Menstrual Suppression

Menses is the monthly shedding of the endometrial lining within the human menstrual cycle that occurs in approximately 26% of the world’s population. Medication-induced secondary amenorrhea is the use of hormonal contraceptives or other medications to decrease menses or achieve amenorrhea purposefully. Manipulating the menstrual cycle is widely known to be safe, and withdrawal bleeding periods that classically occur hormonal contraceptive use are not required for health. Menstruating individuals or their caregivers, if applicable, may desire menstrual suppression for several reasons, including decreasing pain and other perimenstrual symptoms, limiting blood loss, lowering the burden of menstrual hygiene, and improving quality of life. Medication-induced secondary amenorrhea may also be utilized in managing other health conditions, eg, heavy menstrual bleeding, dysmenorrhea, endometriosis, and menstrual-related blood loss in the setting of bleeding diathesis. Additionally, some special populations may benefit from menstrual suppression, including adolescents, persons with developmental or physical disabilities, transgender and gender-diverse individuals, military service members, athletes, and individuals with malignancy. With these potential benefits, primary and gynecologic care clinicians should counsel their patients on menstrual suppression. The American College of Obstetricians and Gynecologists (ACOG) released a clinical consensus on general approaches to menstrual suppression in 2022 to guide clinicians in their patient care and counseling. Agents recommended by ACOG that may be leveraged to achieve menstrual suppression include continuous or extended use of the combined oral contraceptive pill (OCP), the combined transdermal patch, the combined intravaginal ring, the progestin-only pill, and injectable depot medroxyprogesterone acetate (DMPA), as well as hormonal long-acting reversible contraceptives (LARC) (eg, the levonorgestrel-releasing intrauterine device [IUD] and the subdermal etonogestrel implant). Less commonly used options include gonadotropin-releasing hormone agonists and testosterone. Complete cessation of menses is challenging, and success rates and associated side effects vary between methods. Patients should, therefore, be counseled on realistic expectations for each approach and aim to decrease bleeding days and associated burdens rather than achieve complete amenorrhea.