Options for Menstrual Suppression (Mak, 4/16/25)

 A recording of this presentation is available HERE.  

Thanks to Dr. Ray Mak for a good refresher on menstrual suppression. A reminder from Dr. Mak up front that there are varied reasons that people with a uterus prefer to suppress their menstruation -- from personal preference to medical indications, and we can and should know how to counsel them on how to safely do so.

Check out this table that outlines some of the reasons for menstrual suppression. Not included in the table are financial reasons (people spend $6000-$18,000 over their lifetime for menstrual products) or cancer risk reduction. 

Patient preference		Challenges with menstrual hygiene	Intellectual or developmental delay Limited dexterity or mobility
Gynecologic	Dysmenorrhea Endometriosis-related pain and bleeding Menorrhagia PMS Abnormal uterine bleeding	Work or social indications	Military deployment or space travel Athletes Camping or wilderness experience
Hematologic	Anemia Coagulation disorder Malignancy Chemotherapy	Other conditions worsened by menses	Irritable bowel syndrome Asthma Postural tachycardia syndrome Migraines

Combined oral contraceptives

The most commonly accepted and practices way to ensure menstrual suppression comes via continuous Combined oral contraceptives (COCPS)

-efficacy is 49%, 68% and 88% are 2, 6 and 12 cycles respectively

-monophasic OCPs are preferred 

-breakthrough bleeding (BTB) is the most common side effect and decreases with time

-lower estrogen levels in OCPs is associated with more BTB

-a hormone free break of 3-4 days is usually sufficient to manage BTB

-see two images below from the AAFP with guidelines on management of BTB

 

Additionally, menstrual suppression can occur using alternative contraceptive modes, including:

• vaginal ring (skipping ring-free week)>> amenorrhea 89% at 6 months, BTB more common early and diminishes with time (NSAIDs may help, no studies on adding estrogen)
• contraceptive patch (skipping patch-free week), not as well studied, no long term data, higher estrogen exposure, similar issues with BTB
• hormonal IUD (Mirena, Liletta)>> amenorrhea 50% at 1 year, 60% at 5 years; lower dose IUD not effective at attaining amenorrhea, can uses NSAID/estrogen or OCPs for BTB
• depo provera injections>> amenorrhea 50-75% at 1 year, increases with prolonged use; concerns about decreased bone density over time, also weight gain/mood changes. For BTB: NSAID, estrogen, cOCPs, decreasing injection interval (e.g. 2 months)
• etonogestrel implant>> 22% amenorrhea at 1 year, improved with prolonged use, irregular BTB is common

Aside from using contraceptive methods to induce menstrual suppression, other medications can be used, including:

• norethindrone acetate 5mg daily, not approved for contraception>> 76% amenorrhea at 2 years, can titrate up to 15mg daily (for BTB), different than norethindrone mini-pill (0.35)
• testosterone therapy for trans and gender diverse patients >> testosterone therapy usually suppresses by 3-6 months, transmen generally prefer to avoid estrogen  (because of desire for masculinization)
• GnRH agonists (puberty blockers), fast onset 4-6 weeks, high efficacy 96%, no increased prothrombotic use (often used in oncologic patients)
• Danazol

Menstrual suppression considerations for people with disabilities:

• can they swallow pills?
• can they tolerate invasive procedure?
• caution: bone density, weight gain, VTE risk in pts with decrease mobility at baseline
• scheduled withdrawal bleeding may be preferred over random BTB

Don't forget this chart: