When hormonal contraceptive pills were first introduced to the public in 1960, they were initially packaged in a bottle, like other drugs. A few years later, Ortho-Novum was the first to create the circular dispenser that so many of us are familiar with: 21 days on, seven days off. This dispenser gave a sense of temporality to periods, as they occurred in a regular fashion every few weeks. The “off” week was designed by pharmaceutical companies to create a menstrual period because they felt patients, pharmaceutical executives, and religious officials would find hormonal contraception more acceptable this way. Experiencing somewhat regular menstruation is also a major way people know they are not pregnant. Though menstruating people have for decades been hacking their own contraception to avoid periods around certain life events, such as vacations or athletic competitions, it wasn’t until the turn of the 21st century that pharmaceutical companies began to sell hormonal contraceptive pills that explicitly skipped placebo weeks in order to decrease the frequency of menstruation.
Chemical menstrual suppression, like hormonal contraception, represents the next step of what the historian Sharra Vostral calls “technologies of passing.” Menstrual management products were the first “technology of passing,” in that they allow a menstruating person to move through the world as though they are not menstruating. Tampons make it possible to wear bathing suits and go swimming; all forms of menstrual management products decrease the risk of bloodying clothes, furniture, and bedsheets. Menstrual suppression technologies are a logical next step in pharmaceutical executives’ quest to gain customers, but it also seems like a good idea to those looking to survive in hustle and productivity cultures that leave less and less room for experiences like menstruation, not to mention those for whom eliminating menstruation would help affirm their gender. While the acceptance of menstrual suppression technologies was initially quite low, acceptability has increased dramatically over the past several decades, in no small part due to the advertising of pharmaceutical companies and advocacy by vocal physicians. And the increased accessibility to menstrual suppression technologies is part of what we need in our period (or for some, period-free) future.
Menstrual Suppressions and Manipulations
Most menstrual suppression technologies are varying types of hormonal contraceptives, which are not nearly as well tolerated by menstruating bodies as most of us believe. Across multiple studies, about half of people on hormonal contraceptive methods discontinue them. Even those who do stick with hormonal contraception often experience unwelcome side effects, which they endure as an acceptable cost in order to avoid getting pregnant or menstruating. Many groups are invested in menstruating people staying on hormonal contraceptives, including pharmaceutical companies, those who fear teen pregnancy, and those interested in global population control. But it’s possible menstruating people are not always as invested themselves, at least in the management and suppression technologies as they currently exist. According to a recent Cochrane review—effectively, the gold standard in health care if you are trying to assess quality of evidence—direct, in-person counseling, the most common intervention for improving the continuation of hormonal contraceptives, does not increase the rate at which people choose to stay on hormonal contraception. In the papers they sampled, anywhere from a quarter to half of those on a given hormonal contraceptive regimen discontinued their use over the study period. One recent study comparing self-reported continuation rates to actual pharmacy claims suggests people may overestimate how continuously they use hormonal contraception. People skip a month here or there because they forget to get their prescription in time, because the prescription is expensive, because they aren’t having potentially conceptive sex, or because they don’t love how the hormonal contraception makes them feel and need a break from it.
Hormonal contraception, especially shorter-acting forms like pills, rings, patches, and injections, are a hassle, and users often report side effects, such as loss of libido, weight gain, vomiting, dizziness, and depression, as well as amenorrhea, irregular bleeding, and heavy bleeding. Two studies have reported some improvement in continuation among users with adverse side effects who received counseling, but the certainty of the finding was weak. Note that the goal of these studies was to figure out how people suffering serious effects could continue taking hormonal contraception. The fear of pregnancy—particularly the fear of the wrong person getting pregnant (for example, a teenager or a brown or Black person)—motivates the continued use of hormonal contraceptives that cause harm to about half of the people who try them.
Significant side effects and high rates of discontinuation also plague the levonorgestrel-containing intrauterine device, or hormonal IUD. One study that examined the experiences of 161 women who had the hormonal IUD inserted at one hospital in the United Kingdom found that almost half of them had their IUD removed due to side effects, including “bloating, headaches, weight gain, depression, breast tenderness, excessive hair growth, greasy skin, acne, and sexual disinterest.” This finding is particularly striking since these women were great candidates for the hormonal IUD: They had had a gynecological exam before having it inserted and, in most cases, also had hysteroscopic assessment of their uterine cavity to make sure they didn’t have fibroids or other lesions that could complicate their experience.
In a study interviewing physicians who administer hormonal contraception, respondents were less than understanding when patients requested early removal of the IUD. Physicians in this sample were often frustrated when patients were dissatisfied with their IUDs for any reason. Intent on getting as many people as possible to use them, a physician from the study confessed: “I don’t try to influence women’s decisions, but I do try. Like I don’t want me to be the person making the decision, but I do want to guide them to make a good decision for them. But I usually say it’s my favorite method. … And I usually say that it’s our most effective method, and it’s very easy to put in.” When patients asked to have their IUD removed, physicians often discouraged them by requesting that they keep it in for a few more months to see if symptoms change. While many physicians emphasized the importance of patient decision-making, others only grudgingly ceded to patient autonomy. Others expressed disappointment or disagreement with their patients. These coercive stances run counter to the broader goals of reproductive justice.