So You Want to Leave Your Period Behind?

Remember the passage in The Diary of Anne Frank where she talks about the excitement and "sweet secret" of getting her first period? Perhaps many of us felt some excitement, a rite of passage into the world of women, when first visited by "Aunt Flo." But with passing years the perceptions of menstruation might be less kindly. "The Curse" with its pads/tampons/cramps and various inconveniences was not a welcome visitor anymore - unless one was concerned about an unintended pregnancy.

For an excellent read about the cultural history of menstruation I highly recommend that you check out a copy of Delaney, Lupton, and Toth's entertaining discourse The Curse: A Cultural History of Menstruation, first published in 1976. Within that book one can visit "Menstrual Images in Literature," "Menstrual Taboos" and other fascinating topics from a feminist viewpoint.

At the time of the most recent edition of that book (1988), DepoProvera was not yet approved for use in the USA (that happened in October 1992), and all birth control pills were packaged with seven days of milk sugar or iron placebo pills. Women were routinely instructed to start their birth control pills (BCPs) on the first Sunday after the beginning of menses. This would ensure that most women would not be on their "pill periods" during a weekend. More progressive GYNs were suggesting starting BCPs on the first day of flow to decrease the need of a back up method. A few GYNs were advising patients to take only the active pills to try and avoid a scheduled bleed. Usually, this method of pill taking was reserved for medical indications such as menstrual migraines, severe premenstrual symptoms, or endometriosis.

Things have certainly changed. In May of 2007 the Food and Drug Administration approved Lybrel, the first birth control pill approved to be used without any placebo pills. This was the final step that followed the introduction of four days of placebo pills (Yaz), and a week of placebo pills only every third month (Seasonale). What are the pluses or minuses around trying to eliminate menstrual periods? Let's look at things you might want to consider.

"No Period on the Pill" is not the same as "Missed Periods on Your Own"

In a normal menstrual month, estrogen is produced all month long, and the majority of progesterone is produced in the two weeks after ovulation. If your uterine lining could be considered as your grass or lawn—then estrogen is like fertilizer (it stimulates the lining to grow thicker). In this analogy, progesterone is like the lawn mower—it prevents the grass from getting too thick and tall. When progesterone leaves the scene (ie conception does not occur with that ovulation), the grass clippings are dumped—your menstrual flow.

DepoProvera ("the shot") is a very large dose of synthetic progesterone. This is like having heavy duty lawnmower activity everyday. That's why DepoProvera for birth control can prompt women to not have periods. There is not that much lining to shed. All birth control pills (BCPs) contain synthetic progesterone. This is why most women on BCPs will have shorter, lighter periods. Even BCP users can develop such a thin uterine lining that their periods will disappear. So for a woman using hormonal forms of birth control (even the progesterone containing IUD) menstruation can disappear as the uterine lining becomes thin. Generally speaking a thin uterine lining is a good thing. It decreases the risk of the most common form of uterine cancer. Once the hormonal contribution of the birth control is out of the woman's body her original menstruation pattern will return.

By contrast, when a woman misses a period(s), and she is not taking hormonal forms of birth control, that can result in health problems. The most common reason for not having a period (once pregnancy is ruled out) is missed ovulations. In this instance, the uterine lining grows very thick from continued estrogen effects. Without the lawn mower effects of progesterone the lining becomes very thick. When the lining begins to shed, the bleeding can be very heavy and/or prolonged. An overly thickened lining provides a setting for abnormal cells to arise. These can set the stage for cancer of the uterine lining.

What Happens When Continuous Birth Control Pills Are Taken?

Remember in most birth control pills (BCPs) there is both synthetic estrogen and progesterone in each active pill. So everyday the uterine lining gets some fertilizer effects and some lawn mowing effects. During the placebo week of a pill pack, the blood levels of synthetic estrogen and progesterone fall. This causes the lining of the uterus to become destabilized and shed. When pills/patch/ring are used continuously a thick lining is NOT being created, or retained, inside the uterus. If there is no week when the hormones are withdrawn, there is no regular "pill period" ("hormone withdrawal bleed").

In the ideal world this would mean that there is no bleeding until the medication is stopped. However, as many women know from experience, breakthrough bleeding and unscheduled spotting can be common among users of pill/patch/shot/vaginal ring forms of birth control. This is one of the greatest possible drawbacks to "continuous" or "long cycle" regimens of BCPs. In the initial studies on Lybrel, only one third of participants had no bleeding or spotting after about a year's use.

So What Are the Downsides - If Any?

As discussed above, having to deal with some breakthrough bleeding or spotting is a real possibility. Absent menstrual periods can be a big advantage, but if one is worried about an undetected pregnancy, theoretically a woman could be spending more on pregnancy tests. For women who experience decreased sex drive on hormonal birth control (due to loss of pre-ovulatory testosterone, and lower free testosterone levels) increased pill usage would likely not improve the problem. Finally, there is no long term data on using BCPs continuously. With intensive scrutiny for almost fifty years, the largest studies have not suggested a link between BCP use and development of breast cancer.

For some women there is a strong symbolic link between regular menstruation and their concept of femininity. There is a subculture of menstrual rituals including the use of washable menstrual pads, then using the soaking water to water plants. The loss of the cyclic rituals, shared or private, might be mourned with the absence of regular flows.

Am I a Good Candidate to Try and Eliminate My Periods?

Only your own GYN or clinic can give you a conclusive answer. Yet, if you are a successful and satisfied user of hormonal forms of birth control you could easily try an extended use regimen. Your own GYN can discuss the various options such as the FDA approved Lybrel or even using your current method without a hormone free week. Whatever you try, just remember you can always decide to bail out and try something else.

Related Topics:

• Birth Control Health Center
• Choosing a Birth Control Method

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Feel Pregnant but the Pregnancy Test is Negative?

I frequently see posts on my message board which state, "My pregnancy test is negative, but I feel pregnant" or "What about common symptoms of pregnancy; if I’m not pregnant what could be causing them?" Let's look at some of the most common signs of pregnancy:

Nausea and vomiting. Generally speaking the nausea and vomiting of pregnancy are presumed to start about four weeks from conception. Some other causes of nausea and vomiting are viral, or bacterial, infections in the bowel. Appendicitis, or problems with the gall bladder or pancreas, can provoke nausea. Neurologic conditions such as migraine headaches or increased intracranial pressure can induce nausea. Even severe emotional or physical stressors can make one queasy. Less common are the psychiatric causes including anorexia, bulimia, and anxiety disorders.

Breast tenderness/sensitivity. Bilateral breast tenderness can be a very early sign of pregnancy, appearing as early as two weeks after conception. This is thought to be related to increasing levels of hormones such as estrogen. In a month without an ovulation, not only can a menstrual period be missed, but there can be breast tenderness as well. This is similar to the increased breast tenderness experienced by some women when first taking postmenopausal hormone therapy. There are many other causes of breast pain (e.g., infections, herpes zoster) but most often these occur on one breast - not both.

Enlarging abdomen. It is not until the second trimester that most women can begin to feel an enlarging uterus by pressing on the abdomen. Sometimes a large fibroid can feel and look like a pregnancy, but this is not very common. Overall abdominal distension can arise from fluid shifts in the bowel (cause of premenstrual bloating), air in the bowel, or food intolerances (lactose, gluten, etc). Much more remotely, fluid in the abdominal cavity ("ascites") can be a product of ovarian cancer or liver disease.

Fatigue. While many women complain of fatigue in their premenstrual week, early pregnancy can produce profound tiredness. Fatigue in the first trimester has been attributed to the rapid rise in progesterone. One of the metabolites of natural progesterone uses the same brain binding sites as the "Valium-type" drugs. Fatigue is also one of the most common symptoms for a myriad of medical conditions as well. Infections, anemia, electrolyte imbalances, low thyroid, diabetes, MS, cortisol abnormalities, cancer, depression, stress, and a variety of medications have all been linked to the symptom of fatigue.

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Is your pregnancy test giving you a "false negative" result when you are in fact very early pregnant? In this instance the false negative can arise from three problems.

• First of all check the box to be sure that the product has not expired or shows visible signs of damage.
  
• Second, check to see if the sensitivity of the test purchased is 20 international units of pregnancy hormone (HCG). If it is more than that, it could be less sensitive to low levels of HCG. In this instance you might wish to wait until at least a week after the missed period so that HCG levels are high enough to trigger a "true positive".
  
• Third, and the least common problem, would be a missed miscarriage. If there was an early pregnancy, which was then lost but has not yet produced bleeding, the pregnancy test would return as "not pregnant". This is a difficult diagnosis to make. The most conclusive way to confirm a miscarriage is to have sequential blood pregnancy tests which show dropping HCG levels in amount which may be too low for a standard urine test to detect.

To summarize, there are many conditions which can produce "pregnancy symptoms". If one continues to have such symptoms despite a negative pregnancy test, it is best to see your GYN or clinic and get some additional testing.

Related Topics:

• Pregnancy Symptoms: What They Never Told You
• 6 Embarrassing Pregnancy Symptoms

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4 Self-Help Strategies for PMS

Perhaps some 90% of women have symptoms that indicate that their menstrual period is due to arrive. About 60% of those women will indicate that their premenstrual symptoms are troublesome. Nearly all cultures have a set of physical or mood symptoms which are attributed to being "premenstrual". Interestingly, this set of common symptoms varies from culture to culture. Studies done with the US subjects suggest that the "American Top Ten" of bothersome premenstrual symptoms include:

1. Irritability
2. Mood swings
3. Swelling of abdomen/breasts
4. Restlessness
5. Tension
6. Depression
7. Anxiety
8. painful breasts
9. Decreased concentration
10. Forgetfulness
    

The first approach to improving premenstrual symptoms is a trial of "lifestyle" and non-prescription treatments. Which of these is most likely to benefit you?

EXERCISE

Stanley (1989), in a study of exercise and PMS symptom relief, found that women should start to obtain some symptom improvement from as little as: 110 minutes/week of swimming, 70 minutes/week of aerobic dance, or 50 minutes/week of jogging. You will note that aerobic exercise seems to dominate the list. The effectiveness of aerobic exercise was confirmed in a study of women with documented PMS (Steege, 1993). The women were randomly assigned into either aerobic or weight training groups. The aerobic exercise group showed the best symptom relief.

SUPPLEMENTS

Several well designed studies have suggested that an increased daily intake of vitamin D to 800 IU/day, accompanied by an increased intake of dietary calcium to 1200 mg/day may prevent PMS symptoms (Bertone-Johnson, 2005). ThysJacobs (1998) treated women with documented PMS using 1200 mg of calcium carbonate daily to gain significant reductions in mood symptoms, pain, fluid retention, and food cravings.

Magnesium supplementation has also been studied (Facchineti, 1997). Taking up to 360 mg of magnesium daily from cycle day 15 until flow has been found to decrease negative moods when compared to a placebo/sugar pill (Facchineti, 1991).

Vitamin B6 is a cofactor in the formation of serotonin, a neurotransmitter that figures prominently in studies of severe mood swings and depression. Without adequate Vitamin B6 less serotonin can be converted from the essential amino acid tryptophan. The RDA for vitamin B6 is 2mg/day, yet PMS studies have used doses ranging from 50-800 mg/day. For treatment of premenstrual mood swings, irritability and depression doses should be no more than 300 mg/day. Reversible nerve injury has been reported at higher doses.

DIET

Studies have shown that women with PMS crave carbohydrates. In animal models increased carbohydrate intake causes increased release of serotonin, that neurotransmitter in the brain which prompts feelings of improved mood. It has been theorized that women with PMS may be attempting to self medicate for their down moods by increased cravings for starches and sweets. Yet simple sugars can cause the body to release additional insulin, so it is recommended that "complex carbohydrates" be consumed instead. The use of whole grain bread and cereal products can be part of a morning or lunch meal. Legumes in the form of lentils, split peas, or beans can help buffer blood sugar. Think bean burritos on a whole grain tortilla...or lentil soup with a whole wheat bagel plus low fat cheese.

The recommendations to decrease intake of caffeine, alcohol, and salt are based upon much less rigorous science. Early studies in the US (1985) and China (1989) found that increased PMS symptoms were linked to as little as one cup of caffeine beverage per day. Women given an intravenous dose of alcohol were noted to have decreased tolerance for alcohol effects in the premenstrual week, as opposed to their postmenstrual week. The average American diet can contain as many as 8,000-9,000 mg of sodium per day. For women with salt sensitive fluid retention, restricting salt intake to less than 2,000 mg per day may be helpful. Take a look at you favorite snack foods, even among the low fat variety there can be considerable sodium content.

COMPLEMENTARY & ALTERNATIVE TREATMENTS

With an increased interest in "alternative therapies" some researchers have chosen to study herbal, or body work therapies for common premenstrual symptoms.

• Soy isoflavones (68 mg/day) may be helpful for breast tenderness, abdominal bloating, cramps and headaches (Bryant, 2005).
  
• Chasteberry (in the form of Vitex agnus castus extract, 20 mg daily) was found to be more effective than placebo for the relief of mood swings, headache, breast tenderness, and bloating (Schellenberg, 2001).
  
• Ginko biloba (80 mg twice a day from cycle day 15) was most successful in treating breast pain. (Tamborini, 1993).
  
• The only study utilizing St. Johns Wort (900 mg/day in divided doses) for anxiety and depression showed benefit. However, it was evaluated in only 19 women—all of whom knew they were getting the real herb treatment.

Ear, hand, and foot reflexology demonstrated improvement in premenstrual symptoms (Oleson & Flocco, 1993), as did one which utilized nine sessions of Qi therapy (Jang, 2004). Acupuncture on the outer part of the ear decreased cramps, nervousness, food cravings and other premenstrual problems (Gerhard, 1992).

WHEN TO SEEK PROFESSIONAL INPUT

If your symptoms have not responded to self help measures then it is time to see your GYN, or clinic, for some additional evaluations. There may be an underlying medical disorder (e.g., thyroid disease, depression, anemia, atypical migraines, etc) which is responsible for low grade symptoms which are worsened during the premenstrual week.

When symptoms are determined to be PMDD (Premenstrual Dysphoric Disorder) there are numerous prescriptive medication options. While PMDD has a greater emphasis on the mood symptoms of "PMS", if a woman is having marked physical symptoms she might be tried on drugs to target her specific physical concerns such as bloating or severe headache.

The most important take home message: If premenstrual symptoms are bad enough to impair your relationships or quality of life then it is time to take action. Try the self help strategies first. If those do not provide enough relief then your GYN provider may be able to help.

Related Topics:

• WebMD Video: Preventing Menstrual Cramps Before They Start
• WebMD Video: No More Periods: Are Continuous Birth Control Pills Safe?

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Do You Want to Spare Your Daughter a Colposcopy and LEEP?

Between 50%- 75% of adults will acquire some type of human papilloma virus (HPV) if they are sexually active. This is particularly likely if they, or their partner, have had more than one partner. The FDA has recently approved the first vaccine (Gardasil ®) which prevents HPV infections linked to cervical cancer, abnormal PAP smears, and even genital warts. Here are some points to consider if you are thinking about immunizing your daughter - or yourself.

Who Should Get Vaccinated?

The FDA has approved Gardasil for females between the ages of 9 and 26. The greatest number of persons acquiring HPV are young women 15 to 24 years old. The vaccine is most protective for women who have not yet become sexually active. Thus, if a woman is virginal the vaccine might still be given if she over 26 years of age.

Acquiring the virus when a teenager is particularly worrisome. In a young woman there is a proportionally larger area of a more delicate, vulnerable tissue (glandular epithelium) on the face of the cervix. With time this tissue is replaced by squamous epithelium which provides a thicker protective layer—more like our external skin. Viruses are opportunists. The mild tissue trauma of intercourse coupled with a more fragile cervical skin could make it easier for the virus to gain entry.

One well done study by Ho and colleagues (1998) followed older adolescents over three years. At the end of the study some 43% became HPV positive. This confirms the ease with which HPV can be passed between sexual partners. Surprisingly, of this group of newly infected women, only 9% continued to show persisting evidence of HPV. In many cases, especially with the "low risk" subtypes of HPV, a competent immune system can appear to clear the evidences of viral infection. Yet HPV can be acquired and be "dormant". Then, in times of a lowered immune function (e.g., pregnancy, chronic illness, or use of immune suppression drugs), dormant viruses such as herpes and HPV can produce significant infections.

Which Vaccine Should You Choose?

There are more than 30 types of HPV which are sexually transmitted. These have been classified into "low risk" and "high risk" subtypes. HPV subtypes 6 and 11 are considered to be low risk. They are linked primarily to the cauliflower-appearing genital warts, and low grade cervical lesions (eg LGSIL, CIN 1). Subtypes 16 and 18 are considered to be high risk as they are linked with persisting HPV infections and severely abnormal PAP smears. These two high risk subtypes are the probable cause of about 70% of cervical cancers.

The currently available Gardasil vaccine provides protection for all four of the HPV subtypes mentioned above. Another vaccine, "Cervarix" will likely be available in the near future. The Cervarix vaccine has been shown to protect from HPV high risk subtypes 16 and 18. Both vaccines have been shown in large research studies to provide 100% protection for the high risk subtypes.

OK, What Are the Downsides to Getting an HPV Vaccine?

Both vaccine require a series of three injections spread over a six month period. Currently it is not known if a booster shot would be needed when the woman is older to help keep her immunity at a protective level. Studies are ongoing to try and answer this question

While most major insurance companies are hopefully going to cover the cost of this vaccine, paying for the series of injections would be $360.00 if paid out of pocket. If a low income young woman is covered by the Vaccines for Children Program, this vaccine is paid for by the program.

Gardasil is a non-live virus type of vaccine. It does not contain the controversial ingredients thimersol or mercury. There is not enough long term data to suggest that it can be given during pregnancy. There are several medical conditions (eg immune suppressed) where a vaccine may not be as effective.

Like many other immunizations where an injection is required there is the trauma of getting "a shot". The most common side effect of this injection was redness and swelling at the injection site—this was experienced by about 25% of subjects receiving the vaccine. Other less common side effects were soreness or itching at the injection site, or low grade fever.

Are You Going to Get This, Jane?

Alas, I am too old, and have had too many sexual partners over my early life. But if I had the opportunity I would certainly do this. My parents had me vaccinated against smallpox. This was considered routine at the time. Some countries routinely vaccinate for tuberculosis. I believe all parents have to consider the pluses and minuses of giving preventative vaccines to some pathogen their child may never encounter. HPV is an infection that a majority of persons will contract. In my professional opinion this vaccine offers advantages to women not yet sexually active.

For more in depth information consider reading this report from the Centers for Disease Control (CDC): Recommendations of the Advisory Committee on Immunization Practices.

Related Topics:

• HPV Vaccine vs. Vulvar, Vaginal Cancer
• WebMD Video: Diagnosing HPV - DNA Test

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