No. 313-Menstrual Suppression in Special Circumstances



      To provide a Canadian consensus document for health care providers with recommendations for menstrual suppression in patients with physical and/or cognitive challenges or those who are undergoing cancer treatment in whom menstruation may have a deleterious effect on their health.


      This document reviews the options available for menstrual suppression, its specific indications, contraindications, and side effects, both immediate and long-term, and the investigations and monitoring necessary throughout suppression.


      Clinicians will be better informed about the options and indications for menstrual suppression in patients with cognitive and/or physical disabilities and patients undergoing chemotherapy, radiation, or other treatments for cancer.


      Published literature was retrieved through searches of Medline, EMBASE, OVID, and the Cochrane Library using appropriate controlled vocabulary and key words (heavy menstrual bleeding, menstrual suppression, chemotherapy/radiation, cognitive disability, physical disability, learning disability). Results were restricted to systematic reviews, randomized controlled trials, observation studies, and pilot studies. There were no language or date restrictions. Searches were updated on a regular basis and new material was incorporated into the guideline until September 2013. Grey (unpublished) literature was identified through searching websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.


      The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

      Benefits, harms, and costs

      There is a need for specific guidelines on menstrual suppression in at-risk populations for health care providers.


      • 1
        Menstrual suppression and therapeutic amenorrhea should be considered safe and viable options for women who need or want to have fewer or no menses (II-2A).
      • 2
        Menstrual suppression should not be initiated in young women with developmental disabilities until after the onset of menses (II-2B).
      • 3
        Combined hormonal or progesterone-only products can be used in an extended or continuous manner to obtain menstrual suppression (I-A).
      • 4
        Gynaecologic consultation should be considered prior to the initiation of treatment in all premenopausal women at risk for abnormal uterine bleeding from chemotherapy (II-1A).
      • 5
        Leuprolide acetate or combined hormonal contraception should be considered highly effective in preventing abnormal uterine bleeding when initiated prior to cancer treatment in premenopausal women at risk for thrombocytopenia (II-2A).

      Key Words


      AUB (abnormal uterine bleeding), BMD (bone mineral density), CHC (combined hormonal contraception), DEXA (dual X-ray absorptiometry), DMPA (depot medroxyprogesterone acetate), GnRH (gonadotropin releasing hormone), IM (intramuscular), IUD (intrauterine device), IV (intravenous), LA (leuprolide acetate), LNG-IUS (levonorgestrel intrauterine system), OCP (oral contraceptive pill), POP (progestin-only pill)
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        • American College of Obstetricians and Gynecologists Committee on Adolescent Health Care
        ACOG Committee Opinion No. 448: Menstrual manipulation for adolescents with disabilities.
        Obstet Gynecol. 2009; 114: 1428-1431
        • Guilbert E
        • Boroditsky R
        • Black A
        • et al.
        Society of Obstetricians and Gynaecologists of Canada. Canadian consensus guideline on continuous and extended hormonal contraception. SOGC Clinical Practice Guidelines, No. 195, July 2007.
        J Obstet Gynaecol Can. 2007; 29: S1-S32
        • Demers C
        • Derzko C
        • David M
        • et al.
        Society of Obstetricians and Gynecologists of Canada. Gynaecological and obstetric management of women with inherited bleeding disorders. SOGC Clinical Practice Guidelines, No. 163, July 2005.
        J Obstet Gynaecol Can. 2005; 27: 707-732
        • Dizon C
        • Allen L
        • Ornstein M
        Menstrual and contraceptive issues among young women with developmental delay: a retrospective review of cases at the Hospital for Sick Children, Toronto.
        J Pediatr Adolesc Gynecol. 2005; 18: 157-162
        • Zacharin M
        • Savasi I
        • Grover S
        The impact of menstruation in adolescents with disabilities related to cerebal palsy.
        Arch Dis Child. 2009; 95: 526-530
        • Burke L
        • Kalpakjian C
        • Smith Y
        • et al.
        Gynecologic issues of adolescents with Down syndrome, autism, and cerebral palsy.
        J Pediatr Adolesc Gynecol. 2010; 23: 11-15
        • Albanese A
        • Hopper NW
        Suppression of menstruation in adolescents with severe learning disabilities.
        Arch Dis Child. 2007; 92: 629-632
        • Kirkham YA
        • Allen L
        • Kives S
        • et al.
        Trends in menstrual concerns and suppression in adolescents with developmental disabilities.
        J Adolesc Health. 2013; 53: 407-412
        • Grover S
        Menstrual and contraceptive management in women with an intellectual disability.
        Med J Aust. 2002; 176: 108-110
        • Paransky OI
        • Zurawin RK
        Management of menstrual problems and contraception in adolescents with mental retardation: a medical, legal, and ethical review with new suggested guidelines.
        J Pediatr Adolesc Gynecol. 2003; 16: 223-235
        • Stewart FH
        • Kaunitz AM
        • La Guardia KD
        • et al.
        Extended use of transdermal norelgestromin/EE: a randomized trial.
        Obstet Gynecol. 2005; 105: 1389-1396
        • Miller L
        • Verhoeven CH
        • Hout J
        Extended regimens of the contraceptive vaginal ring: a randomized trial.
        Obstet Gynecol. 2005; 106: 473-482
        • Hamerlynck JV
        • Vollebregt JA
        • Doornebos CM
        • et al.
        Postponement of withdrawal bleeding in women using low-dose combined oral contraceptives.
        Contraception. 1987; 35: 199-205
        • Edelman A
        • Gallo MF
        • Nichols MD
        • et al.
        Continuous versus cyclic use of combined oral contraceptives for contraception: systematic Cochrane review of randomized controlled trials.
        Hum Reprod. 2006; 21: 573-578
        • Teichmann A
        • Apter D
        • Emerich J
        • et al.
        Continuous, daily levonorgestrel/ethinyl estradiol vs. 21-day, cyclic levonorgestrel/ethinyl estradiol: efficacy, safety and bleeding in a randomized, open-label trial.
        Contraception. 2009; 80: 504-511
        • Gold MA
        • Duffy K
        Extended cycling or continuous use of hormonal contraceptives for female adolescents.
        Curr Opin Obstet Gynecol. 2009; 21: 407-411
        • Gaffield ME
        • Culwell KR
        • Lee CR
        The use of hormonal contraception among women taking anticonvulsant therapy.
        Contraception. 2011; 83: 16-29
        • Savasi I
        • Spitzer RF
        • Allen LM
        • et al.
        Menstrual suppression for adolescents with developmental disabilities.
        J Pediatr Adolesc Gynecol. 2009; 22: 143-149
        • Cromer BA
        • Stager M
        • Bonny A
        • et al.
        Depot medroxyprogesterone acetate, oral contraceptives and bone mineral density in a cohort of adolescent girls.
        J Adolesc Health. 2004; 35: 434-441
        • Rubinstein ML
        • Halpern-Felsher BL
        • Jr Irwin CE
        An evaluation of the use of the transdermal contraceptive patch in adolescents.
        J Adolesc Health. 2004; 34: 395-401
        • Harel Z
        • Riggs S
        • Vaz R
        • et al.
        Adolescents’ experience with the combined estrogen and progestin transdermal contraceptive method Ortho Evra.
        J Pediatr Adolesc Gynecol. 2005; 18: 85-90
        • Zieman M
        • Guillebaud J
        • Weisberg E
        • et al.
        Contraceptive efficacy and cycle control with the Ortho Evra/Evra transdermal system: the analysis of pooled data.
        Fertil Steril. 2002; 77: S13-S18
        • Sulak PJ
        • Smith V
        • Coffee A
        • et al.
        Frequency and management of breakthrough bleeding with continuous use of the transvaginal contraceptive ring: a randomized controlled trial.
        Obstet Gynecol. 2008; 112: 563-571
        • Black A
        • Francoeur D
        • Rowe T
        Canadian contraception consensus. SOGC Clinical Practice Guidelines, No. 143: Part 2 of 3.
        J Obstet Gynaecol Can. 2004; 26: 219-254
        • Quint EH
        Menstrual issues in adolescents with physical and developmental disabilities.
        Ann N Y Acad Sci. 2008; 1135: 230-236
        • Crawford P
        Interactions between antiepileptic drugs and hormonal contraception.
        CNS Drugs. 2002; 16: 263-272
        • Black A
        Ad Hoc DMPA Committee of the Society of Obstetricians and Gynaecologists of Canada. Canadian Contraception Consensus— Update on Depot Medroxyprogesterone Acetate (DMPA). SOGC Clinical Practice Guidelines, No. 174, April 2006.
        J Obstet Gynaecol Can. 2006; 28: 305-313
        • Zupanc ML
        Antiepileptic drugs and hormonal contraceptives in adolescent women with epilepsy.
        Neurol. 2006; 66: S37-S45
        • de Abood M
        • de Castillo Z
        • Guerrero F
        • et al.
        Effect of Depo-Provera or Microgynon on the painful crises of sickle cell anemia patients.
        Contraception. 1997; 56: 313-316
        • Scholes D
        • LaCroix AZ
        • Ichikawa LE
        • et al.
        Change in bone mineral density among adolescent women using and discontinuing depot medroxyprogesterone acetate contraception.
        Arch Pediatr Adolesc Med. 2005; 159: 139-144
        • Kaunitz AM
        • Arias R
        • McClung M
        Bone density recovery after depot medroxyprogesterone acetate injectable contraception.
        Contraception. 2007; 77: 67-76
        • Harel Z
        • Johnson CC
        • Gold MA
        • et al.
        Recovery of bone mineral density in adolescents following the use of depot medroxyprogesterone acetate contraceptive injections.
        Contraception. 2010; 81: 281-291
        • Isley MM
        • Kaunitz AM
        Update on hormonal contraception and bone density.
        Rev Endocr Metab Disord. 2011; 12: 93-106
        • de Oliveria MRM
        • da Silva CC
        • Kurokawa CS
        • et al.
        Bone mineral density in healthy female adolescents according to age, bone age and pubertal breast stage.
        Open Orthop J. 2011; 5: 324-330
        • Pitts SA
        • Feldman HA
        • Dorale A
        • et al.
        Bone mineral density, fracture, and vitamin D in adolescents and young women using depot medroxyprogesterone acetate.
        J Pediatr Adolesc Gynecol. 2012; 25 (Epub 2011 Nov 12): 23-26
        • Bonny AE
        • Britto MT
        • Huang B
        • et al.
        Weight gain, adiposity, and eating behaviors among adolescent females on depot medroxyprogesterone acetate (DMPA).
        J Pediatr Adolesc Gynecol. 2004; 17: 109-115
        • Jensen JT
        Contraceptive and therapeutic effects of the levonorgestrel intrauterine system: an overview.
        Obstet Gynecol Surv. 2005; 60: 604-612
        • Andersson JK
        • Rybo G
        Levonorgestrel-releasing intrauterine device in the treatment of menorrhagia.
        Br J Obstet Gynaecol. 1990; 97: 690-694
        • Hidalgo M
        • Bahamondes L
        • Perrotti M
        • et al.
        Bleeding patterns and clinical performance of the levonorgestrel- releasing intrauterine system (Mirena) up to two years.
        Contraception. 2002; 65: 129-132
        • Kaunitz AM
        • Bissonnette F
        • Monteiro I
        • et al.
        Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial.
        Obstet Gynecol. 2010; 116: 625-632
        • Paterson H
        • Ashton J
        • Harrison-Woolrych M
        A nationwide cohort study of the use of the levonorgestrel intrauterine device in New Zealand adolescents.
        Contraception. 2009; 79: 433-438
        • Savasi I
        • Moore P
        • Jayasinghe Y
        • et al.
        The use of Mirena IUS in adolescents: a review of the RCH experience.
        J Pediatr Adolesc Gynecol. 2010; 23: e83
        • Toma A
        • Jamieson MA
        Revisiting the intrauterine contraceptive device in adolescents.
        J Pediatr Adolesc Gynecol. 2006; 19: 291-296
        • Pillai M
        • O'Brien K
        • Hill E
        The levonorgestrel IUS (Mirena) for the treatment of menstrual problems in adolescents with medical disorders or physical or learning disabilities.
        BJOG. 2010; 117: 216-221
        • Hillard PJ
        Menstrual suppression with the levonorgestrel intrauterine system in girls with developmental delay.
        J Pediatr Adolesc Gynecol. 2012; 25: 308-313
        • Canadian Cancer Society's Steering Committee on Cancer Statistics
        Canadian Cancer Statistics 2011.
        Canadian Cancer Society, Toronto ON2011
        • Meirow D
        • Rabinovici J
        • Katz D
        • et al.
        Prevention of severe menorrhagia in oncology patients with treatment- induced thrombocytopenia by luteinizing hormone-releasing hormone agonist and depo-medroxyprogesterone acetate.
        Cancer. 2006; 107: 1634-1641
        • Ghalie R
        • Porter C
        • Radwanska E
        • et al.
        Prevention of hypermenorrhea with leuprolide in premenopausal women undergoing bone marrow transplantation.
        Am J Hematol. 1993; 42: 350-353
        • Chiusolo P
        • Salutari P
        • Sica S
        • et al.
        Luteinizing hormone-releasing hormone analogue: leuprorelin acetate for the prevention of menstrual bleeding in premenopausal women undergoing stem cell transplantation.
        Bone Marrow Transplant. 1998; 21: 821-823
        • Lhomme C
        • Brault PH
        • Bourhis J
        • et al.
        Prevention of menstruation with leuprorelin (GnRH agonist) in women undergoing myelosuppressive chemotherapy or radiochemotherapy for hematological malignancies: a pilot study.
        Leuk Lymphoma. 2001; 42: 1033-1041
        • Laufer MR
        • Townsend NL
        • Parsons KE
        • et al.
        Inducing amenorrhea during bone marrow transplantation. A pilot study of leuprolide acetate.
        J Reprod Med. 1997; 42: 537-541
        • Quaas AM
        • Ginsburg ES
        Prevention and treatment of uterine bleeding in hematologic malignancy.
        Eur J Obstet Gynecol Reprod Biol. 2007; 134: 3-8
        • Bates JS
        • Buie LW
        • Woodis CB
        Management of menorrhagia associated with chemotherapy-induced thrombocytopenia in women with hematologic malignancy.
        Pharmacotherapy. 2011; 31: 1092-1110
        • Adegite EA
        • Goyal RK
        • Murray PJ
        • et al.
        The management of menstrual suppression and uterine bleeding: a survey of current practices in the Pediatric Blood and Marrow Transplant Consortium.
        Pediatr Blood Cancer. 2012; 59 (Epub 2012 Feb 13): 553-557
        • Elgindy EA
        • El-Haieg DO
        • Khorshid OM
        • et al.
        Gonadatrophin suppression to prevent chemotherapy- induced ovarian damage: a randomized controlled trial.
        Obstet Gynecol. 2013; 121: 78-86
        • Behringer K
        • Wildt L
        • Mueller H
        • et al.
        • German Hodgkin Study Group
        No protection of the ovarian follicle pool with the use of GnRH-analogues or oral contraceptives in young women treated with escalated BEACOPP for advanced-stage Hodgkin lymphoma. Final results of a phase II trial from the German Hodgkin Study Group.
        Ann Oncol. 2010; 21: 2052-2060
        • Amsterdam A
        • Jakubowski A
        • Castro-Malaspina H
        • et al.
        Treatment of menorrhagia in women undergoing hematopoietic stem cell transplantation.
        Bone Marrow Transplant. 2004; 34: 363-366
        • Sica S
        • Salutari P
        • Di Mario A
        • et al.
        Treatment and prophylaxis of hypermenorrhea with leuprorelin in premenopausal women affected by acute leukemia at diagnosis.
        Am J Hematol. 1996; 51: 248-249
        • World Health Organization
        Medical eligibility criteria for contraceptive use.
        4th ed. World Health Organization, Geneva2009
        • Katagiri S
        • Tsubakio T
        • Minami G
        • et al.
        Successful embolization for uterine hemorrhage in a patient with acute promyelocytic leukemia.
        Acta Haematol. 1983; 70: 199-221
        • Phelan J
        • Broder J
        • Kouides P
        Near-fatal uterine hemorrhage during induction chemotherapy for acute myeloid leukemia: a case report of bilateral uterine artery embolization.
        Am J Hematol. 2004; 77: 151-155