Review articleMenstrual-cycle-related symptoms: a review of the rationale for continuous use of oral contraceptives
Introduction
Menstruation has an important impact on quality of life for many women, ranging from a simple inconvenience to a major health concern for those suffering from menstrual disorders and conditions that are aggravated during menstruation [1]. Up to 80% of reproductive-aged women experience physical changes associated with menstruation, and 20% to 40% experience menstrual-cycle-related symptoms [2]. Recognized menstrual-cycle-related disorders affect approximately 2.5 million women between the ages of 18 and 50 years in the United States alone [3].
Menstrual-cycle-related symptoms contribute significantly to health care costs due to the number of patients accessing the health care system for diagnosis and therapy. Sixty-five percent of women with menstrual disorders in one retrospective study (N=1666) reported having contacted their physician [3]. Furthermore, 12% of emergency room visits have been attributed to gynecologic disorders in women 15 to 44 years of age, based on results from the National Hospital Ambulatory Medical Care survey [4]. It is encouraging to note that women are seeking treatment for these problems, but these statistics underestimate the prevalence of menstruation-associated symptoms. Only 22% of 19-year-old women in one study (N=596) had sought medical attention for dysmenorrhea, although 72% suffered from various degrees of menstrual-cycle-related pain and nearly 40% required regular analgesics or antispasmodics [5].
Menstruation and menstrual disorders have a broader economic impact on women and society, which is a direct result of time lost from work and decreased productivity [1]. Texas Instruments noted a 25% reduction in the productivity of female workers during menses as one example [6]. The total economic cost of menstrual disorders in the United States is estimated to be 8% of total wages, with dysmenorrhea alone estimated at US$2 billion annually [7] and menorrhagia estimated at US$1692.00 annually per woman [8].
Many women, when given the choice, would eliminate or reduce the frequency of their menses [9], [10], [11]. Medically induced amenorrhea relieves many menstrual-cycle-related symptoms and menstrual disorders. Amenorrhea strictly defined is the absence of menses in menarcheal women. The lack of withdrawal bleeding associated with cessation or interruption of the exogenous steroids contained in oral contraceptives (OCs) will be considered as amenorrhea for this review. Continuous use of OCs, without the usual hormone-free week each cycle, has been used for decades to safely and effectively suppress menses or bleeding for the management of dysmenorrhea and menorrhagia [12]. This review will discuss the impact of menstrual disorders, symptoms and associated conditions on women and the evidence in support of the safe induction of amenorrhea with continuous OC use.
Section snippets
The prevalence and impact of menstrual-cycle-related conditions and symptoms
A plethora of symptoms and pathologies are associated with or exacerbated by menstruation. Measurement or quantification of many of these symptoms and conditions is difficult or impossible, and subjective indices are used in assessing the resultant disability.
The physiology of menstruation and hormone withdrawal
Menstruation has a single biological purpose: to allow the endometrium to be reprogrammed for implantation of a fertilized ovum. In a normal menstrual cycle (i.e., without exogenous hormones), estrogen from the ovaries promotes endometrial growth, a surge in LH from the pituitary results in the release of a mature ovum from the ovary and progesterone is secreted from the corpus luteum. The corpus luteum maintains progesterone production in the luteal phase of the cycle, and if pregnancy occurs,
Clinical experience in reducing menstrual frequency
Since the early days of OC use, studies about reducing the number of pill-free periods have shown that it is a safe and effective option for many women. Because each study has used different OC formulations, with different intervals between pill-free periods, retrospective comparison of these regimens is difficult. The earliest such study, conducted by Loudon et al. [56] in 1977, reduced the withdrawal bleed frequency to once every 3 months (84 days of continuous pills) in 196 women using a
Health and quality-of-life benefits associated with elimination of the menstrual cycle
Many women derive health and quality-of-life benefits by eliminating their menstrual cycle, which may reduce the occurrence of menstrual-cycle-related disorders such as menorrhagia, dysmenorrhea and anemia [1].
Cyclic OC use is already known to improve quality of life. A beneficial effect on psychological general well-being (assessed using the Psychological General Well-Being Index) was observed by Cycle 3 in women using an OC that contained 3 mg drospirenone and 30 μg EE in a 28-day cyclic
Summary
Menstruation can be a major cause of morbidity and suffering in women and can exacerbate other disorders. For many women, continuous regimens of combination OCs are already used to alleviate their symptoms and induce amenorrhea. In addition, some women choose to prolong their 28-day cycles for major life events, such as honeymoons and vacations. Studies have clearly shown that many women would like to reduce the frequency of menstruation or eliminate menstruation altogether. The popularity of
Acknowledgments
The manuscript was initially written under a contract with a medical education company. Mr. Jason McDonough provided the first draft of the manuscript and is acknowledged in the manuscript. The principal author, David F. Archer, M.D., has made extensive changes, corrections and additions to the original manuscript without help from the medical education company. Wyeth was the commercial sponsor of the first draft. David F. Archer, M.D., has not received any payment from Wyeth, nor are there any
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