So... do you have to have a period?
While it’s certain that few women enjoy having periods (especially if they're painful or heavy periods) there’s a prevailing belief that putting up with them month after month is the natural thing to do. As well as being an indicator you’re not pregnant, they’re a signifier of health, right?
“Periods are a strong signal that your body is functioning as it should,” says Dr Ulrike Sauer, a consultant in sexual and reproductive health.
“Aside from pregnancy, the most common reasons women don’t get periods are that they’re under-eating or over-exercising. If a woman who [isn’t on] contraception doesn’t bleed, it’s a sign that the womb lining might have changed and that something more serious could be going on.” Katie Ann Hasson, assistant professor of sociology and gender studies at the University of Southern California, agrees that it’s a psychological reassurance and adds, “To some women, having a period is also an important part of their sense of femininity.”
“Our bodies evolved to be almost constantly pregnant or breastfeeding once we hit puberty,” says Sauer. “Centuries ago, women would rarely bleed, and most of our female ancestors died before the menopause.” Indeed, research has found that today, modern Western women will have four times as many periods throughout the course of their lives.
FYI your period on birth control pills isn't actually a period
The ‘period’ you have when you take a break from the oral contraceptive pill every three weeks isn’t 'natural'.
“A withdrawal bleed occurs when the lining of the uterus sheds in response to the pill’s artificial hormones being taken away, while a period is the lining of the uterus responding to the changes in natural hormone levels that occur when a woman is not pregnant,” says gynaecologist Dr Kate Guthrie. “If you run packs together, eventually you’ll get ‘breakthrough bleeding’, where the lining builds up to a point where it needs to shed. This can be after a couple of weeks or up to several months depending on the person, and can become less frequent as your body adapts.”
I’ve seen my body adapt from lasting just two consecutive pill packs before spotting, to having nothing before six months. Bateson points out, however, that if you’re concerned about unusual bleeding, you should visit your doctor to see if there’s anything else going on.
There’s also a misconception that regular bleeds on the contraceptive pill confirm you’re not expecting.
“You can’t rely on that – in the same way you can’t even if you’re not on the pill, as some women have periods when they’re pregnant,” says Guthrie. “The absence of your withdrawal bleed could be either that you’re pregnant, or that there isn’t enough of a reduction in hormones to trigger a breakthrough bleed.”
What's the point of the placebo pills then?
If a monthly bleed while on hormonal birth control is neither real nor reassuring, well, what’s the point?
“It’s all set in history and tradition,” says Dr Jane Dickson, a consultant in sexual and reproductive healthcare. “The creators of the pill designed it to be taken with a seven-day monthly break, even though they knew it wasn’t medically necessary. By mimicking a monthly period, they believed it might be better accepted by the church and other religious institutions.”
Gynaecologist – and devout Catholic – John Rock, along with biologist Gregory Goodwin Pincus, tried to maintain as much menstrual ‘normality’ in their invention as possible to ensure it would secure US Food and Drug Administration (FDA) approval, which it did – initially in 1957 as pain relief, then in 1960 for contraceptive use.
Today, when feminism has never felt stronger, many women remain beholden to a monthly bleed. But what if you knew the wage and promotion gap would be 15 per cent smaller, according to Italian researchers, if your menstrual symptoms and period-related absenteeism weren’t factors? In a YouGov survey in the UK, 52 per cent of women said periods affected their ability to work, and one-third of those said they’d had to take a sick day. In the Western world, menstrual symptoms are one of the main reasons girls miss school.
“Suppressing your period means you can skip the mood swings, headaches, bloating, PMS and disruption to your life – many women perform less well during exams and in sports – and for those with endometriosis it can make life far more manageable,” says Guthrie. I notice my productivity dips at work, thanks to disrupted sleep and the fact that I spend chunks of the day keeled over in a toilet cubicle.
Is it safe to skip your period?
But now, 57 years after the pill changed everything for women, there’s still confusion surrounding its long-term safety. “Hormonal contraception has pros and cons,” says Sauer. A 2014 study published in the journal Cancer Research discovered that recent use of the combined oral pill increased the risk of developing breast cancer by 50 per cent, while a 2007 study published in The Lancet found that being on it for five years or more doubled your risk of cervical cancer. Should we be worried?
“You are slightly more likely to develop breast cancer, but only when you’re on the pill, not once you stop – there’s no lingering effect 10 years after or into your 50s and 60s,” says John Guillebaud, emeritus professor of family planning and reproductive health at University College London. “Most pill-takers are under 35, the age when breast cancer is very rare anyway, so a 50 per cent increase on top of extremely small numbers leaves total cases in this scenario still very low.”
The hormone doses in the present-day pill are much smaller than they used to be. “When it was first invented it contained 100mg of oestrogen, which is what past research on increased breast cancer risk has been based on,” explains Guthrie. “Now it only contains 20mg, so future studies may find there’s even less of a link or none at all.” This lower dose of oestrogen also means blood clot risk has been lowered even further.
There’s also evidence that the pill can in fact be protective against cancer.
“A woman taking it is less likely to get cancer than a woman whose partner uses condoms because it reduces risk of ovarian, endometrial, large bowel and rectal cancer while in use and for 10 years after,” says Guillebaud. A 2008 study published in The Lancet estimated that the pill may have stopped around 100,000 women dying from ovarian cancer, as it suppresses activity and disruption to the surface of the ovaries – this number outweighs the increased risk for other types of cancer linked to taking the contraceptive pill. Dickson agrees, pointing out that other factors can play a much more significant role in cancer risk. “Being overweight, smoking and family history pose a much greater risk to your health than taking the pill,” she says.
Then there were last year’s headlines claiming that the pill has psychological as well as physical effects, upping depression by 23 per cent. “In a small minority it can lead to depression or severe mood changes,” according to Guillebaud. “But depression is very common, and what the study found was that out of every 123 pill-takers with depression, only 23 could truly blame their contraceptive. The other 100 would have expected to be diagnosed anyway.” Interesting.
How does the pill affect your fertility?
But what does switching off your ovaries mean for fertility? While at 24 I’m not looking to have children right away, it’s a concern that does cross my mind.
“It won’t make you infertile, but you can’t be sure how long it’ll take for your natural cycle to return,” says Dr Shazia Malik, consultant obstetrician and gynaecologist. She suggests coming off the pill or LARCs and using condoms six months before you start trying for a baby, to allow ovulation to get back to normal.
But not every woman will need that long. “With the exception of the injection, which can take up to a year to wear off, your cycle should return to normal almost straight away when you stop taking contraception,” says Guillebaud. “In fact, it could even make you more fertile. A 2002 study found that ex-pill-takers were more likely to fall pregnant in the six months after coming off the pill than those who’ve never used it.”
And if you don’t want to get pregnant just yet, running your pill packs together can actually make it more effective as a contraceptive. “All the time you take the pill, your ovaries are asleep, but in the seven days you stop taking it, your ovaries start to wake up again and begin ovulating,” explains Dickson. Taking it every day keeps your ovaries on snooze for weeks, if not months. You’re also less likely to forget to restart a pill pack and fall pregnant. Bateson agrees, but points out it’s still OK to take the break if you want to. “Some women prefer to have that bleeding, they might find it reassuring – and that’s their choice.”
She adds that having a pill with a reduced-hormone break can be another option. “With the traditional seven-day hormone break, if women miss the first tablets in the first week, it puts them at risk of pregnancy. So it makes sense to reduce or get rid of that break in this case. Combined pills with shorter breaks of four or [fewer] days may also result in no withdrawal bleed because the lining of the uterus is thin, which can be beneficial.”
The future of periods
Part of the problem? That society is anti-bleeding.
“Our cultural attitude is that menstruation is dirty and shameful, and that we should avoid it at all costs. We don’t talk openly in society about the nitty-gritty of our bleeds, and we don’t have any reference points for comparison,” says Hasson. “Taking hormones to get away from it means that we often don’t know our own healthy baseline.” Contraception and painful bleeds are reasons enough to stop periods, but we shouldn’t be stopping them for the sake of it, points out Sauer.
That said, contraception is starting to reflect a period-less lifestyle. “As doctors, we’re being more proactive when women start on the pill about informing them that it’s something they can do,” says Bateson. “We’ve also got a new pill on the market that runs three months together, up to 91 pills. It has seven days of lower-dose oestrogen in that break instead. Having a pack that runs the pills together for you may make it easier for some women.” If you’d prefer to stick with your current pill and run it together, always check with your doctor to make sure you’re able to do this with your particular prescription and learn how best to manage it.
If being on an equal footing with men is the ideal, ditching our periods might just allow us to catch up in the workplace – and to be free to spend our cash on items other than painkillers and sanitary wear.
“Women should be able to control their own lives – their bleeds should fit in with them, not the other way around,” adds Guthrie. It’s not black and white – but as I continue not dreading every fourth working week and remain anxiety-free about diving into a pool this summer, for me, it kind of is.