Nabors, G. C.

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The Linacre QuarterlyVolume 33 | Number 1 Article 21February 1966Do Progestins Regulate Menstrual Cycles?G. C. NaborsFollow this and additional works at: http://epublications.marquette.edu/lnqRecommended CitationNabors, G. C. (1966) "Do Progestins Regulate Menstrual Cycles?," The Linacre Quarterly: Vol. 33 : No. 1 , Article 21.Available at: http://epublications.marquette.edu/lnq/vol33/iss1/21JO PROGESTINS REGUl ,E MENSTRUAL CYCLE: G. C. NABORS, M.D.What is the medical evidence that progestins can "regulate" menstrualcycles? The inference has beenthat by using a prescribed regimenof_ trea:ment, irregular menstruatorswill miraculously menstruate every 28 days thereafter. The whole ideahas been misconstrued by the gen -�ral public and the common beliefis that the moral licitness of the useof progestins to regulate mensesmeans taking them indefinitely. An even more ridiculous misconceptionby some is shown by the patientwho comes to the gynecologist andsays that her confessor has "granted her permission" to use the progestinsfor a period of 2 years in order to regulate her menses It is of k · course,n�t. nown if this is the advice of am1�mformed priest, or the interpre­tatwn th� P;nitent wished to putupon a pnest s a_dvice. Be that as it may, th� object of this paper is notto condemn, but to emphasize the fact that there is a very widespreadan_d absurd confusion existing amon priests, pa:ients and physicians. Th!�econd _ob1ect is to examine the med-teal _evidence upon which any such bmed1cal and theological opinion wasased. First of all, it is going to be diffi­cult for us to agree about h . . 1 w o 1s anirregu ar menstruator Most ___ · gyne-Dr. Nabors, a Diplomate of the Am Board of Ob . encan stetncs and Gynecology . . practice in Dallas, Texas. ' is m62 cologists' exiwoman has 25 to 35 day tion should runusual. Fmthat every v. much and if 5because she hrate observer ords. When r shown in one tistically signitof the time diethe 28th daywho would aito menstruate. that it is withi.treatment to s does menstruato heed this s i 1 ce is that every·s that vary fromd that such varia··ven be considered ;·more, it is a fact nn does vary this Jenies it, it is onlynot been an accu·kept accurate rec··ds are kept, as was ' nt large and sta-1t seriesl only 15%enstruation fall onthe cycle. Thosethat it is normal · ry 28 days and he bounds of goodhat every woman �very 28 days need:ficant fact. Very often t; , woman who con­fronts the gyfo O logist with a plea for a prescripti, ,.1 for progestins to regulate her will answer, . when ·asked, that she is so irregular thatshe is unable 10 use rhythm, that her cycles vary from 27 to 32 days. This borders on the ridiculous, tobe called irregular. Be that as !tmay, it is true that there are van· ants of the physiological who aregoing to have cycles longer than_3Sdays. For the sake of eliminat!Ilgargument and in the interest ofevaluating our subject, let us arbi-1Marshall," John, The Infertile Period,Helicon Press, 1964 LINACRE QUARTERLY g agreed then that cycleslast longer than 40 days repre­abnormality, let us try to cate­fllle it diagnostically. We might • to this condition as oligomen­ea or secondary amenorrhea. llgomenorrhea is the same as •odic" secondary amenorrhea. 1'erefore, the difference between lgomenorrhea and secondaryllmorrhea is semantic. Before the confosion wrought byprogestins, gynecologists werealt inclined to treat such states ofIIIIOndary amenorrhea. In treatingsubject, Brown and Kistner2 ee summed up the general gyne­iillogic opinion by saying: Kupperman and Epsteinss, I',oland, Smithand Romney12, Roland39 and Go\d40 havl also used Enovid successfully in the treat­ment of secondary amenorrhea. In bothtypes of amenorrhea, it is known that acourse of Enovid treatment may be fol­loll'ed by resumption of normal menstrua­tion. Brown and Kistner41 state thatEnovid may be similarly used for the management of oligomenorrhea and hypo-menorrhea. Let us go first to the evidenceallegedly produced by Brown andKistner, reference 41 above. Thisis actually what they say in thereference: t;::ly, in the absence of proved organicamenorrhea as a clinical symptomlmlDts treatment only as it relates to dis­flllied emotional states or to infertility.·If adequate estrogen priming is present,cyclic bleeding from a secretory endome­trium may be obtained by the adminis- -tration of 10 - 20 mg. of norethindrone or norethnodrel for 20 consecutive days. Within 2 - 4 days after stopping the medi­cation a bleeding episode lasting from 4 to 5 days will occur. If adequate estrogen priming has not been present bleeding willnot occur and in such cases the prelim­inary use of an estrogen is usually necessaryfor an effective response. It i s suggested that artificial cycles of the type be carriedout for 3 - 4 months. Not infrequently, forreasons unknown, spontaneous menstrua-�ps the woman who considers�larity a hazard to herfllCtice of rhythm has a· disturbedanotlooal state, but this is not likelyID have been what these authorslant 12Roland, M.; Smith, J. J., and Romney, S.L.: New Synthetic Progestational Com­pound in Infertility, Int. J. Fertil. 5:8-18(Jan.-March) 1960 Let us not even argue the point• to whether such treatment of sec­� amenorrhea is warranted. US assume that it is; then whattab medical evidence that proges­• will treat it satisfactorily? If_: to the literature of the G. D.._ __ ,, Company, manufacturers of� fi d _ we n the following: � .. _&. Kistner, Essential of Humanion, Oxford Press, New York,._, p. 155 'i!u, Searle & Co., Physiciani Product1183 e No. 67, Chicago 80, Illinois,38Kupperman, H. S., and Epstein, J. A.: Proceedings of a Symposium on 19-NorProgestational Steroids: Gonadotropic­Inhibiting and Uterotropic Effects ofEnouid, Chicago, Searle Research Labor-atories, 1957, pp. 32-45 39Roland, M.: Proceedings of a Symposium on 19-Nor Progestational Steroids; Ob­servations on Patients with AnouulatoryCycles and Amenorrhea When Enouidis Administered, Chicago, Searle ResearchLaboratories, 1957, pp. 51-66 40Gold, J. J.: Proceedings of a Symposium on 19-Nor Progestational Steroids: Clin­ical Experience with Enouid, Chicago,Searle Research Laboratories, 1957, pp.86-96 63 tio� occurs a,, · the progestogen-induced penods have f;. , n discontinued. · Let us notice carefully just whatthis says. First of all they present no data or  factual evidence that their claim is true. We do not wish to doubt the observations of these outstanding investigators. In the first place they never made the claims that the Searle brochure in -ferred t?ey had. The other thing they said was that their r ecom -mendation was to use it for 3 - 4 m�nths. Based on even this quasi­ev'.den�e, one cannot then justify usmg It for 2 years in order to "regulate" the cycles. The principle of the theory of this treat�ent is well known to gyne­cologists and was first described in relation to the use of estrogen and progesterone and is commonly referred to as the "rebound phe­nomenon." If we now go back again to the Brown and Kistner reference 41 above, we see that they have this to say further : Endocrine preparations are also employed to remove gonadotropic stimulation of the ovaries. The rationale of this treatment utilizes the observation that estrogenic sub-stances, administered in large doses, block the ad�nohypophyseal release of the gona­dotropms. Existing evidence suggests that the gonadotropic hormones are accumu­lated or stored in higher concentrations in the pi�uitary gland during this period of  endocrine therapy. Cessation of the treat­ment, t�eoretically at least, releases the estrogemc blockage and results in a sudden burst of gonadotropic activity. The desired �£feet of _this so-called rebound phenomenon 1s to stimulate the ovaries sufficiently to promote ovulation and normal menstrual function. Unfortunately, the results aredisappointingly poor. [italics mine] 64 Let us exr at this time just what the cl of the rebound phenomenon This work is ex-plained by ? · in a number of publications. essence the work was based ;iving 80 sterility patients incr, · s doses of diethyl·stilbesterol c for three months and increasir ;Ses of progesterone during the : time. Thirteen of the 80 w01 became pregnant within 4 mm of treatment. When one is deali · vi th sterility prob· lems these . lts are astounding. · Please note this point that the patients unc.· discussion in this work were 'lity problems and not hyper-fe 'Y problems. Even so, the prh e of the rebound phenomenon not be ignored and it is only r 1ctively reasonable that such a •ound phenomenonmay result •hose patients whoare very ir. Jar ovulators and menstrua tor -t should be re-emphasized, ,wever, that such treatment is ,,ified for only 3-4 months. No �'dical evidence has ever suggestc � years or indefinite time spans, r, · .. n ything more than 3 - 4 months. . Let us nov ,eturn to the refer-. ence 3 in pat. ,aph 7 which states. "Kupperman : 1d Epstein, Roland, Smith and l' ,,nney, Roland and Gold have als., used Enovid success· fully in the tn'atment of secondary amenorrhea." ff one scrutinizes these articles, he I:n<ls that what these investigators cli covered was that 4Rock, J._; Garcia, _C.-�., and Pinc1·Ju�Synthetic Proge;,ins m the Norena Gman Menstrual Cycle, in Pincus. (editor): Recent Progress in �or;: Research New York Academic Inc., vol.' 13, 1957, pp. 323-339 LINACRE QUARTERLY who have amenorrhea, if Enovid, will bleed when it is wn. There is no evidence that following cessation of , menstrual periods are any regular than previously. As a of fact the reference to the of Roland reveals the follow­striking conclusion in his own withdrawal bleeding be­two and three days after cessation mlication. The bleeding in most in­wu scanty; - in several this scant It continued for eight to ten days. The ovulatory patients had heavy bleeding Illa clots but it was of normal duration .. �tion during the cycles ,vhich fol­lflllll the treated ones reverted back to .... One assumes that when ·he says le, reverted back to "normal," he lllew to what they had been pre� -1y, since they were c1.ealingwith ovulatory women. One can liudly deny that women with �-fertility are also ovulatory llllnen. As we understand this, then The above investigat ,ns of Ro­land and perhaps others apparently led the G. D. Searle Company to print in their  brochure (3) on page 20, the following: "Ovulation in the fm t cycle after treatment may be dclaved for three to  five days or  evc1; longer; subsequent cycles will usually revert to the duration pre­viously typical of the individual patient." To sum up, the most liberal of medical evidence would only support the use of progestins for a period of means that using progestins for a JISlod of several months allows a l'lllllan to bleed at predictable inter-1111 IS long as she is being medi­Clled, but following withdrawal of '-tment, one can expect her pattern 1D lie uninfluenced. 3 - 4 months in conditions of irregu­lar menstruation. Even those who believe that this has merit admit that the results are disappointingly poor. These cases were women who had gone f or several months with­out menstruating. Actually there has been no work published, to the knowledge of this author, which even attempts to show that the very fertile woman who menstruates on cycles varying from 26 to 4.0 days can cause these habits to change by the use of progestins. There is even evidence to support that this does not occur: the quotation of Roland above and the admission of the G.D. Searle Company who make it clear that "subsequent cycles will usually revert to the duration pre­viously typical of the individual patient." 65 ' 

Do Progestins Regulate Menstrual Cycles?

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Do Progestins Regulate Menstrual Cycles?

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