Premenstrual Dysphoric Disorder Symptoms Following Ovarian Suppression: Triggered by Change in Ovarian Steroid Levels But Not Continuous Stable Levels.

OBJECTIVE: Premenstrual dysphoric disorder (PMDD) symptoms are eliminated by ovarian suppression and stimulated by administration of ovarian steroids, yet they appear with ovarian steroid levels indistinguishable from those in women without PMDD. Thus, symptoms could be precipitated either by an acute change in ovarian steroid levels or by stable levels above a critical threshold playing a permissive role in expression of an underlying infradian affective "pacemaker." The authors attempted to determine which condition triggers PMDD symptoms. METHOD: The study included 22 women with PMDD, ages 30 to 50 years. Twelve women who experienced symptom remission after 2-3 months of GnRH agonist-induced ovarian suppression (leuprolide) then received 1 month of single-blind (participant only) placebo and then 3 months of continuous combined estradiol/progesterone. Primary outcome measures were the Rating for Premenstrual Tension observer and self-ratings completed every 2 weeks during clinic visits. Multivariate repeated-measure ANOVA for mixed models was employed. RESULTS: Both self- and observer-rated scores on the Rating for Premenstrual Tension were significantly increased (more symptomatic) during the first month of combined estradiol/progesterone compared with the last month of leuprolide alone, the placebo month, and the second and third months of estradiol/progesterone. There were no significant differences in symptom severity between the last month of leuprolide alone, placebo month, or second and third months of estradiol/progesterone. Finally, the Rating for Premenstrual Tension scores in the second and third estradiol/progesterone months did not significantly differ. CONCLUSIONS: The findings demonstrate that the change in estradiol/progesterone levels from low to high, and not the steady-state level, was associated with onset of PMDD symptoms. Therapeutic efforts to modulate the change in steroid levels proximate to ovulation merit further study.

Missed pills: frequency, reasons, consequences and solutions.

OBJECTIVES: Oral hormonal contraception is an effective contraceptive method as long as regular daily intake is maintained. However, a daily routine is a constraint for many women and can lead to missed pills, pill discontinuation and/or unintended pregnancy. This article describes the frequency of inconsistent use, the consequences, the risk factors and the possible solutions. METHODS: The article comprises a narrative review of the literature. RESULTS: Forgetting one to three pills per cycle is a frequent problem among 15-51% of users, generally adolescents. The reasons for this are age, inability to establish a routine, pill unavailability, side effects, loss of motivation and lack of involvement in the initial decision to use oral contraceptives. The consequences are 'escape ovulations' and, possibly, unintended pregnancy. Solutions are either to use a long-acting method or, for women who prefer to take oral contraceptives, use a continuous or long-cycle regimen to reduce the risks of follicular development and thus the likelihood of ovulation and unintended pregnancy. A progestogen with a long half-life can increase ovarian suppression. CONCLUSIONS: For women deciding to use oral contraceptives, a shortened or eliminated hormone-free interval and a progestogen with a long half-life may be an option to reduce the negative consequences of missed oral contraceptive pills.

The 'nonmenstrual woman' in the new millennium? Discourses on menstrual suppression in the first decade of extended cycle oral contraception use in Canada.

In the early-twenty-first century, extended cycle oral contraception (ECOC) became available by physician prescription in North America. Researchers speculate that this drug, with its capacity to reduce or eliminate menstrual bleeding, may shift not only women's biological processes but also their experiences of menstruation. In this paper, I discuss women's experiences of menstrual suppression drawing on findings from a qualitative study conducted before ECOC was available, and examine these findings against recently published research on menstrual suppression in an ECOC era. Findings suggest that the body as a natural entity figures strongly in women's discourses on suppression. They further suggest that suppression is a contingent, paradoxical and practical achievement, not a securely or fully realised embodied state. This paper reads women's accounts of menstrual suppression prior to ECOC as a challenge to the modern artifice of a mind/body split, and questions whether this challenge is perhaps made less discernible in an ECOC era, where attention may no longer be paid to the daily practices of menstrual suppression. Hence, a case is made for the varied political effects of ongoing non-menstruation versus event-specific practices of non-menstruation.

"More natural but less normal": reconsidering medicalisation and agency through women's accounts of menstrual suppression.

This paper revisits the concept of medicalisation and considers its value as a framework for understanding the ongoing development of new reproductive technologies, and their impact on women's reproductive decision-making. This evaluation is drawn from a qualitative discourse analysis of the public debate about the first extended cycle oral contraception (ECOC) to suppress menstruation in the United States of America in 2003/2004, and subsequent interviews with women living in Australia who had already extended their cycles without it being medically approved for widespread practice. Firstly, the debates about menstrual suppression are couched within a discussion of the ongoing usefulness of medicalisation as an analytical tool. It is posited that medicalisation occurs in a particular social and cultural moment, and is a dynamic process where dominant social relations can be both reproduced and challenged. Secondly, qualitative interviews with women about practices of menstrual suppression are used to explore the productive nature of agency in this particular medicalisation contest. Specifically, the ways in which these women engage with the discourses of 'risk', 'choice' and 'nature', as canvassed by menstrual suppression advocates, reveal accommodation and modification as much as resistance and contradiction. This paper suggests that if the concept of medicalisation is to have ongoing traction as a frame of analysis, such a critique must incorporate a generative discussion of agency.

Military women's attitudes toward menstruation and menstrual suppression in relation to the deployed environment: development and testing of the MWATMS-9 (short form).

PURPOSE: To determine military women's attitudes toward menstruation and menstrual suppression with oral contraceptives in the deployed environment. METHODS: A cross-sectional descriptive design with the administration of the Menstrual Attitude Questionnaire (MAQ) and the 55-item Military Women's Attitudes Towards Menstrual Suppression Scale (MWATMS) to a convenience sample (n = 278) of women in the U.S. Army with deployment experience. FINDINGS: The MAQ's five subscales' mean scores ranged from 3.4 (+/-1.11) to 5.1 (+/-1.06), indicating neutral to moderate attitudes toward menstruation. Measurement development on the MWATMS produced a nine-item scale with three components: stress effects, benefits to self, and environmental barriers. CONCLUSION: Menstrual attitudes were generally neutral in this sample; however, military women favor menstrual suppression during deployment owing to the effects of stress during deployment, benefits that suppression would provide, and the barriers to menstrual hygiene in the deployed environment. Women who perceived menstruation as bothersome and debilitating had positive attitudes toward menstrual suppression. These findings can contribute to appropriate predeployment women's health care and improve the readiness for deployment in female soldiers. Providers should educate women on the risks and benefits of menstrual suppression methods and provide guidance on impact that the deployed environment can have on their menstrual experiences.

Development of the Military Women's Attitudes Toward Menstrual Suppression Scale: from construct definition to pilot testing.

The Military Women's Attitudes Toward Menstrual Suppression scale (MWATMS) was created to measure attitudes toward menstrual suppression during deployment. The human health and social ecology theories were integrated to conceptualize an instrument that accounts for military-unique aspects of the environment on attitudes toward suppression. A three-step instrument development process was followed to develop the MWATMS. The instrument was pilot tested on a convenience sample of 206 military women with deployment experience. Reliability was tested with measures of internal consistency (alpha = .97); validity was tested with principal components analysis with varimax rotation. Four components accounted for 65% of variance: Benefits/Interest, Hygiene, Convenience, and Soldier/Stress. The pilot test of the MWATMS supported its reliability and validity. Further testing is warranted for validation of this instrument.

Attitudes toward menstrual suppression and conformity to feminine norms in young and middle-aged Mexican women.

Seventy seven college students and 66 middle-aged Mexican women completed an adapted questionnaire of attitudes toward menstrual suppression and the Conformity to Feminine Norms Inventory. Participants showed a great interest in menstrual suppression, but few were familiar with this issue. Young women would like to have longer menstrual cycles than monthly and were more supportive of menstrual suppression than middle-aged women. Women who would prefer to have longer menstrual cycles showed less conformity to feminine norms. These findings are discussed in light of differences between age cohorts, and the relationship between the studied variables and attitudes toward menstruation.

Theoretical substruction: establishing links between theory and measurement of military women's attitudes towards menstrual suppression during military operations.

AIM: The aim of this paper is to establish a theoretical model for the exploration of the phenomenon of menstruation and women's attitudes towards menstrual suppression during military operations. BACKGROUND: In the emerging field of literature that explores menstruation among military women, there are indications that menstrual symptoms and hygiene are problematic under the circumstances of deployment to military operations. While menstrual suppression may be a solution to problems that women encounter with menstruation during deployment, there is little research exploring the phenomenon. DATA SOURCES: CINAHL and Medline were used to locate peer reviewed journal papers published from 1977 to 2007. International military reports were obtained through an internet search engine (Google). DISCUSSION: Issues that military women encounter surrounding menstruation during deployment are framed according to components of human ecology and social ecology theories, creating a theoretical model for the study of military women's menstrual health. Theoretical substruction is then used to evaluate the proposed theoretical and operational systems for measuring military women's attitudes during deployment. The process of theoretical substruction validates the model and the theoretical integrity of the proposed research on women's attitudes towards suppression. CONCLUSION: A theory-based model for women's health under challenging environmental conditions will enhance the holistic consideration of women's health issues by care providers. The theoretical model clearly explicates the phenomenon of menstruation during deployment and the theoretical and operational systems are soundly linked in the proposed measurement model of military women's attitudes towards menstrual suppression.

Young women's attitudes toward continuous use of oral contraceptives: the effect of priming positive attitudes toward menstruation on women's willingness to suppress menstruation.

The present study investigated American women's attitudes toward menstrual suppression and the effect of priming attitudes toward menstruation on women's willingness to suppress menstruation. One hundred college women randomly were assigned to either a positive priming group or a negative priming group. The positive priming group first completed the menstrual joy questionnaire (MJQ) followed by a willingness to suppress menstruation (WSM) questionnaire, the beliefs and attitudes toward menstruation (BATM) questionnaire, the menstrual distress questionnaire (MDQ), and a demographic questionnaire. The negative priming group completed, in the following order: the MDQ, WSM, BATM, MJQ, and demographics. Priming affected women's reports of positive cycle-related changes on the MDQ, but not women's willingness to suppress menstruation. Higher scores on the MJQ, positive attitudes toward menstrual suppression, and previous oral contraceptive (OC) use were predictors of women's willingness to suppress menstruation. Women's primary source of information about menstrual suppression was "media," and their primary concern was "safety." Thus, researchers should continue to investigate the long-term effects of continuous OC use and to analyze information about menstrual suppression in the popular press.

Elements of the menstrual suppression debate.

In this article I review common arguments and frameworks used by participants in the debate about extended use of combined hormonal contraceptives (CHCs; usually oral contraceptive pills) for menstrual suppression. I examine the way in which menstruation is described and the scope of risks considered. I consider the role of the pharmaceutical industry, personal and clinical experience, and concerns about the contraceptive effectiveness of contraceptive formulations with lower doses. I also address public consequences of the debate, including the possibility of inciting a pill scare, and increasing product awareness and off-label practice.

The implications of objectification theory for women's health: menstrual suppression and "maternal request" cesarean delivery.

Menstrual suppression with oral contraceptives and cesarean delivery on maternal request (CDMR) are relatively new options for women and increasingly are available, particularly in developed countries, around the world. In this article, I explore these issues using objectification theory as a framework for deconstruction. I offer a provocative hypothesis: Women who objectify their bodies are not only interested in menstrual suppression, but also in surgicalized childbirth at their request. I argue that because patriarchal societies have aligned women's reproductive functions with nature, disinterest in menstruation and vaginal childbirth has become another way for women to separate themselves from their "earthly" nature and transform or maintain their bodies as idealized cultural symbols.

The causes of physiological suppression among female meerkats: a role for subordinate restraint due to the threat of infanticide?

In many animal societies, subordinates exhibit down-regulated reproductive endocrine axes relative to those of dominants, but whether this 'physiological suppression' arises from active interference by dominants or subordinate self-restraint is a matter of debate. Here we investigate the roles that these processes play in precipitating physiological suppression among subordinate female meerkats, Suricata suricatta. We show that, while subordinate females are known to suffer stress-related physiological suppression during periodic temporary evictions by the dominant female, their low estrogen levels while within their groups cannot be readily attributed to chronic stress, as their fecal glucocorticoid metabolite levels during this time are comparable to those of dominants. The low estrogen levels of subordinate females also cannot be explained simply by self-restraint due to factors that could reduce their payoff from maintaining their fertility regardless of the presence of the dominant female (young age, a lack of unrelated mates, poor body condition and limited breeding experience), as substantial rank-related differences in fecal total-estrogen metabolite levels remain when such factors are controlled. We suggest that this residual difference in estrogen levels may reflect a degree of subordinate restraint due in part to the dominant female's ability to kill their young. Accordingly, subordinate female estrogen levels vary in association with temporal variation in the likelihood of infanticide by the dominant. Attempts to identify the causes of physiological suppression should be cautious if rejecting any role for dominant interference in favor of subordinate restraint, as the dominant's capacity to interfere may often be the reason why subordinates exercise restraint.

Reproductive shame: self-objectification and young women's attitudes toward their reproductive functioning.

The purpose of this study was to measure and compare women's attitudes toward menstruation and breastfeeding and to determine whether self-objectification was associated with negative attitudes toward these events. We hypothesized that women who viewed menstruation as shameful would also report high levels of shame about breastfeeding and that women with greater self-objectification tendencies would have more negative or shameful attitudes toward both menstruation and breastfeeding. One hundred and seventy-six undergraduate women completed questionnaires measuring self-objectification, as well as attitudes toward menstruation and breastfeeding. As predicted, women who viewed menstruation as shameful also reported shameful attitudes toward breastfeeding. Women who reported higher levels of Body Shame and Self-Surveillance had significantly more shameful attitudes toward these reproductive functions than women with lower scores on these measures of self-objectification. Health care providers may be able to reduce women's feelings of shame about reproduction or minimize its negative impact on women's health behavior.

Ovariotomy for menstrual madness and premenstrual syndrome--19th century history and lessons for current practice.

Ovariotomy--the removal of normal ovaries, known as Battey's Operation--began in 1872 and became the fashionable treatment of menstrual madness, neurasthenia, nymphomania, masturbation and "all cases of insanity". This practice was supported by distinguished gynecologists and psychiatrists, becoming one of the great medical scandals of the 19th century. In modern times, if menstrual madness is considered to be premenstrual dysphoric disorder (PMDD), and ovariotomy, the surgical equivalent of ovulation suppression of GnRH analogues, it can be argued that the surgery would have been effective for this limited indication, although the side effects of long-term estrogen deficiency would have made the treatment unacceptable. Currently, the successful hormonal treatment of PMDD is one of suppression of ovulation and removal of the cyclical hormonal changes in the luteal phase, probably progesterone, which is the essential cause of PMDD. Such therapy would be by GnRH analogues, transdermal estradiol and, in a few cases, the surgical option of hysterectomy and bilateral salpingo-oophorectomy with adequate hormone replacement. A study of medical history can help us prevent the mistakes of over-enthusiasm but positive lessons can be learned.

Women's and providers' attitudes toward menstrual suppression with extended use of oral contraceptives.

The United States Food and Drug Administration approved a dedicated extended regimen of oral contraceptive (OC) pill in the fall of 2003. Few studies have explored how women or providers feel about menstrual suppression. This study describes women's and providers' attitudes toward menstrual suppression. A national sample of 1470 women and 512 providers responded to surveys asking about attitudes toward menstrual suppression. Seventy-eight percent of the women sample had never heard of menstrual suppression with OCs. Fifty-nine percent of women would be interested in not menstruating every month and one third would choose never to have a period. Only 7% of the providers thought it was physically necessary to have a period every month and 44% thought that menstrual suppression is a good idea. While 57% of providers said that their patients do not ask about extended use of OCs, 52% do prescribe them; patient request was the most common reason. Both samples thought that more research should be conducted and that the factors that would influence their decisions included long-term health effects, side effects, future fertility and cost. Results demonstrate that providers need to discuss this option with their patients.

The need to bleed: women's attitudes and beliefs about menstrual suppression.

PURPOSE: To describe how women feel about monthly menstruation in general and menstrual suppression in particular. DATA SOURCES: This descriptive, exploratory study used a convenience sample of 221 women who completed a self-administered questionnaire on attitudes toward monthly menstruation and menstrual suppression. Descriptive statistics and correlations were used to analyze the data. CONCLUSIONS: Women not using oral contraceptives (OCs) had more menstrual symptoms than women using OCs. Negative feelings about menstruation were correlated with interest in menstrual suppression. Over two thirds expressed interest in reducing menstrual pain and the amount of menstrual discharge, particularly if not taking OCs. Women who were not interested in changing their menstrual pattern said they would be anxious about not having a menstrual flow and said it would not be normal. IMPLICATIONS FOR PRACTICE: Advanced practice nurses play an important role in educating women about menstrual health. Clinicians can use this information to assess women's attitudes and beliefs about menstrual symptoms and to educate them about misconceptions. The FDA approved Seasonale in September 2003, the first dedicated OC created to reduce the number of menstrual cycles yearly. Women need to be educated about the pros and cons of suppression; some women will benefit from suppression, and others will consider it unnatural.

To bleed or not to bleed: young women's attitudes toward menstrual suppression.

The purpose of this study was to investigate women's knowledge about and attitudes toward the medical suppression of menstruation. One hundred and three female undergraduate students completed several questionnaires. Thirty-five percent of the participants were familiar with menstrual suppression, and 12% reported using birth control methods to suppress their menses; oral contraceptive users were more knowledgeable about menstrual suppression than other women. Women who regarded menstruation as bothersome and shameful were more supportive of suppression than women with more positive attitudes. Women who scored higher on measures of body consciousness were not more likely to support menstrual suppression or to report a desire for more information about menstrual suppression. Future investigations of women's attitudes toward menstrual suppression could inform reproductive health care and health education.