No more going with the flow.
The end of the period
A new contraceptive will soon let women stop menstruating. Is it the pinnacle of liberation, or a reckless experiment?
For the average woman, life holds not two but three certainties: death, taxes and 35 years of monthly hormonal mayhem. Periods can be wretched. But from a young age, girls are comforted with the promise that the bleeding, cramping and radical mood swings are all part of the special alchemy of womanhood. Menstruation is -- to use the mother of all feminine-hygiene euphemisms -- a precious gift. Which is why the introduction of a new product that invites women to opt out of the whole ordeal is something of a cultural upheaval. Health experts are predicting that by this time next year, menstruation will no longer be an inevitable function but rather an optional feature, a bit like power steering or pay-per-view.
In 2006, a new oral contraceptive called Anya, developed to "put women in control of when or if they want to menstruate," is expected to hit the Canadian and U.S. markets. Manufactured by Collegeville, Penn.-based Wyeth Pharmaceuticals -- and currently pending approval by Health Canada -- Anya is the first low-dose birth control pill designed to be taken 365 days a year, without placebos (the hormone-free sugar pills taken at the end of every 28-day cycle). Early findings report that Anya is just as effective in preventing pregnancy as traditional oral contraceptives (98 per cent). And as an added bonus, since Anya provides a steady stream of hormones, it promises to quash a woman's usual cyclical fluctuations, virtually wiping out all the irksome symptoms of PMS.
The elimination of periods -- politely called menstrual suppression -- is an objective the pharmaceutical industry has been chasing for several years. In the fall of 2003, Barr Laboratories of Pomona, N.Y., introduced Seasonale in the U.S., the first extended-cycle contraceptive pill, with the slogan "Fewer periods. More possibilities." Unlike traditional oral contraceptives, which a woman takes for 21 days, followed by seven days of placebo pills, Seasonale is taken for 84 consecutive days, followed by seven days of placebos, which gives her four periods a year instead of the usual 13. Despite widely reported side effects, including irregular bleeding, Seasonale -- still pending approval in Canada -- has quickly emerged as a popular option in the U.S. Last year alone, Barr recorded Seasonale sales of US$87 million. Anya takes this concept and raises it to the next level.
So, for any woman who ever found herself staring down a Tampax vending machine without a quarter, the advent of a drug like Anya would seem an occasion for rejoicing. It will mean all sorts of choices for the next generation of adolescent girls. It will mean being able to customize their cycles to suit their lives. (Maybe she's an athlete who doesn't want to bleed during swim meets. Or maybe she just likes to wear white cotton capris.) It will mean no more tampons, panty liners or maxi pads with wings. No more Midol or hot water bottles. No more feeling not-quite-fresh -- even after a shower.
And yet, in theory anyway, the whole idea of menstrual suppression is outrageous. Isn't the whole point of "the curse" that it's not optional? Isn't it natural for women to menstruate? On these questions, the experts -- doctors, feminists, bioethicists and women themselves -- are bitterly divided. On the one hand, advocates say, it's all about providing women with choices and giving them control. We've already been manipulating Mother Nature for decades, so why stop now? But detractors say menstrual suppression is a reckless and profit-driven enterprise -- or, as one women's health expert calls it, "the largest uncontrolled experiment in the history of medical science, hands down." Reckless or not, the need to bleed is poised to become the next front in the ongoing battle over women's bodies.
Dr. Shari Brasner, a 40-year-old Manhattan gynecologist, says she, for one, just doesn't have time to menstruate. Brasner has been suppressing her period for a decade with the continuous use of birth control pills, "whatever samples I've got in my cabinet at my office." (While many women have used this off-label method to skip a single period that is ill-timed to a vacation or honeymoon, it is generally practised only by women with severe menstrual difficulties, under doctor's supervision.) "I have an incredibly busy day," she says, "and the reality is, I just don't have time to get to the bathroom every two or three hours to change a tampon or a sanitary napkin." Brasner adds that she believes her use of birth control pills "to be safe. I know it to be effective, and it saves me time, energy and in the long run, some money. Just in dry cleaning bills alone."
Brasner and other advocates of stopping menstruation point out that among the greatest fallacies in modern popular medicine is the notion that women on oral contraceptives -- roughly 1.5 million in Canada -- experience a period every month. In fact, what they experience is "a fake period," what doctors call a withdrawal bleed. "Women on birth control bleed not because they're having a menstrual cycle, but because when they take their placebo pills, their bodies are withdrawing from the progesterone cycle in the active tablets," says Dr. Leslie Miller, a professor of obstetrics and gynecology at the University of Washington, who runs the pro-suppression website Noperiod.com. In other words, she says, there's nothing natural about it.
In fact, the reason women on oral contraceptives bleed at all is because of one man, a devout Catholic named Dr. John Rock, the co-inventor of the pill. Forty-five years ago, Rock determined that if he could design the pill to replicate the menstrual cycle of the average woman of child-bearing age -- 28 days -- he might succeed in convincing the Church to endorse his invention as a natural form of birth control. Despite his efforts, the Vatican denounced oral contraceptives in 1968, but the 28-day cycle persisted because -- fake or not -- women were comforted by the idea of monthly bleeding. (As evidence of how deeply women have internalized this idea, even Anya, which is taken every single day, will be sold in packages of 28 to preserve the notion of a natural cycle.) But Miller argues that since the bleeding serves no apparent purpose -- except a psychological one -- why not get rid of it altogether?
In 1999, a Brazilian gynecologist named Dr. Elsimar Coutinho polarized the women's health community with the publication of Is Menstruation Obsolete? How Suppressing Menstruation Can Help Women Who Suffer From Anemia, Endometriosis, or PMS. In the book, Coutinho argues that the contemporary woman has many more periods than nature likely intended. A hundred years ago, he points out, the average age of onset was roughly 16. Now, a girl's first period often comes as early as 10 or 11. (Theories to explain this phenomenon run the gamut from higher childhood obesity rates to increased exposure to chemicals in the environment.) Also, women are waiting longer to get pregnant and having fewer pregnancies. Which means that whereas a 19th-century woman may have had fewer than 50 menstrual cycles in her lifetime, the modern woman often has more than 400.
To have so many periods, he says, isn't only a nuisance, but may be an unnecessary hazard to a woman's emotional and physical health. Menstruation, he says, can exacerbate anemia, migraines, endometriosis and polycystic cysts. Also, the frequent use of tampons puts women at risk for toxic shock or vulvar irritation. (Coutinho, as it happens, also helped develop Depo-Provera, a controversial injectable contraceptive that suppresses a woman's period for three months at a time and is believed to cause serious complications in some women, including significant loss of bone density.)
Miller, meanwhile, contends that there are potential health benefits to taking the pill continuously, particularly for those who choose not to have children. "We know that the pill can reduce risks of uterine and ovarian cancer, endometriosis, uterine fibroids," she says. Then there are the savings for women on feminine hygiene products, which collectively cost billions of dollars a year. (In Canada, both the NDP and Conservative parties have toyed with the idea of scrapping the GST on feminine hygiene products to woo female voters.) "There's no downside in terms of health risks to stopping your period," concurs Dr. Julia Johnson, a reproductive endocrinologist at the University of Vermont and one of Anya's primary researchers. "The only drawback is that up to 30 per cent of women still experience some bleeding or spotting in the first six months at unpredictable times."
The upside, however, is potentially enormous, says Miller. "Imagine the freedom to go swimming anytime," she says, "You can wear a skirt with no underwear. You can have sex without thinking about blood on the sheets. You never get anything stained. Every day your hormones are the same. Your breasts aren't tender, you don't feel ovulatory pains. It's a modern problem to have 13 periods a year for 35 years. I think the continuous pill is a modern solution to a modern problem."
But all of this good news, detractors say, is based on the assumption that periods serve no function other than reproduction -- and that you can isolate them from every other system in the body. This, they argue, is preposterous. "Menstruation, this amazingly intricate, carefully crafted cycle, is a vital sign of our health," says Dr. Jerilynn Prior, an endocrinologist and the scientific director of the Centre for Menstrual Cycle and Ovulation Research at the University of British Columbia. "To wantonly disrupt it is a horrifying thought. Regulatory bodies are saying, 'We approved the original pill, so this must be okay. It's just taking the pill more frequently.' But even the original pill probably contains negatives we still don't really know about." The continuous-use pill, she says, is just a way for pharmaceutical companies to revive flagging products -- to find fresh ways to market them by giving them a "new face and a new name."
In 1993, Margie Profet, an evolutionary biologist at the University of Washington, published a groundbreaking thesis asserting that, aside from its obvious function, menstruation serves to protect women against STDs and infertility by flushing out the reproductive system, ridding it of pathogens, bacteria and other sperm-borne toxins. Also, says Dr. Susan Rako, a Boston-based psychiatrist and women's reproductive health expert whose 2003 book No More Periods? denounced menstrual suppression, a woman's blood pressure is reduced for two weeks of every month during a normal menstrual cycle. "There's a normal physiology that causes this to happen," she says. "It's like your body puts out its own antihypertensive medication every month for two weeks. Women on the birth control pill don't have this experience."
Even the "fake period" of those on the birth control pill serves a purpose by mimicking the body's natural cycle, says Rako. "Menstrual bleeding is the only way a woman's body can rid itself of excess stored iron, which is a risk factor for cardiovascular disease, heart attacks and strokes," she says. "The fact that women have regular bleeding is one of the factors that likely contributes to their having lower incidence of heart attack and strokes than do men before women are menopausal." Prior adds that the break from the high hormone levels of the normal menstrual cycle is likely important for the breasts and bones, particularly among adolescents and younger teens who are at a crucial time in their development. (Even Leslie Miller is reluctant to support menstrual suppression for young people. "I'll get emails to my site from a mother who's got a 12-year-old, and she'll say, 'Oh, I want to take away all of her periods, because she wants to be wearing her bikini down in Tahiti, or because menstruation is messy.' And I'll say, 'You know what, she probably needs a few periods.' Most studies are never done on women under 18.")
Geraldine Matus, a holistic reproductive health care practitioner in Edmonton, asserts that the notion there is no connection between birth control use and fertility rates is another fallacy long perpetuated by the pharmaceutical industry. "My clinical experience is that there is a connection," says Matus, who has been charting the cycles of women with fertility problems for 30 years. A 2002 study published in the journal Gynecological Endocrinology found that it often took up to nine months, and in some cases longer, for women to regain their fertility after the cessation of oral contraceptives. "When coming off the birth control pill," says Matus, "there are often many things missing: proper menstrual bleeds, the presence of ovulation, the presence of cervical mucus necessary for sperm survival. With something like continuous use, it's even more deleterious."
Among detractors of menstruation suppression, hormone replacement therapy (HRT) for women in the years before menopause is upheld as the cautionary tale. "We were told for a very long time that there was no problem with HRT, that it would benefit our health, and there were mass prescriptions," says Kathleen O'Grady of the Canadian Women's Health Network. "But when the science finally came out, we found there were serious health risks associated with HRT [including heart problems and breast cancer]. We can't make presumptions first and wait for the science after, especially when we're talking about exposing healthy women to continuous hormones purely for lifestyle purposes." Also, adds Prior, the notion that these pills are low-dose should be in quotations. "It's low dose compared to the kind of pills that were marketed in the '60s and '70s," she says, "but it's not low dose compared to the natural estrogen level. We've been sold that it is, and we accept it as though it is true. We've lost our perspective."
The argument for cessation of periods is couched in feminist notions of choice and control, says Prior, but you can't truly have either when you don't have all of the information, the regulatory bodies aren't demanding it, and the pharmaceutical industry stands to make billions by pushing the drug through. "From a cultural perspective, I think it's misogynistic," says Matus. "Women's bodies are a marvellous thing to commodify. We have all sorts of processes that can be turned into diseases and disease models: pregnancy, nursing, menstruation, menopause -- all of these things. And because we tend to use the health care system more than men, we're a great market share."
While science marches on, perhaps the greatest champion of menstrual preservation is, oddly enough, a 63-year-old bachelor and retired employee of the U.S. Department of Defense named Harry Finley. For four years, Finley ran the Museum of Menstruation -- or MUM for short, a play on "mum's the word" -- out of his home in New Carrollton, Md., attracting over 1,500 visitors, mostly on weekends and by appointment. Ultimately, however, he found it too taxing to have to continually explain to people why the collection is housed in his wood-panelled basement. ("Here I am, a single male going to my basement," he says, in a gentlemanly tone, "and I understand that it just seemed so weird.") For now he hosts the museum online while he searches for a permanent public venue.
An artist and graphic designer by trade, Finley originally became interested in menstruation as a collector of advertisements and other rare and interesting paraphernalia. The "semi-taboo" nature of the subject appealed to him. Now he has one of the most comprehensive private collections in the world, featuring 4,000 to 5,000 items. Included among his finds are antiques like a 1955 "cotton puckerette Sanitary Panty" by Sears, decorated with "bright, gay colors" and featuring a "moisture-resistant crotch which is rubber-lined." There are also works by contemporary artists, including one who uses her own menstrual blood as a medium. His personal favourite is a reproduction of an early 20th-century sanitary apron he commissioned from a local artist. "A sanitary apron is just another thing women wore in order not to have menstruation leaking through their clothing," he says. "I'm always amazed by how much more women are -- and I used this in quotation marks -- 'burdened' by menstruation. Men have nothing comparable to this at all."
A couple of years ago, Finley posted a question on his website that he deemed a very interesting hypothetical: "Would you stop menstruating if you could?" To his surprise, it sparked an impassioned debate. Answers poured in -- and continue to pour in -- from all over the world: "Yes, when your body turns into an enemy every month, you don't want to celebrate it, you want to declare a ceasefire and negotiate release of hostages." "No, but I do believe a woman should have a choice, without judgment!!" "Personally, I'll keep it. I don't trust doctors and medication enough to give up something that is a mild inconvenience which makes me feel human and womanly." "No, it gives me power that men don't have and cannot have over me." "I am a stripper and I dread the monthly demon." "Being a woman is not a disease." And so on.
The results of Finley's crude survey reflect the deep-seated ambivalence women feel about their periods. In a recent U.S. survey by the Association of Reproductive Health Professionals, 75 per cent of respondents said they believe men have a real advantage by not having the monthly disruption. Sixty-seven per cent wouldn't miss it if it disappeared. Sixty-nine per cent said they'd try using a birth control method that stopped it altogether if they could be sure it wouldn't hurt them.
Women's conflicted feelings about menstruation, while rooted primarily in its attendant pain, discomfort and inconvenience, are also stoked by centuries, if not millennia, of superstitious rhetoric that has, in many ways, reinforced the perception of women as the morally, physically and intellectually weaker sex. There is a long-standing belief that, for at least one week out of every month, women are practically insane, and unfit for anything requiring logic or rationality. In 1878, the British Medical Journal published an essay about the potential hazards of allowing women to practise medicine, since menstruating women tainted meat when they touched it. In France as recently as 100 years ago, menstruating women were not permitted to enter sugar factories for fear they would spoil the boiling sugar. Scientific studies designed to combat suffragettes in the 1920s "proved" that women were too unstable to participate in the civic process because of their cycles. Among other things, menstruation has been deemed the root cause of female hysteria, marital problems, "cussedness," weight gain, bad mothering, murder and indigestion.
There is another, more humanist aspect to the whole discussion. Among women, menstruation has always been the great leveller. There is a strange sisterhood forged by swapping stories of gym class horrors, leaking at the most mortifying moments, and reading dog-eared copies of Judy Blume's Are You There God? It's Me, Margaret in the back of the school library and snickering at the word "men-stroo-ation." (That book -- a slim 1972 volume about a group of preteen girls coming to terms with adolescence -- remains among the top-selling children's titles of all time.) It is a uniquely female experience to sit in health class while the teacher explains why tampons won't, in fact, take one's virginity -- and to watch in horror and fascination as the same teacher drops said tampon into a clear jar of water, causing it to expand like some sort of wispy sea creature. "The menstrual cycle is really the one thing that all women have in common," says Joan Chrisler, a social psychologist at Connecticut College in New London, Conn., who specializes in women's relationships with their bodies, "and I'd feel very sad if we took this away. We'd no longer have this connection to nature and to each other any more."
The onset of menstruation, called menarche -- pronounced like anarchy -- tends to be a formative memory, wrote the Pulitzer Prize-winning science writer Natalie Angier in her book, Woman: An Intimate Geography, one that is "seared into the brain with the blowtorch of high emotion." "It's very, terribly sad," says Rako, "the idea that teenage girls would grow up in a world where the idea of menstruating is considered undesirable and a nuisance. In fact, there's a certain kind of rhythm that goes with your monthly cycle: where sometimes in the month you feel more energetic, sometimes more creative, sometimes more sexual, sometimes more vulnerable. That's all part of being female."
Which is why for many the question "is menstruation obsolete?" is a bit like asking whether being a woman is obsolete. "It's ridiculous," says Matus. "I could make the same argument about men and ejaculation. I could say, 'Men don't need to ejaculate. It's messy; it means a loss of essential nutrients; it's embarrassing when you have a wet dream and your mother comes in. So take a pill to suppress it.' But that would change everything about how he works. And they'd probably burn us at the stake if we suggested it. But that's how ridiculous this is."