Clinical Practice Support – Menstrual Management and Suppression
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Clinician Practice Support - Menstrual Management
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Menstrual Management
Menstrual management, which includes menstrual suppression, is a reversible way of using hormonal treatments to reduce and/or temporarily stop period bleeding. Menstrual management includes any method of manipulating menstrual bleeding, including:
- reducing flow
- treating dysmenorrhea
- delaying periods (e.g., to avoid having the period on a vacation)
- skipping periods (e.g., to have a period only every 3 months or to avoid having the period during a 3-month deployment)
- to avoid menstruating altogether (iatrogenic amenorrhea) for an interval of time
This document will focus on changing the timing of periods such as delaying periods, skipping periods, and achieving amenorrhea. For more information on seeking lighter flow or treating dysmenorrhea, please see complementary resource documents listed below.
Indications
The primary indication for menstrual management is patient desire. No medical indication is required. People who menstruate should be given full control over their menses. This can significantly improve quality of life. Menstrual management is safe and healthy, as are skipped periods and amenorrhea when induced by medical therapies. Other indications for menstrual management include:
- heavy periods to reduce flow and/or improve anemia
- dysmenorrhea
- chronic pelvic pain that is worse during the menses and/or endometriosis
- premenstrual syndrome (PMS) due to hormonal fluctuations (estrogen-withdrawal headaches, bloating, breast tenderness or mood changes) or pre-menstrual dysphoric disorder (PMDD)
- to regulate irregular periods, e.g., in Polycystic Ovary Syndrome (PCOS)
- gender dysphoria
- contraception
As some of these conditions may require further investigations and/or medical management, clinicians are urged to consider a full investigation in anyone presenting with symptoms (rather than someone seeking menstrual management who has normal menses).
Barrier Protection
Patients at risk of contracting Sexually Transmitted and/or Blood Borne Infections (STBBIs) should be counselled to use barrier protection. Patients whose menstrual management method of choice is not a contraceptive should be counselled to use barrier contraceptives if they wish to avoid pregnancy.
Is it Safe to Medically Induce Missing Periods?
Some people may worry that missing periods is not “natural” and could be bad for their health. In the absence of medications, missing periods can indicate medical issues and can be a ‘vital sign’ that something is wrong. Patients can be reassured that it is safe and healthy to miss periods when it is done iatrogenically. Patients can be reminded that there are other times that people may not have periods that are equally safe and healthy such as pregnancy, after hysterectomy, or in menopause.
Clinically, people with functional hypothalamic amenorrhea don’t have periods because their bodies are energy-deficient due to excessive exercise or inadequate caloric intake. In this state, they are hypoestrogenic and putting their bone health at risk for osteoporosis. In addition, people with PCOS who don’t menstruate regularly have a build-up of their endometrium that puts them at future risk of endometrial cancer.
Most menstrual management options do not put a person in a hypoestrogenic state and do not put them at risk of osteoporosis. Menstrual management options can also keep the endometrium thin and reduce the risk of endometrial cancer.
Specific Populations
Transgender patients may prefer to use a progestin-only method of menstrual management to avoid estrogen and its feminizing effects.
Gender-diverse patients may prefer a progestin-only method or may be comfortable with an estrogen-containing method. Patients may choose to combine or not with other gender-affirming care. Anyone who menstruates is eligible for menstrual management/suppression.
Aircrew are grounded for 7 days on initiation of hormonal contraception and for 3 days on a change of dosage or product. Intrauterine devices (IUDs) require a 7-day grounding period post-insertion. Depo-ProveraTM can be considered on a case-by-case basis after discussion with Aeromedical Standards and Clinical Services (ASCS) Flight Surgeon. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) can cause gastrointestinal (GI) upset and the first week of use should be trialed after duty shift is complete and at least 10 hours prior to the next shift. Celecoxib is preferred. For other NSAIDs, consider co-prescribing a proton pump inhibitor (PPI).
Postpartum patients can initiate all progestin-only methods immediately postpartum and combined hormonal contraceptive options (“birth control pill”, patch, and ring) 6 weeks postpartum. It is recommended that combined hormonal contraceptive options are initiated after breast milk supply has been well-established, if the patient is breastfeeding, as it can slightly reduce breast milk supply in some users. Gonadotropin-releasing hormone (GnRH) agonists could be initiated immediately but should not be used for patients who are breastfeeding. Tranexamic acid and NSAIDs can be used immediately postpartum.
Cyclic, Extended-cycle, and Continuous Use
The uses outlined below apply to any method that has a hormone-free interval, such as the placebo pills for the combined hormonal contraceptive pill or progesterone-only contraceptive pill or for the week of no application for the patch or ring.
Cyclic use is the use most people are familiar with. A patient takes all the pills in the pack, including the placebo pills, and during that time has a withdrawal bleed. Patch and ring users take a 1 week break after 3 consecutive weeks of use (3 weekly patches or one 21-day ring).
Extended-cycle use is when the hormone-free interval is skipped for several cycles before allowing a hormone-free interval and withdrawal bleed.
- One commonly used extended-cycle regimen is to take 3 pill packs in a row (skipping the placebo pills for pack 1 and pack 2), then taking the placebo pills from pack 3. This allows users to have less frequent periods or skip their periods at certain inconvenient times, like for a holiday or short deployment. The same can be done with the patch or ring, where they are used consecutively for 9 weeks (9 weekly patches or three 21-day rings) and then take a 4-7 day hormone free interval.
- Another common way to do extended-cycle hormone use is to use pills/patches/rings continuously until a user has breakthrough bleeding and then take a 3-7 day hormone free interval to reduce ongoing breakthrough bleeding.
Some key elements:
- The patient must take the hormone pills for at least 21 consecutive days before taking a break
- The hormone free interval cannot exceed 7 days (usually 3-7 days), otherwise they will be at risk of pregnancy (if relevant) and will have more breakthrough bleeding.
Continuous use is when users never take a hormone free interval and use their hormonal method (pill, patch, or ring) every day, with the intent of achieving amenorrhea. To prescribe these, you can use the same prescription that you would usually provide your patients for these methods. For the pills, monophasic formulations work better for extended-cycle or continuous use (see Appendix B).
Tips for Prescribing
“[Brand Name] 21” packs contain only the 21 active (hormone) pills. These are best for people using the extended-cycle or continuous method, where they skip the hormone-free interval and start a new pack right away. These users will not take any pills if/when they choose to have a withdrawal bleed.
“[Brand Name] 28” packs contain the 21 active (hormone) pills and 7 placebo pills. These are often prescribed for cyclic use where the person has a withdrawal bleed each month. These can also be used for extended-cycle and continuous use by skipping the placebo pills and continuing to the next pack.
When using extended-cycle or continuous use methods, the prescription will be consumed faster. To avoid refill delays, make sure the prescription clearly states the intended schedule (e.g., continuous use) so the pharmacy knows to authorize refills sooner. Another easy way to prescribe extended-cycle pill use is to prescribe the “Combination extended regimen pills” (Appendix C).
Options for Menstrual Management.
Note: For all contraceptive methods listed below, they are prescribed in the same way as if they were being used for contraception
Hormonal Options
Levonorgestrel IUD (hormonal, not copper) such as “MirenaTM” and “KyleenaTM”
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|---|---|---|
| Ideal User | Prefers a “set it and forget it” method Can tolerate a small intravaginal procedure Has a long deployment |
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| Dosing and Frequency | 1 IUD inserted for 5 years (KyleenaTM) or 8 years (MirenaTM) If patients find a return in their bleeding, dysmenorrhea, or other bothersome symptom before these timelines, it is reasonable to replace the IUD sooner. |
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| Health Canada approved contraceptive | Yes, 99+% effective | |
| Amenorrhea rates* | 45%; higher with MirenaTM than KyleenaTM | |
| Important Considerations | Rule out pregnancy before insertion. Any provider can remove an IUD. Insertion requires training. Instructional videos for IUD insertion and removal can be found at this industry-sponsored website: https://www.mirenahcp.com/insertion-and-removal |
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Depo-Medroxy Progesterone Acetate (DMPA) such as “Depo-ProveraTM” |
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|---|---|---|
| Ideal User | Can access an injection every 3 months Can get adequate vitamin D and calcium intake |
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| Dosing and Frequency | 150 mg intramuscularly every 12-13 weeks | |
| Health Canada approved contraceptive | Yes, 94% effective | |
| Amenorrhea rates* | 70% at 2 years | |
| Important Considerations | Risk of weight gain of ~10 lb in 56% of users, mediated by increased appetite Ovulation may not resume for up to 1 year after discontinuation. Therefore, this method is not as appropriate for users who are trying to time a pregnancy (e.g., with a deployment). |
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Oral progesterone pills such as norethindrone acetate (NETA); NorlutateTM; dienogest; VisanneTM |
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|---|---|---|
| Ideal User | Able to consistently take daily pill (may be challenging for shift workers and frequent travelers) Has daily pelvic pain or endometriosis Uses condoms to prevent pregnancy (if relevant) |
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| Dosing and Frequency | NETA 2.5-15 mg by mouth daily (average dose is 5 mg by mouth daily) – typically start at 2.5 mg by mouth daily and increase by 2.5 mg no more than weekly until amenorrhea is achieved or encountering side effects Dienogest 2 mg by mouth daily |
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| Health Canada approved contraceptive | No, but should not be used in people who are trying to get pregnant (*Note: Norethindrone acetate is the same medication used in the progestin-only contraceptive pill, but here it is used at more than six times the dose) |
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| Amenorrhea rates* | 80% at 6 months with dienogest | |
| Important Considerations | Norethindrone acetate is the same active ingredient used in the “mini-pill” or progestin-only contraceptive, but here it is prescribed at more than 6x the dose of the progestin-only contraceptive pill | |
Birth control pill, patch, or vaginal ring
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|---|---|---|
| Ideal User | Can remember and access daily, weekly, or monthly option Does not have contraindications to estrogen (see Appendices A and B) Wants control over their cycle, e.g., to skip or delay a period but not necessarily wanting amenorrhea |
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| Dosing and Frequency | 1 tab by mouth daily (multiple formulations, see Appendix C) or 1 patch changed every 7 days or 1 ring changed 21 days *See descriptions below of cyclic, extended-cycle, and continuous use |
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| Health Canada approved contraceptive | Yes, 91% effective *The patch is less effective in users with weight of 90 kg (198 lb) or higher |
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| Amenorrhea rates* | 4% pill (cyclic use) 15% ring (cyclic use) *Higher rates with extended-cycle or continuous use |
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| Important Considerations | Patch is good for shift workers (steady state is longer than for pill). Daily pill may be challenging for shift workers and frequent travelers. Oral contraceptives are associated with an increased risk of venous thromboembolism (VTE), which is nominal in the average person, but significantly increased with air travel. Therefore, risk-benefit discussion about the risk of VTE and consideration of other risk factors is important for air crew and others who fly frequentlyFootnote i . |
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Progesterone-only birth control pill (“mini-pill”), norethindrone i.e. MovisseTM, JencyclaTM; drospirenone i.e., SlyndTM |
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|---|---|---|
| Ideal User | Able to remember and access a daily pill | |
| Dosing and Frequency | 1 tab PO daily (multiple formulations) *See descriptions below of cyclic, extended-cycle, and continuous use |
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| Health Canada approved contraceptive | Yes, 91% effective (norethindrone) - 96% effective (drospirenone) | |
| Amenorrhea rates* | 5 % with norethindrone, 25% with drospirenone | |
| Important Considerations | Norethindrone-containing pills must be taken within a 1-hour window each day and are a poor option for people who frequently change time zones (frequent travelers) and shift workers | |
Arm implant: etonogestrel i.e. NexplanonTM |
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|---|---|---|
| Ideal User | Prefers a “set it and forget it” method Does not mind some occasional spotting |
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| Dosing and Frequency | 1 implant for 3 years | |
| Health Canada approved contraceptive | Yes, 99.9% effective | |
| Amenorrhea rates* | 20% | |
| Important Considerations | Most effective reversible contraceptive Clinician can learn to insert easily: Nexplanonvideos.com for product videos |
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Gonadotropin-releasing hormone (GnRH) agonists (leuprolide, goserelin) i.e., LupronTM, ZoladexTM |
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|---|---|---|
| Ideal User | Severe abnormal uterine bleeding (e.g., with significant anemia), very large uterine fibroids (e.g. near level of umbilicus), severe dysmenorrhea, endometriosis, PMDD | |
| Dosing and Frequency | Leuprolide 3.75 mg intramuscularly every 4 weeks or 11.25 mg intramuscularly every 12 weeks Goserelin 3.6 mg subcutaneously every 4 weeks or 10.8 mg subcutaneously every 12 weeks |
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| Health Canada approved contraceptive | No, but should not be used in people who are trying to get pregnant | |
| Amenorrhea rates* | 89% | |
| Important Considerations | Induces temporary menopause and a hypoestrogenic state. Should not be used longer than 3-6 months without “add-back” hormone therapy with estrogen/progesterone. Typically used as a diagnostic trial or as a bridge to another therapy. Most used by specialists rather than primary care clinicians. | |
Non-Hormonal Options
Tranexamic acid (TXA) “Cyclokapron®” |
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|---|---|---|
| Ideal User | Wants to take medicine only when needed Prefers to avoid hormones |
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| Dosing and Frequency | As needed pill every 8 hours during heavy flow | |
| Health Canada approved contraceptive | No | |
| Amenorrhea rates* | Not Applicable (N/A) | |
| Important Considerations | Can be used in people trying to conceive | |
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
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|---|---|---|
| Ideal User | As needed pill every 4 to 12 hours during pain and heavy flow | |
| Dosing and Frequency | Wants to take medicine only when needed Can take with food, prefers to avoid hormones |
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| Health Canada approved contraceptive | No | |
| Amenorrhea rates* | N/A | |
| Important Considerations | Can use in people trying to conceive Celecoxib is preferred for air crew as it has less GI effects; for other NSAIDs, consider prescribing with a PPI |
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Options for Reduction of Menstrual Flow and Pain
| Hormonal | Non-hormonal | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| IUD (hormonal) | Depo-Medroxy Progesterone Acetate injection | Oral progesterone pills (NETA, dienogest) | Combined hormonal contraceptive | Progesterone-only mini-pill” (norethindrone, drospirenone) | Arm implant (etonogestrel) | GnRH agonists (leuprolide or goserelin) | Tranexamic acid | Anti-inflamma-tories (naproxen, ibuprofen) | |
| Treats acne, unwanted facial hair, and menstrual irregularity of PCOS | |||||||||
| Suppresses ovulation (helps with ovarian cyst prevention, PMS, PMDD) | |||||||||
| Safe for those with migraines with aura, history of VTE, or people who are 35 years and older and smoke | |||||||||
| Approved contraceptive in Canada | |||||||||
| Decreases risks of uterus andovarian cancer | |||||||||
| Shrinks fibroids | |||||||||
| Treats endometriosis & dysmenorrhea | |||||||||
| Reduces risk of anterior cruciate ligament (ACL) injury requiring surgery, osteoporosis, osteoarthritis, and stress fractures | |||||||||
Contraindications
Contraindications are specific to the prescription provided, e.g., contraindications to estrogen-containing menstrual suppression include history of venous thromboembolism, migraine with aura, or breast cancer. Contraindications to progestins vary by method but generally includes current breast cancer for all methods. For a full list of contraindications to any contraceptive method, please refer to cdc.gov/contraception/hcp/usmec (link available at the time of publication). A helpful summary table has been included in Appendix A. Oral progesterone pills have the same contraindications as progestin-only contraceptive pills. For a full list of contraindications to estrogen-containing menstrual management, see the Canadian Contraception Consensus (Part 4 of 4): Chapter 9 – Combined Hormonal Contraception. Contraindications to GnRH agonists have not been provided as primary care clinicians are not expected to prescribe these medications (though they can if they feel comfortable).
Risks and Side Effects
Hormonal Adjustments: Patients may experience nausea, breast tenderness, mood changes, and/or headaches. These often resolve within a few weeks as the body adapts to the medication or may not occur.
Irregular Bleeding: Patients may experience spotting and may refer to this as “getting their period”. If they are using their menstrual management product reliably (i.e. not skipping pills), they are not having a period but are having breakthrough bleeding. This bleeding is common during the first few months but can be long-term. If the patient is dissatisfied with the amount of bleeding, they may require a change in therapy. Some patients never achieve complete amenorrhea regardless of method, but it is important to try several methods before assuming this will be the case. Ensure to rule out STBBI or other causes of bleeding, poor adherence to therapy, and pregnancy.
Weight Changes: Patients may experience weight gain and bloating, sometimes caused by fluid retention or appetite changes. Evidence shows that hormonal options (except Depo-Medroxy Progesterone Acetate (DMPA)) do not increase weight. DMPA causes an average of 10 lb / 4.5 kg of weight gain in 56% of users mediated by increased appetite.
Venous Thromboembolism: There is an increased risk of blood clots with estrogen-containing products (8 people in 10,000 with highest risk during the first three months). It is important to assess for contraindications.
Temporary Delayed Fertility Restoration: With Depo-Medroxy Progesterone Acetate (DMPA), there can be up to a 1-year delay in resumption of ovulation and fertility. There are no permanent impacts on fertility.
Bone Density: Some patients may have decreased bone density with prolonged use of injectable progestin or LoloTM, but this is not associated with an increased fracture risk. Bone density loss stabilizes after the first two years and is reversible after discontinuation. Vitamin D and Calcium within the patient’s diet or by supplementation and weight-bearing exercise is encouraged with long-term progestin use. Alternately, some patients may have increased bone density with some estrogen-containing products.
Resources
Appendix A - WHO Medical Eligibility Criteria for Contraceptive Use Summary Chart
Appendix B - Contraindications to combined hormonal contraceptives
Reference: No. 329-Canadian Contraception Consensus Part 4 of 4 Chapter 9: Combined Hormonal Contraception
Black, A., Guilbert, E., Costescu, D., Dunn, S., Fisher, W., Kives, S., ... & Whelan, A. M. (2017). No. 329-Canadian contraception consensus part 4 of 4 chapter 9: combined hormonal contraception. Journal of Obstetrics and Gynaecology Canada, 39(4), 229-268.
Appendix C – Formulations of combined hormonal contraceptives available in Canada in 2017
Note: This list was published in 2017 and may include formulations that are no longer available and may omit more recent formulations.
Reference: No. 329-Canadian Contraception Consensus Part 4 of 4 Chapter 9: Combined Hormonal Contraception
Black, A., Guilbert, E., Costescu, D., Dunn, S., Fisher, W., Kives, S., ... & Whelan, A. M. (2017). No. 329-Canadian contraception consensus part 4 of 4 chapter 9: combined hormonal contraception. Journal of Obstetrics and Gynaecology Canada, 39(4), 229-268.
Appendix D – Additional resource documents
- CAF Women and Diversity Health Professional Development Session on Demand: Clinical Approach to Dysmenorrhea
- CAF Women and Diversity Health Clinician Resource: Pain Management during Intrauterine Device (IUD) insertion
- Consult the Women and Diversity Health Clinical team at the below positional mailbox:
+WDH PROF TECH - SFD PROF TECH@CMP CF H SVCS Gp@Ottawa-Hull <WDHPROFTECH-SFDPROFTECH@forces.gc.ca>
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