Off the rag

Most women would agree that getting their period is a big drag. Now, a growing movement argues for reducing menstruation during childbearing years, or even getting rid of it altogether -- for the sake of women's health.

by Julie Dulude

Elizabeth Strein hasn't had her period since September. Although many women would view this as cause for alarm -- a sign of pregnancy, or an indication of gynecological trouble -- the 25-year-old Brookline resident hasn't lost any sleep over Aunt Flo's prolonged absence.

That's because Strein, a flight attendant, is one of a growing number of women who are using birth-control pills to limit the frequency of their menstruation. After reading several articles in women's magazines listing many pros and few cons to the practice of deliberately skipping periods, she was intrigued. She had a brief consultation with her father, a pharmacist, and then decided to give it a try. "I work out a lot so I don't get much of a period anyway, and I just figured, why bother with it at all?" she says. "It's great. I have no PMS. There's less stuff I have to lug around with me on trips, less money I'm spending on that stuff."

Forget conventional wisdom about menstruation. The monthly curse that women were told they had to put up with in order to experience the miracle of childbirth -- it turns out they might not have to tolerate it after all. Women like Elizabeth Strein are discovering that regular monthly menstruation simply isn't necessary -- period.

A growing body of medical research supports the idea, arguing that incessant ovulation is a relatively recent and unnatural phenomenon. In their book Is Menstruation Obsolete?, for example, doctors Elsimar Coutinho and Sheldon Segal claim that menstruation isn't meant to be a monthly event; after citing research linking fewer periods to decreased risk of modern-day diseases like ovarian and endometrial cancer, they advocate the seemingly radical position that menstruation should be suppressed.

Limiting periods is nothing new. For years, using birth-control pills to reduce the frequency of menstruation has been fairly standard in treating certain medical conditions, including painful periods, endometriosis, and recurring ovarian cysts. And doctors have routinely counseled women on how to use the pill to skip periods during special occasions -- a honeymoon, say, or a beach vacation. But now, women are using these methods simply to avoid the hassle of getting their periods. To do it, they throw away the week of placebo pills in their monthly dial packs and immediately start on the active hormone pills of the next segment. Continuing this way, they can theoretically go for years without menstruating, although most choose to cut down to about four periods a year.

The pharmaceutical companies are catching on, too, and several companies are studying extended pill regimens in clinical trials right now. What's surprising is that so many doctors seem to agree on the benefits of period suppression. In one survey, 56 percent of doctors said they do not think a monthly period is necessary to a woman's health. And I was hard-pressed to find doctors in the Boston area who would advise women not to take the pill continuously -- even if patients' only reason is that they don't want to bother with periods. Says Phillip Stubblefield, director of obstetrics and gynecology at Boston Medical Center and chair of the OB/Gyn Department of BU's School of Medicine, "I've been practicing this way for 30 years, so I kind of chuckle that it's news."

Avoiding PMS, bloating, headaches, and bloodstained sheets, it seems, is all the reason one needs to keep periods at bay. Says Elizabeth Strein, "I listen to my friends complain about their periods now and I say, `Look, why don't you just not get it?'"

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For someone who changed the world, John Rock had pretty conventional ideas about women. Before 1960, when the Harvard Medical School doctor co-invented the birth-control pill, the only way for premenopausal women to stop ovulating was to get pregnant. But though his invention opened the door to unprecedented sexual liberation, he hadn't wanted to revolutionize nature -- in fact, he'd prided himself on exploiting the natural mechanisms of a woman's own body. Rock's personal beliefs deeply influenced the way he thought about the pill and, consequently, the way we think about birth control today. "When the pill was developed," says Stubblefield, "an arbitrary decision was made that women would probably feel more comfortable about the pill and be more likely to use it if they [stopped taking it] once a week each month and had their period, reassuring themselves that they weren't pregnant. It was perceived that society expects women to have a period once a month."

That perception still prevails, which accounts for much of the resistance to period suppression. But biologically speaking, fewer periods are more "natural" than monthly ones. Back in the caveman days, women menstruated about a hundred times in their lives (as compared to modern women, who average 350 to 400 times). Why? Because, according to Coutinho and Segal in Is Menstruation Obsolete?, "ancestral women were either pregnant or lactating almost continuously" until menopause or death, which usually came first. "During pregnancy and lactation they would remain free of menstruation," the authors explain, and "even before the suckling baby was weaned, the mother would often become re-impregnated. Release from this repetitive chain of reproductive events would come only with secondary infertility ... or the unlikely event of reaching menopause."

In tribal societies, where pre-modern conditions prevail, monthly periods are still the exception rather than the rule. Scientist and anthropologist Beverly Strassman, for example, spent two and a half years tracking the menses of women in the Dogon tribe of Mali between 1986 and 1989. Strassman found that a Dogon woman, on average, reaches menarche -- the onset of menstruation-- at the age of 16. From her first period to the age of 20, she averages seven periods a year. From 20 to 34, she averages slightly more than one period per year. During the less fertile years from 35 until menopause, she averages four periods a year. She gives birth eight or nine times in her lifetime. During Strassman's years with the Dogon tribe, the only women who made regular visits to Strassman's menstrual hut were the village's two sterile women.

Contemporary Western women, in contrast, menstruate many more times over the course of their lives, for several reasons: they live longer, they reach menarche earlier, they are less likely to breastfeed (an activity that prolongs menstruation-free stretches), they have fewer children, and they begin bearing them later in life. Historically and anthropologically, the original, "natural" state for women is having fewer periods. And this leads to a somewhat counter-intuitive conclusion: in today's contemporary landscape, where women marry late and hold full-time jobs, a woman must engage in the "artificial" practice of oral contraception to return to her "natural" physiology of infrequent menstruation.

"It's a pity that gynecologists think that women have to menstruate every month," Strassman told the New Yorker earlier this year. "They just don't understand the real biology of menstruation."

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Forty years after Rock's invention, the long-term, uninterrupted use of oral contraception is increasing. Doctors, scientists, and drug companies are studying the consequences: they're particularly interested in how the pill may held prevent certain cancers. According to American Cancer Society data, endometrial and ovarian cancer strike an estimated 62,600 women a year and prove fatal for approximately one-third of them. But many studies show that taking the pill even for one year dramatically reduces women's risk of getting these cancers. The decrease is at least 40 percent, and could be as much as 60 or 70 percent, compared to women who have never taken the pill. In fact, the more time women spend in a state of pseudo-pregnancy or pseudo-breastfeeding -- that is to say, on the pill -- the more their risk goes down.

Understanding how the pill can prevent reproductive cancer begins with an understanding of ovulation. When a woman ovulates, an egg pushes through the wall of one of her ovaries and implants itself in the uterine lining. To repair the rupture, a period of cell division and reproduction within the ovary walls must follow. Cancer occurs when cells -- which are constantly dividing and reproducing -- make mistakes that cripple the cells' defenses against runaway growth. Older people, for instance, are more likely to develop some form of cancer because their cells have had more time to make mistakes. But any change leading to cell division, ovulation included, can increase cancer risk. The pill's promise, at least with respect to ovarian and endometrial cancer, lies in its ability to disrupt a woman's cycle, causing her to ovulate less frequently.

At the same time, however, some doctors theorize that progestin, the hormone in birth-control pills that suppresses ovulation, increases the risk of breast cancer. The theory is supported by the fact that women who have had their ovaries removed, and thus do not manufacture progestin, have a significantly decreased risk of the disease, which kills more than 40,000 women a year. Although there is absolutely no definite link between birth-control pills and breast cancer, some critics think it's still unwise for women to take oral contraceptives without interruption simply because they don't want to be bothered with menstruation. Judy Norsigian, co-author of Our Bodies, Ourselves for the New Century, urges women to be concerned -- young women and smokers especially. At least three studies document a small but statistically significant increase of breast-cancer risk for women who begin taking birth-control pills at an early age and continue long-term, she explains.

"This is a massive experiment," says Norsigian. "Even though there was a time when women didn't menstruate as much as they do now, that is not the same as using artificial hormones to prevent ovulation. There are benefits to doing this, but there ought to be a good reason for taking hormones to avoid one's period, because we don't know what the long-term effects of this practice will be."

Defenders of continuous oral contraception acknowledge that earlier versions of the pill posed some health risks, but they point out, among other things, that the higher hormone levels women ingest this way -- 13 extra weeks' worth a year, or 33 percent more in any given four-week interval -- is still far lower than the levels they would have received on a conventional schedule of the older high-dose pills. And doctors do caution that suppressed menstruation should not be confused with irregular menstruation. Professional athletes or dancers, for example, may skip their periods because they're suffering from critically low levels of estrogen. This is a serious medical condition that must be treated.

But when it comes to suppressing menstruation with the pill, many doctors think the only real downside is spotting. Because the progestin in birth-control pills acts to suppress ovulation, taking birth-control pills without interruption means that the uterine lining doesn't have a chance to build up and, therefore, doesn't need to be shed. But the lining may build up a little or start to deteriorate, which can lead to irregular light bleeding. "If you're taking the birth-control pill not to have a period, and then you start bleeding irregularly, it's kind of a nuisance," says endocrinologist Isaac Shiff, chief of the Vincent Obstetrics and Gynecology Service at Massachusetts General Hospital. For this reason, many doctors recommend that women withdraw from the pill once every three or four months, and have their periods.

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Another issue, at least as important, is not medical but cultural and political. Is menstruation the essence of "femaleness" -- the thing that sets women apart from men and defines their identity as women? Or is it simply a physical process that women should be able to control as they see fit?

Some women see menstruation as a hindrance to their lives and argue that objections to suppressing it are, like objections to abortion, expressions of a society that wants to deny women control over their bodies. "Our culture is very uncomfortable when women do anything that makes the visible differences between men and women less visible," says Susan Reverby, a professor of women's studies at Wellesley College and a medical historian. "There's nothing natural about Viagra," she continues. "Are we uncomfortable with that? If you make a nature argument, why are we uncomfortable with things that are unnatural for women but not for men? Because there's no such thing as Father Nature. Women are allowed to do something non-natural to increase our bust, but only because that's for men. God forbid we stop menstruating." Pointing to articles in women's magazines ranging from Style to Redbook that bear titles such as "Lifting the Curse" and "A Pill To Uncramp Women's Style," Reverby says most women see getting their period as a pain.

On the other hand, she admits, some women see it as a wonderful reminder of the fact that their bodies are different from men's. The onset of menstruation is a woman's most important rite of passage, and the mystical connection between monthly menses, the phases of the moon, and Mother Nature is an important part of a woman's identity. Comments received by survey analysts underscore this idea: "Keep technology out of our wombs," writes one woman. "To stop or inhibit [menstruation] would be to remove one important aspect of the intricate and glorious facet of a woman's body and nature," writes another.

There is even a Museum of Menstruation in Maryland whose Web site (www.mum.org) is full of informative and entertaining articles, including a complete list of code words and expressions women have used to refer to their periods: Old Faithful, the Dot, Bloody Mary, Closed for Maintenance, That Time of the Month, Surfing the Crimson Wave, and the Plague, to name a few. Women may not be ready to put the tampon industry out of business after all; the idea of putting an end to menstruation could be just the latest passing fad in women's health.

"Why do women hate it?" Reverby asks. "That's the biggest issue we have to think about. Do women still loathe their bodies?" She adds that in her mother's generation, women referred to getting their periods as "being unwell." "I think this goes back to women being taught to feel ashamed of their bodies," she says. "There's been some change, but [research shows that] the pressure on women to be taller and skinnier -- that has gotten worse."

Norsigian agrees that women stand to lose more than their periods if they begin taking the pill continuously. She fears that they also stand to lose their self-esteem and their identity. That's why it's important to draw a distinction between women who are doing this because their periods are so painful they get knocked out of commission and women who are doing it because they just don't want to get their periods.

"If you're doing it because it's a little messy and inconvenient, one has to wonder whether this feeds into an ongoing and insidious negative view of reproductive functioning," Norsigian says. "The idea that women might start thinking about menstruation as a horrible thing to be avoided if at all possible -- I don't think that's the thing we want to encourage."

Julie Dulude is a freelance writer who lives in Wellesley. She can be reached at jdulude@hotmail.com.