Women's Sexual Health Section

How to avoid those dreaded
visits from 'Aunt Flow'

Extended-cycle OC controversy draws blood from some ob/gyns. Other say it's a red letter day for PMS sufferers

By Katherine Addleman

Not many women would be sorry to bid adieu to their monthly 'curse.' Last fall that wish became their command — at least in the US. In September the FDA approved a new birth control pill formulation designed not only as a contraceptive, but also to reduce a woman's annual number of menstrual cycles. This extended-cycle oral contraceptive, marketed under the brand name Seasonale, has the same combination of hormones as the conventional pill — levonorgestrel/ethinyl estradiol — but the major difference is in the regime. The extended-cycle pill is taken for 84 days straight followed by seven days of placebo, instead of the usual 21 days of active pills followed by seven days of placebo. The result: only four periods per year. (Health Canada hasn't yet approved the new formulation.)

THE LONG AND THE SHORT
The approval of this long-cycle method of contraception has sparked a debate about whether the extended dosage level puts women at greater risk for stroke and blood clots than short-cycle contraception. For one thing, no large long-term studies were done before the formulation was approved, which raises the spectre of problems down the road, a pattern already demonstrated

by the results of the Women's Health Initiative hormone replacement therapy trial and resulting fiasco. Also, concerns have been expressed by people like Judy Norsigian, co-author of the groundbreaking, Our Bodies, Ourselves, about the ethics of treating something that is clearly not dysfunctional, with an implicit stigmatization of menstruation by the medical and pharmaceutical community.

REHASHING AN OLD DEBATE
In fact, extending the time between periods is nothing new. Women have long opted to skip their period occasionally for personal convenience by discarding the placebos in their pill packs and continuing to take the active pills beyond the specified three weeks. Dr Christine Derzko, an associate professor of obstetrics/gynecology and endocrinology at the University of Toronto, already advises many of her patients to do just that. The only side-effect that's emerged is breakthrough bleeding.

"There are many women who experience relatively severe symptoms every month — headaches, dysmenorrhea, cyclical mastalgia — who welcome the option of simply continuing their pills," she says. Dr Derzko thinks that older women also benefit from this approach. "Perimenopausal women who are suffering from intolerable hot flashes also do well, and physiologically it's perfectly safe." Dr Derzko has yet to have a patient complain about the approach. "There's no reason to stop the hormones every month just to allow bleeding to occur," she adds.

Dr H K Williams, a gynecologist from the University of South Florida in Tampa, agrees. He says that the reason the original birth control pills were marketed to mimic a 28-day menstrual cycle was historical and not biological. At the time, the drug companies were trying to make the pill seem "as natural as possible in order to get them accepted."

Some women may feel more comfortable once more long-term data are in, but Dr Williams points to information from a small group of endometriosis patients who've been using this regimen with no negative long-term consequences reported so far.

Dr Williams also notes that the estrogen levels in OCs are so much lower than in HRT that, "all of those estrogen risks are essentially gone... the risks that we talk about now are the progesterone risks," including increased likelihood of breast cancer and fibroid growth.

SEEING RED
The safety of the extended-cycle pill has not yet been put to rigorous testing and some physicians in the US are expressing concern. "I would hate to see us put millions of women on combined long-term birth control pills without their periods and then find out 30 years later that we were wrong," says Dr Connie Micklavzina, a gynecologist from Winter Park, Florida.

But for many women, uncertainty about the safety of extended cycles is a risk they're willing to take. Aside from the benefit of increased iron levels from reduced bleeding, the most tempting appeal of long-cycle contraception is the easing of the pain and distress that are part and parcel of so many women's monthly period.