THE RELIGIOUS CONSULTATION
on population, reproductive health & ethics

Source : Washington Post, June 8, 2004

Seasonale May Make Monthly Periods Obsolete. But at What Psychological Price?

by Elizabeth Gettelman, Special to The Washington Post

How's this for a description of menstruation?

"Contact with it turns new wine sour, crops touched by it become barren, seeds in gardens dry up, and fruit of trees fall off. Hives of bees will die. Even bronze and iron are at once seized by rust, and a horrible smell fills the air. To taste it drives dogs mad and affects their bite with an incurable poison."

Roman scholar and scientist Pliny the Elder wrote that, circa 65 AD, and the general attitude toward women's monthly cycle has been little tempered by the centuries: It's potent, damning and gross. It's also a universally recognized rite of passage and a sign of fertility.

Or at least it has been until now. The launch of Seasonale, Barr Pharmaceuticals' expensively promoted new oral contraceptive, is likely to challenge the universality of the period and the notion that the monthly ritual is an inevitable part of womanhood. The first FDA-approved extended-cycle oral contraceptive -- a pill regimen specifically designed to suppress menstruation through continuous doses of hormones -- Seasonale reduces the number of annual periods from 13 to four. A major marketing campaign for the product began this spring.

Seasonale is the multi-million dollar gamble of Barr Pharmaceuticals, the largest supplier in the $3.4 billion oral contraceptive market. In the late 1990s, Barr's CEO Bruce Downey agreed to manufacture and market the drug after other companies, in the words of one of Seasonale's inventors, Andy Anderson, "laughed us out of the room." Downey, who has a relative with endometriosis (an often-painful condition exacerbated by menstruation), could imagine a sizable niche of women willing to cast off messy monthly periods.

If that potential niche extends not just to the 2.5 million women with menstrual complications but to the more than 70 million of reproductive age, it becomes a market of awesome size. And if women are convinced Seasonale is safe and that periods are not necessary, then a steady absolute will become a matter of choice. We women will have to ask ourselves a wholly new question: What does my period mean to me?

This is a thick and complicated question. But I think it's even thicker and more complicated for me. I went six years without my period and, having experienced the "promise" of Seasonale involuntarily, I found it neither liberating nor a relief. Instead, I felt abandoned and not altogether whole without the monthly marker of what it is to be female.

My grandfather, a pediatrician for 65 years, has his own take on first periods that he passed on to hundreds of fathers: "On that special day, buy her flowers, take her out to dinner and make a good fuss."

Nobody gave me flowers when I first got my period, probably because I was too mortified to tell anyone. In a strange bed, staying with family friends, I woke up with stained sheets. I did what any embarrassed 11 year-old would do; I stripped the sparkling white fitted-twin and stuffed it into the hamper. Then I jammed toilet paper down my pants and waited a whole day to tell my mother.

I didn't love my period back then. But I was a loner in school, tall enough to tower over my classmates, and I was thankful that at least in one way, I was like every other girl. Then I went to Harvard, where I was a varsity athlete in basketball and crew.

I was not gifted; I knew I had to work hard, and my coaches advised me to lose some weight. The next fall I got leaner, and faster. I worked out four, five, six hours a day. With the constant physical exertion -- I was always the first to the gym and the last to leave -- by the fall of my sophomore year my periods slowed, and then disappeared.

At first I didn't notice, I was so busy. But then, as teammates (they all menstruated together, something not uncommon for women in close quarters) passed Tampons and Advil between lockers, I realized I didn't have the need for either.

The first ob-gyn I visited told me not to worry. "You should feel lucky," he laughed. "Other women would love to be in your position. Enjoy it!"

I learned (not from him) that I had athlete's amenorrhea, a condition that most often strikes elite runners, ballerinas and gymnasts (all sports in which low body fat, and anorexia, are common). Amenorrhea, the cessation of menses, strikes 5 percent of women of reproductive age reproductive women, according to the National Institutes of Health. It means the hypothalamus, pituitary, ovaries or the uterus are not functioning properly and it can also affect women with thyroid problems, obesity, pituitary tumors, severe depression or drug addiction.

My teammates worried about me. Was I exercising too much? There were doubts that I was okay. I was careful about my health; I didn't let myself get too thin (I never have been). But I was also competitive and continued to worked out hard. "That is not okay, Liz," our point guard warned.

In evolutionary terms, my body was too stressed to conceive, so my body shut down my reproductive system. Up until a century ago, women menstruated only 50 times in a lifetime -- the rest of their months they were pregnant, breastfeeding or too lean or stressed to conceive. Now women have up to 500 periods during their reproductive lives.

What is truly "natural," in terms of our bodily adaptation, is serial pregnancy -- something most women (myself included) do not wish to revisit. Yet the tradeoff is 10 times more periods in our lifetimes. That may be more than an inconvenience: Some research links more periods with a higher risk of breast and uterine cancer and anemia. (See "Skipping Periods: The Pros, the Cons, the Science" below.)

I didn't want to get pregnant then so temporary infertility from my amenorrhea wasn't a problem. The lack of hormones, I was to learn, was. The third ob-gyn I saw finally told me that every month I missed my period was a month lost of building bone density -- a month where, instead, I lost bone mass at a rate nearing the steep 5 percent per year of postmenopausal women. This loss, occurring smack in my critical bone-building years, could put me at increased risk of a stress fracture and osteoporosis. That's why menstrual suppression must be balanced with an intake of hormones to build and maintain bone density.

So I started popping Tums for the extra calcium and hormone pills to get the estrogen. I could take hormone pills or birth control pills -- I ended up taking a dozen varieties of both -- to get enough estrogen to stave off osteoporosis. But there was no guarantee when and if I would get my period back. The doctors told me the cure: "Slow down" in your training, they said. But I was faster than ever, and playing better, too.

Still, I wanted my period. I realized that it was more than just blood; it was my body speaking to me, regulating itself with monthly check-ins, both physically and emotionally. Periods were something I had taken for granted as a constant, markers of a time where I was allowed to be a little more reflective and a lot more forgiving of my body and spirit.

Chemically there's nothing radically new about the contents of Seasonale. Traditional birth control pills, taken continuously, can achieve the same "revolution" that Barr is buzzing about.

But the designers of the original birth control pill were well aware of the socially charged innovation of the Pill and so deliberately avoided the controversy that menstrual suppression might have caused. They created the 21/7-dosage program: 21 days of hormone pills, 7 days of sugar or placebo pills. In this way, for the past 45 years, the traditional pill regimen has mimicked the natural menstrual cycle. And it is in this "off week" that women on most oral contraceptives have, what most of us are now learning, is a purely cosmetic "pill period."

Anita Nelson, professor of obstetrics and gynecology at UCLA School of Medicine and an ob-gyn at UCLA Harbor Medical Center's Women's Clinic in Los Angeles, has for decades prescribed continuous use of birth control pills to her patients for everything from honeymoons and pilgrimages, to menstrual migraines and fibroids.

And now, with Seasonale, Nelson sees "such an enthusiasm with women. The first wave, when women hear about it -- they are uncertain. They think it is unhealthy, but in fact it is very healthy not to lose blood. Then there is the second wave, when they start asking, 'Why haven't people done this before?' "

Through May, pharmacies have filled more than 120,000 prescriptions for Seasonale, results that exceeded even Barr's expectations, according to Carol Cox, vice president of investor relations for Barr. A $50 million marketing campaign -- including two-page ads in nearly a dozen magazines from Vogue to US News and World Report with televisions spots starting this month -- will portray deciding not to menstruate as a bold and glamorous move. The campaign's tag line: "Fewer Periods, More Possibilities."

This message of more possibilities suggests periods are holding women back. Candace Bushnell, creator of HBO's "Sex and the City" and a spokeswoman for Seasonale, said as much at the launch for the pink pill in November.

"When you think about what women have accomplished with 13 periods a year," she said. "Think about what we can accomplish with only four. We have come a long way, but we've only just begun."

I was there that day, listening to Bushnell and wondering whether I would have taken Seasonale if I heard about it when I arrived at Harvard. If the promise is a life with more potential and accomplishment, who wouldn't? But what if, as I believe, having had my period could have helped me deal with some of my own challenges -- of working perhaps too hard, losing balance, closing myself off to emotion and vulnerability -- rather than hindered me? Eager to hear from other women, those with and without menstrual histories like mine, I found a menstruation Web site where, since testing for Seasonale began, women have answered the question: "Would you stop menstruating if you could?" An athlete responds, "I can't afford to slow down for the mess and pain of periods while training to win!"

A 29-year-old did the math: "1,359 days (45 months, 3.7 years) of my life spent bleeding so far."

A 17 year-old writes: "If I don't have my period I may forget what it's like, and not be able to relate to my daughter (if I have one) when she gets it."

And this from a former anorexic, who lost her period for two years: "I almost felt I was without an identity. You lose a lot of things without it. I think the mood swings, which everyone complains about, including myself, do have an upswing and bring about huge swells of creativity and sensory awakenings."

I get that. In college I was someone who changed my body to succeed in two sports that demanded much from me. But why couldn't I remain just as female and fertile while still being a hard-core athlete? I didn't have the surges of emotion that come with the menstrual cycle's monthly peaks and valleys of hormones. What some see as the terrors of PMS (premenstrual syndrome), I saw as actual feelings.

Simone de Beauvoir, in her landmark 1949 book "The Second Sex," called menstruation the "essence of femininity." Perhaps Seasonale will prompt a revision of this definition. If periods are a pain and inconvenience, why should women sacrifice a week of every month for the cause of femininity? They shouldn't, if their period is indeed a sacrifice.

For me, I am absolutely a more thoughtful, creative and reflective person with my period, someone who actually slows down and takes stock of my life and decisions when I am menstruating. (This makes biological sense, given the hormone fluctuations that happen with the menstrual cycle.) I actually feel more: pain, joy, confusion, passion, all of these more acutely. Without my period I took fewer emotional risks and was certainly less kind to my body.

A decade later, without any help from hormones or contraceptives, I get my period each month. The cramps are worse than I remember ever having as a teenager, but I won't take Seasonale. I missed out, not only on something my teammates shared, but also on a monthly process that would have kept me in touch with a body I have not always liked, and have often pushed to its limits.

My experience is particular. With 2.5 million women of reproductive age having menstrual disorders that could be ameliorated by fewer periods, and others who just plain see menstruation as a nuisance, I won't judge a woman's right to choose.

Women's reproductive health choices inevitably become public debate, steeped in "cultural overlay and guilt trips," says Felicia Stewart, an adjunct professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco.

The fact is, women differ greatly in what their menstrual cycle is like and what it means in their lives, and until today they have had to discover and deal with that relationship. The message that the ad campaign for Seasonale sends to women is that menstruation is a hindrance. If women and girls do not have full information -- if the messages of menstrual freedom are not balanced with a glimpse of menstrual possibilities -- then they may choose Seasonale and miss out on a part of themselves, as I believe I did.

I will turn 30 this year and sometime soon I may want to take advantage of the gift the menstrual -- or better called reproductive -- cycle offers, to have a child; my period is a caretaker of that. Perhaps more than the childbearing aspect, I appreciate my period not for the blood (which I won't glorify), but as an indicator of a body I am treating right and that is capable of extraordinary things.*

Elizabeth Gettelman is a freelance writer based in Berkeley, Calif.

<< Washington Post -- 6/8/04 >>