Managing unscheduled bleeding in non-pregnant premenopausal women
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3251 (Published 04 June 2013) Cite this as: BMJ 2013;346:f3251All rapid responses
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Dear Professor Lumsden and Ailsa Gebbie,
Hormonal contraception has been a health disaster. There have been no fundamental improvements for women’s health in 50 years. In the UK average family size was barely at replacement level in the 1930s which was long before the aggressive promotion of hormonal contraception to teenagers.
Manipulations to types and doses of progestogens and oestrogens have merely switched which side effects are most likely.1 Doses of oestrogens have fallen or disappeared in an attempt to prevent breakthrough bleeding and venous thrombosis. However, increases in cancers, depression, accidents and violence, infections like HPV and HIV, immune diseases like ME, MS, LE, APS and disastrous effects on children including increases in autism and sexual development have been ignored.2-5
I was a pathology consultant in Yugoslavia in 1969 where several progestogen only contraceptives were first tested.6 It is not possible to prevent ovulation and unintended pregnancies unless more powerful progestogens are used. Increasing doses or power of progestogens lowers the pregnancy rate but also increases the risk of serious side effects such as depression and cancer.
If progestogen doses are increased with a constant dose of oestrogen
1 Peak levels of breakthrough bleeding and pregnancies are followed by
2 Peak levels of venous dilation and thrombosis followed by
3 Peak levels of increased arteriolar development, migraine, myocardial infarctions or haemorrhagic strokes and increases in aggression and violence followed by
4 Peak levels of depressive mood changes including increases in mortality from suicides and accidents and violence
“Newer” hormonal contraceptives attempt to turn BTB into amenorrhoea and lower the risk of venous thrombosis but arterial changes, depression and all the other disastrous effects of progestogenic steroids are ignored. Antidepressant use has increased most in 16 to 19 year olds – the age group most targeted by so called “newer” long-acting progestogen contraceptives. Autism (ASD) in children has become a tragic epidemic.
Progesterone up and down regulates thousands of genes and increase toxic DNA adducts. It is more than time to face all the dangers of hormone use.
www.harmfromhormones.co.uk
Yours sincerely
Ellen CG Grant
1 Changing oral contraceptives. BMJ 1969;4:789-91
2 Grant ECG. Re: A young women presenting with severe headache. BMJ (Published 30 May 2013)
3 Grant ECG. Re: Newer non-oral hormonal contraception. (Published 22 March 2013)
4 Grant ECG. Re: Study finds no association between autism and vaccination (Published 19 April 2013)
5 Grant ECG. Re: Parental depression, maternal antidepressant use during pregnancy, and risk of autism spectrum disorders: population based case-control study (Published 29 April 2013)
6 Mears E, Vessey MP, Andolsek L, Oven A. Preliminary evaluation of four oral contraceptives containing only progestogens. BMJ 1969;2:730-4
Competing interests: No competing interests
Dear Dr Grant
Thank you very much for responding to our article. However, it is well established that hormonal contraception has known benefits and risks which can be communicated to women who are considering using these methods in order that they make an informed choice.
Monthly menstruation as such is not 'natural', as nature intended women to be largely amenorrorhoeic due to repeated pregnancies and lactation. In addition to acting as highly effective birth control, hormonal contraception offers women a great advantage in being able to control menstruation which can be heavy, painful or irregular; issues which strongly affect quality of life. 'The pill' has been with us for over 50 years and the evidence base is strongly in favour of efficacy and safety for the vast majority of women whatever the regimen, dose or combination of oestrogen and progestogen.
We are aware of Dr Grant’s publication of 1967 but would like to point out that since this time the dose of ethinyl oestradiol in the combined oral contraceptive pill has decreased from 50 to 30 or even 20 micrograms. Although we agree that, as we mention in our article, there is an increase in break though bleeding, it is associated with a decreased incidence of deep vein thrombosis and other major side effects. In addition, progestogens are used for effective contraception worldwide and limiting their use would have a major impact on the health of many developing nations. The authors thus feel that minimising the break through bleeding is very important and anticipate with interest the development of new and more effective methods of improving the acceptability of hormonal contraception.
Yours Sincerely
Mary Ann Lumsden
Ailsa Gebbie
Competing interests: No competing interests
Evolution organised monthly menstrual bleeds which helpfully flushes out the uterus. Now it seems bleeding should be “scheduled” by “sisters doing it for themselves”, preferably by avoiding menstruation .1 This profits the “Big Pharma” which manufactures hormonal contraceptives and later frequently needed fertility drugs.
It is simplistic to believe that continuous exposure to progesterogens prevents the inevitable biochemical and vascular effects which harm women.
It was a myth that breakthrough bleeding (BTB) with combined oral contraceptives decreased after the first few cycles because women just changed to higher dose combinations. Now it seems that early cycle BTB caused by high doses of long-acting progestogens is usually replaced by amenorrhoea by 12 months.1
My 1967 paper, “Hormone balance of oral contraceptives”, matched incidences of BTB with the duration of endometrial glandular subnuclear vacuoles.1 Most BTB was caused by lower dose combinations which were neither predominantly progestogenic nor oestrogenic. Increasing the doses of either hormone changed the effects on endometrial venous sinusoids and arterioles and glandular enzymes activities. These effects matched changes in incidence of venous complaints including venous thrombosis, migraine, heart attacks and strokes and depression. 2-5
Thousands of genes are up or down regulated by progesterone. Suppressing monthly hormone withdrawal warning symptoms like headaches and migraine does not prevent weight gain, strokes, venous or arterial thrombosis, or depression and loss of libido, or immunosuppression with increases autoimmune diseases and a wide range of infections including HPV and HIV, or the increased risk of breast and cervical cancers.6 -13
Perfect use of fertility awareness contraception methods match progesterone implants methods in efficacy but are not much use for drunken teenagers. A cultural change is needed to protect young women from sexual and steroid hormone abuse. World overpopulation is the biggest problem – hiding from reality is unacceptable.
1 Lumsden MA. Managing unscheduled bleeding in non-pregnant premenopausal women. BMJ;346:f3251.
2 Grant ECG. Hormone balance of oral contraceptives. J Obstet Gynaecol Brit Comm 1967;74:908-18.
3 Grant ECG. Relation between headaches from oral contraceptives and development of endometrial arterioles. BMJ 1968;3:402-5.
4 Grant ECG, Pryce Davies J. Effect of oral contraceptives on depressive mood changes and on endometrial monoamine oxidase and phosphatases. BMJ 1968;3:777-80.
5 Grant ECG. Venous effects of oral contraceptives. BMJ 1969;2:73-7.
6 Mantha S. Krap R, Raghavan, Terrin N et al. Assessing the risk of venous thromboembolic events in women taking progestin-only contraception: a meta-analysis. BMJ;2012; 345:e4944.
7 Wiréhn AB, et al. Use of hormonal contraceptives in relation to antidepressant therapy: A nationwide population-based study. Eur J Contracept Reprod Health Care 2010;15:41-7.
8 Brabin L. Interactions of the female hormonal environment, susceptibility to viral infections, and disease progression. AIDS Patient Care STDS 2002;16:211-21.
9 Huijbregts RP, Helton ES, Michel KG, Sabbaj S, Richter HE, Goepfert PA, Hel Z. Hormonal Contraception and HIV-1 Infection: Medroxyprogesterone acetate suppresses innate and adaptive immune mechanisms. Endocrinology 2013;154:282-95.
10 Heffron R, Donnell D, Rees H, et al; Partners in Prevention HSV/HIV Transmission Study Team. Use of hormonal contraceptives and risk of HIV-1 transmission: a prospective cohort study. The Lancet Infectious Diseases, 2012;12:19 – 26.
11 Gollub E, Stein Z. Living with uncertainty: acting in the best interests of women. AIDS Res Treat. 2012;2012:524936.
12 Johnson RH, Chein FL, Bleyer A. Incidence of breast cancer with distant involvement among women in the United States, 1976 to 2009. JAMA 2013;309(8):800-805.
13 Foley G, Alston R, Geraci M, Brabin L, Kitchener H, Birch J. Increasing rates of cervical cancer in young women in England: an analysis of national data 1982-2006. Br J Cancer 2011;105:177-84.
Competing interests: No competing interests
Re: Managing unscheduled bleeding in non-pregnant premenopausal women
The review by Lumsden et al[1] on managing unscheduled vaginal bleeding in non-pregnant premenopausal women is very helpful. It addresses salient features in the assessment and treatment of women with premenopausal bleeding and will be useful for all categories of health care workers including primary care physicians. However there are a few areas which need further consideration.
The authors state that antibiotics are no longer thought to decrease the effectiveness of combined oral contraceptive pills (COCP) or to cause breakthrough bleeding. There is however conflicting evidence that shows that non liver enzyme inducing antibiotics such as ampicillin or doxycycillin used in the short term (less than three weeks) can cause a reduction in the efficacy of COCP by altering the gut flora. Women in the reproductive group should be advised to use additional contraceptive protection whilst taking the antibiotic and for 7 days after the antibiotic is stopped. In the case of a woman on long-term antibiotics the gut flora will have adapted to treatment[2].
The authors have clearly elaborated the salient features to be assessed in a women presenting with unscheduled vaginal bleeding including the last menstrual period, likelihood of a pregnancy, sexual history, possibility of sexually transmitted infections and the smear history. It is worth noting the family origin and the immigrant status as cervical cancers were found to be significantly higher in women of some ethnic groups in UK such as asylum seekers[3] as they are unlikely to have been covered by a routine cervical screening program.
The problem arises when a young lady who is yet to be protected by a cervical screening program presents with post coital bleeding with significant cervical erosion induced by the long term use of COCP. She does not warrant a smear or a colposcopic assessment because of her age. She needs appropriate swabs taking and a course of antibiotics to clear the possibility of cervicitis and cryotherapy for the ectropion. However the lady is likely to be very anxious because of her symptoms and the clinician should act logically to say that the possibility of her having a cervical cancer is very remote. The case of a young celebrity who died of advanced cervical cancer at the age of 26 [4] before being included in a cervical screening programe could be uppermost in the mind of the woman and considered by her clinician. This factor could create some emotional arguments between the woman and her clinician and it is unlikely to lead to reasonable answers for both of them.
The authors have clearly stated that endometrial cancer is unlikely in a women aged less than 40 years of age. However nearly 10% of endometrial cancer cases occur at or before the age of 45 [5]. The authors have failed to provide a cut off value for the endometrial thickness assessed by a Trans vaginal ultrasound scan in premenopausal women, so that the clinician could proceed with endometrial biopsy logically. This is important before labeling these women as having irregular bleeding due to hormonal factors and/or the peri menopause. The burden on the pathologist due to a large number of endometrial biopsies and the burden on the outpatient hysteroscopist due to failed pipelle biopsy should also be considered and a very careful clinical judgment has to be made before performing an outpatient endometrial sampling.
The review by Lumsden et al does however provide much valuable guidance on the management of unscheduled vaginal bleeding in non-pregnant premenopausal women.
References
1 Lumsden MA, Gebbie A, Holland C. Managing unscheduled bleeding in non-pregnant premenopausal women. BMJ. 2013 Jun 4;346:f3251. doi: 10.1136/bmj.f3251.
2 First Prescription of Combined Oral Contraception; Faculty of Family Planning & Reproductive Health Care Clinical Guidance, RCOG, London, January 2007
3 Grulich AE, Swerdlow AJ, Head J, Marmot MG. Cancer mortality in African and Caribbean migrants to England and Wales. Br J Cancer. 1992 Nov;66(5):905-11.
4 Tran BN, Connell PP, Waggoner S, Rotmensch J, Mundt AJ. Characteristics and outcome of endometrial carcinoma patients age 45 years and younger. Am J Clin Oncol. 2000 Oct;23(5):476-80.
5 Woman, 26, who was 'too young' to be given a smear test dies from cervical cancer.www.dailymail.co.uk/health/article, accessed online 14/06/2013
Competing interests: No competing interests