Except for the year-and-a-half I was pregnant and breastfeeding, I've been getting my period every month for the last 23 years. I've bought tampons in Venezuela and crafted makeshift pads from wadded-up, scratchy tissue paper in Poland, and I once helped a friend in Mexico buy and insert her first tampon (put Vaseline on the tip). I've had blood gush out onto my skirt during typing class, creating a stain so dark and enormous that a teacher stopped me in the hall and advised me to turn the skirt around so kids might think I had dumped a Coke in my lap. I've been told at yoga not to do headstands because I had my period; my sister went to a wedding where the bleeding women were asked to leave. My other sister wasn't allowed to board Kuwait Airways until she promised she wasn't bleeding. I've had cramps so painful I couldn't leave the house and premenstrual migraine headaches that left me temporarily blind.
If you're not much interested in periods, here's all you need to know: Most women don't need to bleed on a monthly basis ever again. On Sept. 5, the U.S. Food and Drug Administration (FDA) approved Barr Laboratories' Seasonale, a form of birth control pills that will allow women to have just four periods a year. If you haven't heard about it yet, you're not paying attention: The company launched a massive marketing campaign in mid-November.
If you're like many of the women I know, your first reaction may be that this new drug sounds like too much messing with Mother Nature. But the truth is, if you're already taking the pill, you're already messing with Mother Nature -- just without the benefit of not bleeding. The reason why the 16 million American women currently taking the pill still have monthly bleeding is a complicated mess involving the Catholic Church, earth-mother feminists, and just plain ignorance about how the female body works -- ignorance that's spread by some pretty intense weirdness when it comes to discussing the existence of Aunt Flo.
Doctors with patients suffering from painful periods, anemia and other period-related disorders -- and women planning honeymoons or outdoor adventures -- have known that by skipping the inactive pills in the 28-day packets, they are less likely to bleed. But many more women, even those who have taken birth control pills for years, are unaware that their bleeding is arbitrary and unnecessary -- and unnatural. What's natural is for women between the ages of 16 and 45 to be not bleeding because they're pregnant or breastfeeding (or both) nearly all the time. Giving birth is the primary biological goal of the female body, and without modern contraceptives women would be having a lot more babies and a lot less bleeding. Women in 1900 had around 150 periods in a lifetime; women today have closer to 450.
The University of Washington's Dr. Leslie Miller is one of many doctors studying women who use birth control pills to avoid bleeding entirely, suppressing their menstrual cycle for months, years, even decades. Seasonale may be the first to get FDA approval to market itself as the "less bleeding" pill, but others will likely join it. Dr. Miller, who is something of an evangelist on the issue, says her vision is a pill that comes in a bottle. Women would be able to choose if and when they want to bleed. "My real interest is just not bleeding at all," Miller says.
An associate professor of obstetrics and gynecology who has suppressed her own bleeding for years, Miller says women used to feel that they had to bleed to feel healthy, but "once they accept the idea that the bleeding is artificial," they often change their minds. It may not sound natural, but getting your period every month isn't natural either. "Natural is getting pregnant and breastfeeding," says Dr. Miller. "That's what the body is designed for."
Despite what parents of preteens would like to believe, at about age 11-and-a-half a girl's body starts to think she's ready to have babies. Every 28 days or so, an egg is released from one of her two ovaries, and it meanders down the fallopian tube toward the uterus, where a thick nest is building up ready to snuggle the egg -- if it's fertilized. If the egg fails to get cracked by a sperm, it's turned out of its cozy home, like a baby bird that's been fouled by human hands, and the whole mess is washed out the vagina in bloody dribs and drabs.
That's a period.
In 1960, the FDA approved the first birth control pills, developed by John Rock -- a devout Catholic and a professor at Harvard. His method, which opened up a new world of sexuality for millions of women, used naturally occurring female hormones to trick the body into thinking it's already pregnant -- thus no ovulation, no chance of pregnancy. Initially, the drug was designed, like nearly all others, to come in a bottle; women would take one a day. "In view of the ability of this compound to prevent menstrual bleeding as long as it is taken," Rock's co-developer, Gregory Pincus, wrote in 1958, "a cycle of any desired length could presumably be produced."
But because of Rock's ultimately fruitless hope of receiving the Catholic Church's approval of the pill, he and Gregory Pincus came up with the three-weeks-on, one-week-off method -- for purely cultural, not medical, reasons. Natural hormones, natural cycles, women still suffering their Biblically mandated punishment for Eve eating the damn apple -- why would the Church have a problem with that?
Birth control pills come in packs of 28, but only 21 of the pills contain hormones. The other seven are blanks. It's easier to remember to take a pill if you do it every day, and forgetting to take one means, obviously, you're more likely to get pregnant. But that's not the only reason for the week of sugar pills. Rock wanted to create birth control for the faithful and he hoped that by using natural hormones -- already in the female body -- and maintaining natural cycles, he could get the pope's approval. The Church had already allowed the rhythm method, which doesn't seem like much now, but it was an acknowledgment that Catholics could try to avert some pregnancies. The key was that the rhythm approach was deemed "natural." So-called artificial methods were never allowed -- condoms and diaphragms blocked the eager sperm, and vasectomies and tubal ligations snipped what God had created. In fact, the Vatican did allow the pill until 1968 as long as it was taken primarily to cope with physical problems, such as painful periods, and the birth control was a secondary effect. I'm sure plenty of good Catholic women felt some pretty intense cramps during the '60s.
So from the beginning, all women who have taken the pill have bled for no good reason. And though they may have been fooled into thinking they're following a natural cycle, the blood they shed is not the same stuff as in a true period. The nest that builds in a non-medicated cycle is thick and spongy; for women on the pill it's more like a few dry sticks and leaves -- much lighter than a regular period, especially over time.
Seasonale and its accompanying barrage of media attention and advertisements may help educate the public on menstrual suppression, but the "Silent Spring" for the "no-period movement" was the 1999 publication of Is Menstruation Obsolete? How Suppressing Menstruation Can Help Women Who Suffer from Anemia, Endometriosis, or PMS by Elsimar Coutinho, a Brazilian doctor who helped develop Depo-Provera, a four-times-a-year birth control shot that also prevents periods. That influenced a March 2000 New Yorker article by Malcolm Gladwell, "John Rock's Error: What the Co-Inventor of the Pill Didn't Know about Menstruation Can Endanger Women's Health." Dr. Miller stocks copies in her exam rooms.
In April of this year, there was another surge of attention to the subject after Dr. Miller published an article in Obstetrics & Gynecology revealing the positive results of her study following 60 women for a year. About half were on the traditional 28-day birth control cycle, while 32 women took the pills continuously. The main concern here isn't safety: What Dr. Miller and others are testing isn't that different from the pill that now exists -- just no week of blanks, so roughly 25 percent more hormones. Actually, it's not necessarily 25 percent more hormones: Dr. Miller, for example, tests using the lowest dose of pill possible (no more than 20 mcg of estrogen a day, compared to the 150 mcg a day in the first birth control pills). Women on the no-blanks regimen might actually be getting fewer hormones overall than some women on a 21-day plan.
At the end of the year, nearly 80 percent of the women taking continuous pills showed no bleeding or spotting. To those who worry that "stuff is building up in there," Dr. Miller reports that they did uterine biopsies on a subset of the study group and found that all was very quiet on the uterine front.
The debate continued in June at the conference of the Society for Menstrual Cycle Research held in Pittsburgh. A three-part panel presented mixed opinions of menstrual suppression, basically concluding that more research is needed. They specifically encouraged research comparing women who don't take the pill with those on the continuous cycle.
The question I'd like to see asked is this: Why are women who are already on the pill still bleeding, and why are they not being told that they can stop?
For more than 15 years, I've gotten pill prescriptions from maybe a dozen doctors, and I've taken it on and off. Overall I've been happy with the pill, but I've never had a doctor ask me if I wanted to stop bleeding, even when I've complained of various side effects from both the pill and from periods and changed the type of birth control I've used. It seems that unless women happen to have endometriosis (which causes extremely painful periods), anemia, intense cramping or PMS, doctors rarely offer women the option of not bleeding. Maybe it's ignorance, maybe it's another form of "don't ask, don't tell." It's true that pills haven't been approved for continuous use until recently with Seasonale, but it's also true that legal drugs are frequently prescribed off-prescription (Botox for example, was only recently approved for wrinkle-erasing -- long after your favorite news anchor had her facial expressions removed).
I surveyed 20 women in their childbearing years on this topic. Only three said they definitely wouldn't stop their periods even if they knew it wasn't bad for them. The positive responses included two "hell yes" replies, an "absolutely" and an "of course," but only three women had actually tried it. Those currently taking the pill averaged 9 on a satisfaction scale of 1 to 10, but several of the others reported feeling that the idea of the pill was "creepy," even when they didn't really understand how it works.
In her new book, No More Periods: The Risks of Menstrual Suppression and Other Cutting-Edge Issues about Hormones and Women's Health, Dr. Susan Rako says she wants to be the voice for maintaining a regular monthly menstrual cycle without coming out and saying she's opposed to the pill. The beginning of the surprisingly readable book offers a meant-to-be-alarmist selection of quotes from a variety of newspaper articles on the subject of menstrual suppression, such as this one by Dr. Charlotte Ellertson: "We're into the era of medicine making life more convenient." Rako quotes Dr. Miller as well: "The longer you go without a period, the more you realize you didn't need it."
Rako writes about her personal reaction to Gladwell's article, which explains the bizarre reasoning for the pill's 28-day cycle and details how excessive periods may cause cancer: "While I was reading the New Yorker piece, I had a visceral response: nausea and fear. My female nature shouted an intuitive 'NO' as my brain began to spin with what I knew to be some of the implications for our intricate physiological chemistry."
While she objects to the concept of eliminating a woman's periods, Rako basically agrees that women with period issues who fit the ideal criteria for taking the pill (nonsmokers under age 35 who have a single partner and no history of blood clots) may find that the benefits outweigh the potential risks.
It's only once you get well into Rako's book that you suspect that her fundamental concern is that by using the pill to eliminate bleeding, doctors (and drug companies) will make the pill more attractive to women and more of them will take it. "If the possibility of doing away with one's period through the use of the more or less nonstop birth control pill is presented as innocuous, more women will use oral contraceptives -- many of them smokers -- and more women will die," she writes.
Taking the pill does increase a woman's chance of having a heart attack or a stroke, but even most of those women who smoke are more likely to die from pregnancy than from a pill-related complication. Of women 25 to 29 years of age, 9.1 per 100,000 will die from pregnancy, while 6.6 smoking women will die from effects of birth control. Once you're over 35, you are twice as likely to die from the pill than from childbirth (but the number is still only 56.1 per 100,000).
Even if Rako is right, she sounds a little Big Brotherish. There's no pill pack in the world that doesn't come with a warning label. Doctors already advise women who smoke not to take the pill. Shouldn't women be informed of all the potential benefits and drawbacks of the pill and then allowed to make up their own minds? It's true that people will take risks no matter what you tell them. One in 200 people will develop skin cancer; yet there are still plenty of people running around shirtless during the summer. Surely some of them realize the connection. Yet they are able, even expected, to make the choice between taking the risk, using sunscreen, or staying indoors swaddled in long sleeves.
Still, I can understand why Rako writes, "Manipulating women's reproductive hormonal chemistry for the purpose of menstrual suppression would be the largest uncontrolled experiment in the history of medical science."
But there are benefits to the pill -- and to eliminating your periods -- that Rako seems reluctant to acknowledge. There's no way most women would revert to the true natural order by having six or more pregnancies and breastfeeding each for three or more years, all in an effort to cut down the number of periods they have over their lifetime. Established risk factors for breast and ovarian cancers include the age you started your period, the number of pregnancies you have, and how long you breastfed -- all factors that impact the total number of "real" periods a woman has (the fewer periods a woman has in her lifetime, the lower her risk of cancer). Therefore it stands to reason that decreasing the number of periods by other means would lower your cancer risk as well. Taking the pill has been shown to reduce a woman's chance of endometrial cancer by 50 percent, ovarian by 40 percent.
Even if the pill isn't better protection against cancer than eating bushels of blueberries, it seems to be helpful with a host of less life-threatening but still unpleasant female problems. Menstrual complaints are the most common gynecological problem, affecting 2.5 million American women a year. And the pill is the easiest way to deal with most of them. Dr. Miller often prescribes continuous-cycle pills for women who experience a lot of herpes outbreaks, yeast infections, and other problems with their vulvas -- "just to make the genital area feel better," she says.
Many women find that the pill lessens PMS symptoms, though there's a debate over whether acknowledging PMS is good or bad for women. In the women-written, women-centered 1998 edition of Our Bodies, Ourselves (which doesn't mention the option of not bleeding in the birth control pill section) the PMS section reads, "The authors of this book are concerned that some medical professionals and drug companies have picked up on 'PMS' and use it as an excuse to prescribe, and to sell, more medication to women."
On the other hand, all 20 women in my survey reported having mild to severe PMS symptoms, from crying all the way through The Hours to cramps, moodiness and headaches. The five taking birth control reported the mildest symptoms. One 39-year-old woman who's been prescribed Zoloft for premenstrual dysphoric disorder wrote, "My period makes me so impatient, sensitive, bitchy and irrational that I can honestly relate to the theory that a woman should never be president because she'll start a war or something if she's on her period. I guess only menopausal women or women on your tricky pill should be allowed to run for office."
It makes you wonder: What does Condoleezza Rice do?
In Is Menstruation Obsolete? Dr. Coutinho offers plenty of reason to keep PMS-ing women away from the red button, drawing heavily on research done by the British doctor Katharina Dalton. She claims PMS costs U.S. industry 8 percent of its total wage bill, that it makes surgeons clumsy, leads to mechanical accidents and crime sprees, and causes career-threatening hoarseness for singers and decreased taste sensitivity for cooks. If you ever wonder what the astronauts do, there's the story of Russian cosmonaut Valentina Tereshkova, whose journey, reports Dr. Coutinho, "ended abruptly in 1973 when she had to be brought back to Earth after only three days because she began to menstruate excessively and there was no apparent way to control or stop the flow."
It's hard to know what to make of this. On one hand, I don't want to diminish the suffering of all these women I know, and I don't think they should be penalized for it either. But it reminds me of the common 19th-century diagnosis of hysteria, a host of "female" problems blamed on an overactive uterus, which led many women to get unnecessary hysterectomies for mental problems. As one friend of mine wrote, "Is it PMS or am I just grumpy/sad for other reasons?"
Is PMS another way to say depression -- albeit depression exacerbated by having to deal with a bloated belly, tender breasts and bloody underwear once a month? It's only been since the advent of birth control that women have had to deal with so many periods in their lifetimes -- otherwise they'd be pregnant and nursing nearly all the time. In the preface to Is Menstruation Obsolete? co-author and translator Sheldon J. Segal, the former director of population sciences at the Rockefeller Foundation, observes that menstruation emerged "as a regular part of life [only] for modern women." Birth control prevents pregnancy, but it has led to a lot more bleeding.
Despite PMS, plenty of women claim to feel inspired by their bleeding. The only one I know responded, "I kind of like the creative energy that comes along with the mood swings." Rako writes that she remembers the "crystal-clear energy of my reproductive years, the 'nesting instinct' that impelled me to clean house near the end of an occasional month's cycle. The surge of sexual desire I pretty regularly experienced for the couple of days before a monthly bleed, my need for quiet and rest, and a feeling of natural vulnerability during my menstrual days."
It takes only a short visit to www.yoni.com to realize Rako's not alone in her blood fever. The site has plenty of poems celebrating the bleeding, and the menstrual tip board offers advice for how to deal with the discomfort and pain, for example, "Eat lots of chocolate, drinks lots of coffee, stay in bed for a week." Also suggested are hot baths and hot red teas. The site recommends ordering Wemoon reusable menstrual pads so you can soak out the blood in water and use it to feed your plants (there are reusable tampons too, made from sea sponges -- nothing like putting a dead animal up your vagina).
Why do so many women feel like suffering is part of their essential makeup? They can't really feel responsible for Eve, can they? Dr. Miller reports getting plenty of nasty calls and e-mails from self-described feminists who say basically, "Periods are what makes a woman a woman." So we should have periods as nature intended -- oh, and the childbirth-without-drugs movement has convinced scores of women that suffering is natural. Is suffering and being "natural" a woman thing? No one complains that Bob Dole is promoting an unnatural treatment -- Viagra -- for "erectile dysfunction." Instead Dole is lauded for being honest and speaking up about a "natural problem." You'd never hear anyone say, "Sorry your dick won't work. Just deal with it. It's natural."
But while impotence has become a topic of casual TV sitcoms, talk shows and aged politicians, periods are still something most women keep within their intimate circles. At any given time 25 percent of women ages 12 to 45 are actively bleeding, yet I still see men wince when commercials for the euphemistically called "feminine protection products" air on TV. Even the name "feminine protection" implies that all hell would break loose if someone found out you were raining down there.
I once had a boyfriend who became furious if I left tampons out in plain view. I found his squeamishness annoying. At the same time, I realized one of my regular stories to drag out when asked to share "my most embarrassing moment" was this: I was at a play about a children's concentration camp. At the end, of course, the children were all dead and the audience was sniffling. As everyone somberly made their way to the exits, I rummaged in my bag for my keys, which had somehow become entangled with a tampon in my bag. When I pulled out the keys, the tampon came flying out with them and sailed across the auditorium, hitting an old man in the head. I'm still blushing.
If you want to check out someone who's really not embarrassed about periods, go to the Museum of Menstruation's Web site (www.mum.org), run by Harry Finley. He posts updates monthly (big surprise) to the question "Would you stop menstruating if you could?" Among the July postings the most negative came from a man who wrote, "I am a male, black retired clergyman (Presbyterian) who once considered menstruation as something unclean. But I have come to see it as a divine gift given only to women. Women are the bearers of humans and also divine beings. I am beginning to see menstruation as one of the most beautiful things in life. Women have the special DNA code that starts the life process, and it is in the blood of the female."
But overall the comments for that month ran seven to two in favor of stopping bleeding. One 30-year-old in Oregon wrote, "Science and medicine are good things! I would definitely take a pill that would stop menstruating if I could afford it. Cramps are miserable to suffer through, maxi pads are expensive, and bleeding makes a mess!"
At the end of No More Periods, Dr. Rako quotes several other women from earlier months on the Museum of Menstruation message board; it's not a representative sample, as Rako chose to quote only women who would as soon cut off their breasts as stop their cycles. Not only does the post-menopausal Rako long for her periods, she also writes with fond nostalgia for a courtly time when men wore hats, tipped them for ladies, stood up for them, and gave them their seats on buses: "I felt that those customs reflected, on a deeper level, a respect for the mysteries of the female -- of which having one's period was a fundamental manifestation."
I've never had that experience. If anything, getting my period makes me feel less female: one more month when I haven't done what nature intended. There goes one more little egg, a tiny potential life, to use the anti-abortionists' term, that didn't get a chance. During my worst times of period symptoms, I've wondered if my body's reaction -- grumpiness, discomfort, and bloating -- is because it's mad at me for not doing what it wants: having another baby.
But it also sounded weird when Dr. Miller told me that after a patient had been on menstrual suppression pills for a few months, "Her husband told her, 'You're just like me now.'"
Is that a good thing or bad?
I guess I'm going to find out. My last bleeding for, I hope, 12 months began on August 10. I woke up early that morning with a weird taste in my mouth and an unsettled feeling. I thought it was a bad sleep -- rowdy neighbors next door had a party that lasted until 3 in the morning; it never quite woke me up but wove into my dreams. I was at a high school keg party, making out with a pirate with a hook arm -- typical weird things. When I woke up, I went into the bathroom and smelled the weird smell and saw the tissue smeared brownish-red. It's always kind of surprising, though it certainly shouldn't be after more than 20 years of it.
More than the actual experience of getting my period for the first time, I remember learning about it in fourth grade in Lebanon, Pennsylvania. We girls were taken into the auditorium and shown a bizarre film that mostly, as I recall, involved girls in pretty, flowered dresses running through a field while "I Am Woman" played softly in the background. At the end, we were given a starter kit with a pad thicker than most diapers. I remember my friends saying afterward on the playground, "No way. We're going to bleed from there?!"
Not anymore, girls, not unless you want to.