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The Profuse Misconceptions of the Extended-Cycle Oral Contraceptive

16 November 2017
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Translated by Chloé Sautter-Léger

When I was 8 years old, I found out what menstruation were and I dreaded the day they would arrive. When I was 10, I heard about hysterectomies and I feared periods so badly that I earnestly considered getting one. At age 12, the ordeal began: my first menstrual period, the onset of my allergies to the bleaching agents used in tampons, and profuse periods that sometimes lasted up to 45 days. When I was 15, my cycle had become regular: 29 days, with 13 days of abundant flow and 5 days of spotting. One (hypoallergenic) “super plus” size tampon would do its job for only two hours—a moment longer, and it was like the Saguenay flood of 1996 in my underwear. When I was 16, I had a boyfriend whom I could only see on weekends and I was spending 8 hours in the pool twice a week for lifeguard training—I decided that I’d had enough. With the advice of a doctor, I began taking an extended-cycle oral contraceptive: no more periods. I suddenly experienced physical liberation, a uterine emancipation—a carnal feeling of freedom.

Why so many details about my catamenial flow? Because even seven years after I started to take the extended-cycle oral contraceptive, I still find myself justifying my choice to people around me, who seem to have difficulty accepting it. Granted, the extended-cycle contraceptive seemed to be taboo when I was 16 years old, and that has changed a lot since. I get fewer questions about my choice, and more women have made the same decision as me. Still, many questions, false impressions, and misinformation remain about the subject today.

Oral Contraception for Dummies

While varied across different types of contraceptives, the hormones usually contained in the pill are estrogen and progesterone (Kaunitz, 2017). These hormones act to inhibit ovulation and implantation of the ovum, making the endometrium too thin for implantation. They also act to thicken the cervical mucus (ARHP, 2008; Kaunitz, 2017; SV, 2013; PP, 2015). Generally, users take one active pill every day for three weeks, followed by one inactive pill daily for one week, during which bleeding occurs (ARHP, 2008; Wright and Johnson, 2008; Kaneshiro et al., 2012; Hee et al., 2013). This week of bleeding, however, is not actually menstruation. What occurs is withdrawal bleeding (Jain and Wotring, 2016), set off because the body receives a different dose of hormones compared to what it is used to receiving (ARHP, 2008; Chaplin and Mansour, 2009 FQPN, 2013).

There is no biological need for these bleedings to occur (Glasier et al., 2003; Wright and Johnson, 2008; FQPN, 2011; Kaneshiro et al., 2012; Hee et al., 2013; Edelman et al., 2014; Kaunitz, 2017).

In other words, “voluntary infertile cycles do not have to happen” (FQPN, 2013). Even if withdrawal bleeding seems very similar to menstruation, it is not an actual period, because under the effect of the active pills, the endometrium does not receive any of the signals to thicken and subsequently be eliminated—the hormone level remaining constant the entire time (Wright and Johnson, 2008; Kaunitz, 2017). Bleedings are thus usually less abundant and last fewer days (Chaplin and Mansour, 2009): it is a period of artificial menstruation (CHUQ, 2011; FQPN, 2013).

A Foreword on the Contraceptive Pill

The pill was approved by the Food and Drug Administration in 1957 (PP, 2015). The Seasonale pill, an extended 91-day cycle oral contraceptive, only became available in 2003 (Anderson and Hait, 2003; Aengst and Layne, 2010; FQPN, 2013). Since then, an increasing number of women have decided to space out their periods (Glasier et al., 2003; Wright and Johnson, 2008; Rad et al., 2011; Kaneshiro, et al. 2012; Nanda et al., 2014; Jain and Wotring, 2016; Fiala et al., 2017).

Why did it take half a century before the moratorium on artificial menstrual cycles could be lifted? Frankly, it was simply because of social, cultural, and religious pressures (Hee et al., 2013; Edelman et al., 2014; PP, 2015).

Indeed, the classic sequence (21 days of active pills followed by 7 days of placebo, imitating the natural cycle) was established for marketing—not medical—reasons (CHUQ, 2011; Edelman et al., 2014; Fiala et al., 2017). It was already hard enough to push this contraceptive method forward (Legro et al., 2008), if it had disrespected even the menstrual dogma, it would have seemed like blatant heresy.

Another advantage of the 28-day cycle is the illusion that the withdrawal bleedings provide. When users of an oral contraceptive (OC) experience the bleedings, they can be reassured that their menstrual cycle still works well and that their fertility is intact. Also, it seems like proof of non-pregnancy (Glasier et al., 2003; Legro et al., 2008; Wright and Johnson, 2008; Edelman et al., 2014; Fiala et al., 2017). It is important to note, however, that these bleedings, which occur during the placebo period, have nothing to do with an absence of fecundation: a woman who does not know that she is pregnant and continues to take the OC could experience bleedings, including during the seven placebo days, since occasional bleedings are common during the first trimester (APA, 2015).

Possible Danger?

So far, there is no evidence to suggest that the extended-cycle contraceptive has pernicious effects that are not already recognized in the monthly-cycle pill (ARHP, 2008; Chaplin and Mansour, 2009; CHUQ, 2011; Edelman et al., 2014). Side effects and possible complications are the same whether active pills are taken in cycles or continuously. Urban legends purport that a continuous usage of the pill increases the risk of cancer or may disrupt fertility in the long term. However, no positive correlation has been established between continuous-cycle OCs and cancer (CHUQ, 2011), and fertility is in no way affected either (Wilkie, 2007; CHUQ, 2011; Hee et al., 2013; Jain and Wotring, 2016).

On the contrary, a large number of studies show that the extended-cycle OC is safe (Wilkie, 2007; ARHP, 2008; Wright and Johnson, 2008) and could even be better than the 28-day cycle one (Nanda et al., 2014).

Menorrhagia, uterine myoma, and premenstrual syndrome are some of the common ills associated with a repetitive ovulatory cycle (Wright, 2008; FQPN, 2013; PP, 2015). Moreover, the extended-cycle pill is deemed to be a bit more reliable at preventing pregnancies (Legro et al., 2008; Hee et al., 2013; Nanda et al., 2014), because there are fewer disruptions and, therefore, less chances of forgetting between packs (Wright and Jonhson, 2008; CHUQ, 2011), and of ovulating (Wilkie, 2007). Also, women who take the extended-cycle OC report experiencing fewer headaches, fatigue, genital irritation, bloating, premenstrual or menstrual pains, or other unwelcome effects of the period (Wilkie, 2007; ARHP; 2008; Chaplin and Mansour, 2009; Rad et al., 2011; Hee et al., 2013, Edelman et al., 2014; PP, 2015; Jain and Wotring, 2016). It has also been observed that menses affect the life quality of women who take the extended-cycle OC less than that of those who do not (work absenteeism and reduction of physical activity are less significant, and the menstrual cycle is better overseen). And, during premenopause, life quality is also improved by a reduction of hot flashes (Wright and Jonhson, 2008; Chaplin and Mansour, 2009; CHUQ, 2011; FQPN, 2013; Edelman et al., 2014; Fiala et al., 2017). This is due to the fact that hormonal fluctuations are reduced when the OC is taken without pauses (CHUQ, 2011). For these reasons, it is also now commonplace to treat conditions like endometriosis, dysmenorrhea, and other menstrual syndromes with extended-cycle OCs (Wright and Jonhson, 2008; CHUQ, 2011; Hee et al., 2013, Edelman et al., 2014; Kaunitz, 2017). In the long term, evidence suggests that the extended-cycle contraceptive pill could actually reduce the risk of endometrial or ovarian cancer more than the popular 28-day cycle contraceptive.

When Womanhood “Requires” Menses

I have stopped counting the number of times I have heard or read biased opinions about the extended-cycle OC : it is unnatural, puts your health at risk, harms your reproductive system, de-feminizes women, etc. I have read these opinions on different online forums, but have also heard them from a (too) large number of health professionals. The lack of knowledge about how OCs function is a huge weakness in the professional health community, and it also represents a value judgment that, according to me, is inappropriate. To say that someone who decides to reduce or eliminate menstruation by taking an OC is less of a woman for doing so is a discriminatory judgment that does not hold water. Just stop to think for a moment what that would say about menopausal women, trans women who do not menstruate, athletes who do not get their period because of intensive physical activity, or women going through chemotherapy who experience amenorrhea.

Menstruation is one trait associated with the female biological sex, but it in no way defines womanhood (Hasson, 2016).

Furthermore, many people seem to share the opinion that taking an OC for an extended period is unnatural (Wright and Johnson, 2008; Edelman et al., 2014; Hasson, 2016). But the false menstruation provoked by a drop in hormone intake are first and foremost artificial (CHUQ, 2011; FQPN, 2013). The idea, then, that an extended-cycle is less natural than artificially induced monthly withdrawal bleeding, is somewhat fallacious. From a sociohistorical perspective, what is unnatural is menstruating every 28 days for years, without any intention of getting pregnant. Historically, women menstruated much less frequently than nowadays (CHUQ, 2011). In addition to getting their first period later, menstrual periods were much more spaced out because of repeated pregnancies and breastfeeding (Glasier et al., 2003; CHUQ, 2011; Edelman et al., 2014). It is estimated that women formerly had approximately 160 periods in their lives, compared to the current 450 (FQPN, 2013; Edelman et al., 2014; Jain and Wotring, 2016). In any case, “the 28-day cycle serves only to provide 13 chances per year to get pregnant—this cycle is completely unnecessary for women who do not wish to have children in the foreseeable future” (CHUQ, 2011).

Double Standard

It seems there is societal pressure for women to experience their menstruation. Carried out to its logical extreme, this expectation can be considered detrimental to female empowerment. For some, menstruation are so painful, they become an obstacle to active life (CHUQ, 2011). This means periods are an obstacle to conforming to social standards of productivity and uninterrupted efficiency (FQPN, 2013).

Passing judgment on contraceptive choices and prescribing the ways menstrual cycles should be managed is, in a sense, contradictory to feminist values and makes no sense if we want women to be more empowered (Hasson, 2016).

In conclusion, although this text is specifically about the extended-cycle oral contraceptive, this rationale also applies to the usage of hormonal intrauterine devices or contraceptive injections. These contraceptive methods also reduce the quantity and length of menstruation, and they seem to be gaining popularity (Edelman et al., 2014; ARHP, 2008; Hasson, 2016; Jain and Wotring, 2016; Kaunitz, 2017). Whether you use Alesse, Mirena, or Depo-Provera, menstruation-less contraception is safe, practical, and usually more pleasant (Nanda et al., 2014). When using a contraceptive, bleeding each month is a choice, and the decision should be respected either way. To those who cringe when they learn that a woman does not menstruate by choice and to health professionals who continue to spread the idea that extended-cycle oral contraceptives are unhealthy and undermine fertility, my advice is to get informed and set the record straight. Although research on the long-term effects of extended-cycle OCs is still lacking (Hee et al., 2013), all current evidence suggests that menstrual-less oral contraceptives are exactly as safe as periodic OCs.

As for me, I take the pill with liberty!

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References
contraceptive pill, oral contraceptive, oral contraceptive continuously, feminism, menstruation, contraception, Emmanuelle Gareau

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