No Periods, No Pain?

From the WebMD Archives

Aug. 22, 2001 -- It was not cramping, Melanie says. It was constant pain -- the pain of endometriosis. With every monthly cycle, hormonal changes made it worse. "It got to be every day the pain was there," she tells WebMD. "I was so fatigued all the time. "

But Melanie has relief at last, thanks to surgery and a little improvisation with her monthly cycle. She's now takes birth control pills every day for nearly three months at a time, bypassing the usual week of placebo pills that trigger what doctors call "hormone withdrawal" and the monthly period of bleeding.

By suppressing her periods for months at a time, her hormone levels remain steady and she keeps endometriosis, where tissue from the inner layer of the uterus grows on the ovaries and other areas, at bay. "I'm getting ready to have my first period in three months," says Melanie, an Atlanta-area customer-service representative who spoke to WebMD on condition that her full name not be used.

An estimated 25% of women take birth control pills for their non-contraceptive benefits, says Melanie's gynecologist, Michael Randell, MD, of Atlanta's Northside Hospital. "They decrease symptoms of PMS, ovarian cysts, endometriosis," he tells WebMD. More and more pills are being formulated to help women take advantage of these benefits, with the bonus that those who take them have shorter menstrual periods each month -- or periods only a few times a year.

Migraine headaches, bloating, irritability, and other less-than-charming attributes of PMS are all caused by hormone withdrawal, Randell explains. "You delay the period and you delay the occurrence of those events."

It's something that gynecologists have figured out in the 40 years since oral contraceptives hit the market. And marketers have gotten the message. Today, some 50 brands of oral contraceptives are available as pharmacologists adjust the basic estrogen-progestin formula to target various market niches. Estrogen levels range dramatically among the different brands of pills, with some now at all-time lows.

All these pills meet the FDA's standards of 99% contraceptive effectiveness. And allowing women to buy these pills without a prescription has many proponents and has been considered by the FDA -- with no official decision yet. So what are the pill shopper's choices?

One new pill contains a diuretic or a medication that increases urination. Another has a fine-tuned estrogen dosage regimen, offering low- and ultra-low doses during the cycle, with just two days of placebo [dummy] pills. The result: fewer PMS symptoms -- along with the reassurance of a brief monthly period.

"I think we're going to see more pills coming down the pike with a decreased pill-free interval," Robert Hatcher, MD, MPH, a professor of obstetrics and gynecology at Emory University School of Medicine in Atlanta, tells WebMD.

Still another of these new pills claims to clear up acne, and a clinical study has been done to prove it. But gynecologists say that all birth control pills help with acne. "It's just a matter of to what extent and how effective the different pill formulas are," Lane Mercer, MD, tells WebMD. He is a professor of gynecology at Northwestern University Medical School in Chicago.

Also among the so-called third-generation pills are those with varying forms of the hormone progestin. Pharmacologists are now trying to develop a true natural female progestin, not a synthetic derivative of the male hormone testosterone, as progestin traditionally has been, Mercer says. "It promises less of side effects like weight gain, depression, PMS symptoms," he says.

The makers of a pill called Seasonale would like to go a bit further in their claims. Last year, a large clinical trial was launched to test Seasonale, which gives women the option of "seasonal" periods -- one every three months. A woman takes the pills daily for 81 days, then is off them for seven days. "We're interested in quality of life. We want to show that it can relieve menstrual migraines and other PMS symptoms," says F.D. Anderson, MD, the trial's principal researcher and an associate professor of gynecology at the Jones Institute at Eastern Virginia Medical Center in Norfolk.

The truth is, gynecologists have long experimented with the monthly cycle. Is a honeymoon or a vacation approaching? A period need not ruin your plans! Toss away those placebo pills and jump to the next pack of "active" pills, gynecologists have often advised patients.

"We've been doing it for years and years," Anderson tells WebMD. "It's just not been studied. "

And delaying the period is very safe, Randell tells WebMD. "The new pills make it even safer."

"Frankly, I would like to see all pills packaged with only two or three days of placebo," Hatcher tells WebMD. Pregnancy prevention is his reason. Miss the first day in a standard pack -- where you've already been pill-free for seven days -- and you sorely test the system, says Hatcher, co-author of the book Contraceptive Technology. "Your chances of pregnancy go way up." But miss the first pill after two or three days off, and not so much is at stake.

For many years now, doctors also have been able to completely halt a woman's periods, which Hatcher says is "perfectly safe." Products are available that can do just that, including Depo-Provera, an injected contraceptive that requires shots every three months, and Norplant, which consists of six timed-release capsules that are implanted in the upper arm. Norplant works consistently for approximately five years.

"To have a period is more of a sociological issue," Mercer says. "Women want periods to know they are not pregnant. What we really don't know is the effect on future fertility. Any woman who has taken the pill has half the pregnancy rate at six months [after going off the pill] as one who has never taken it. We don't know if this is going to change with the newer combinations, such as Seasonale.

"If you're older -- 35 -- and thinking about getting pregnant, you may want to stay with the more standard pill, just until we have numbers, until we have a randomized study."

As for all the pill brands on the market, "If it were clear that one was better than the others, I or any other clinician would say so," Hatcher tells WebMD. "The pills are all quite similar, and they all have huge margins of safety. For most women, their huge benefits are dramatically greater than their risks, and therefore money becomes the big factor in which to buy.

"One of the biggest reasons why people discontinue their pills is because of money," he says. "That's one of the reasons why I'm strongly in favor of over-the-counter pills. ... The cost of pills is just ridiculous. You can produce the product for 10 to 14 cents a cycle. Women are paying 30 and 40 dollars."

Over-the-counter pills are safe for most women, Hatcher says. "If a woman can safely take estrogen, then she can safely take any of the pills that have less than 50 mg of estrogen in the formula," he says. Only women at risk of blood clots should be cautious, he adds.

Further, Hatcher says, allowing their sale over-the-counter would allow more women to take advantage of the pill's positive side effects.

"The big non-contraceptive benefit of all pills [is] decreased menstrual pain and cramps, which is the leading cause of women missing work," Hatcher tells WebMD. "And they all have a dramatic protective effect against ovarian cancer."