rev Med Pharmacol Sci. 2013 Jul;17(13):1804-13.

[24]Robakis T, Williams KE, Nutkiewicz L, Rasgon NL. “Hormonal Contraceptives and Mood: Review of the Literature and Implications for Future Research.” Curr Psychiatry Rep. 2019 Jun 6;21(7):57.

[25]Mountjoy M et al., “International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update.” Int J Sport Nutr Exerc Metab. 2018 Jul 1;28(4):316-331.

[26]Elliott-Sale, K & Hicks, K 2018, Hormonal-Based Contraception and the Exercising Female. in J Forsyth & C-M Roberts (eds), The Exercising Female: Science and Its Application.Routledge Research in Sport and Exercise Science, Taylor & Francis.

[27]Beverly G Reed, MD and Bruce R Carr, MD. “The Normal Menstrual Cycle and the Control of Ovulation” 2018 Aug 5. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-.

Nicola Rinaldi, PhD

Nicola Rinaldi has a PhD in computational biology from MIT. The author of No Period Now What—a comprehensive guide for how to recover from hypothalamic amenorrhea—Rinaldi has been counseling women on how to recover their missing periods for over a decade.

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