Fooling With Mother's Nature
In ancient Persia, menstruating women were kept in isolated chambers, and those who continued to bleed after four days were whipped. If a woman's bleeding persisted longer than nine days, the Persian patriarchs believed evil spirits possessed her and the prescribed cure was 400 purifying lashes.Dr. Elsimar M. Coutinho begins his controversial new book, "Is Menstruation Obsolete?"(Oxford Press), with this disturbing portrait of cultural misunderstanding in his discussion of the historical vilification, exaltation and acceptance of menstruation. Coutinho also recalls Roman geographer and naturalist Pliny the Elder, who posited that menstrual blood was a deadly poison capable of destroying the fertility of seeds, capable of killing crops, insects, fruit and flowers, and could even blunt knives. Pliny opined with sober foreboding that if menstruation coincided with an eclipse, all hell would break loose, and that having sex with a menstruating woman when the sun was in full lunar eclipse could be fatal to a man. Pliny's work wasn't questioned until 1492.Women have long been murdered, tortured, banished and despised for a bodily function no more singular than urination -- aside from the very important distinction that men can't do it. Though a product of female sexuality, men have historically tended to fear it, despising all hints and reminders that it exists.Dr. Coutinho's work -- which concludes by suggesting that chemically suppressing menstruation would benefit many if not all women -- may lead some to suspect a darker motivation. Would Dr. Coutinho achieve with technology what the patriarchs of Persia failed to do with their whips? Although my interview with Coutinho relieved any suspicions of misogyny or ill-will, it is understandable that a woman might find his theory a bit shocking if not downright offensive.And though it directly affects only half the species, the concept of menstrual suppression may set the precedent for an increasingly profound dilemma as we march blindly into a millennium already dominated by technology and medical advancement. With the ability to alter, prolong, and even clone life, our narcissism may coax us too far, and nature may very well exact a heavy retribution for treading too long on her domain. It makes one wonder how much control will satisfy us and if we should, in fact, ever terminate our quest to outfox the universe.In my experience, contemporary women depend less on menstruation and other physical proofs of womanhood for their sense of self than their predecessors did. Whether it's because science has demystified the human body or because fertility is less crucial now than it was for our ancestors now that women have more career options than motherhood and prostitution, I'm not sure.My admittedly unscientific survey of friends and colleagues yielded much ambivalence. One woman had been on the contraceptive DepoProvera, which suppresses menstruation completely in most women, and couldn't wait until her last dose wore off. Although she was initially excited to dispense with the hassle of menstruation, she instead felt like she had constant PMS with no relief in sight. A colleague of mine explained that she can't wait to be rid of her period but doesn't consider unnatural methods an option, and another woman asked me how soon she could sign up for Coutinho's scheme.Most of the women, including myself, didn't much care about the fate of our periods either way and only bristled at the thought of being told we couldn't or shouldn't have them anymore -- not that Coutinho is advocating a universal mandate.At the beginning of his book, Coutinho tracks the evolution of menstruation's biological function as well as its role in Western thought, ultimately suggesting that while menstruation still holds sway in the feminine psyche, it's biologically unnecessary if a woman isn't trying to get pregnant.He also posits that menstruation can be harmful, causing and aggravating many conditions including endometriosis, endometrial cancer, anemia, migraine, dysmenorrhea (severe menstrual cramping), acne, epilepsy and arthritis. Coutinho notes that suppressing ovulation seems to reduce a woman's risk of ovarian cancer, and he believes that it may reduce the risk of breast cancer as well.While most physicians agree that menstrual suppression is necessary and beneficial for some women, Coutinho has instigated controversy in his native Brazil, and will undoubtedly do so here, by advocating menstrual suppression as standard practice for all women.Coutinho, a professor of gynecology, obstetrics and human reproduction at Federal University of Bahia School of Medicine in Brazil, arrived at his theory after nearly four decades of research. In 1959, he was a guest investigator at the Rockefeller Foun-dation in New York, where he met Hartsdale resident Dr. Sheldon Segal, a biomedical scientist who was studying the action and effect of certain hormones, as well as new contraception methods.Inspired by Segal's work, Coutinho returned to Brazil and began clinical trials on DepoProvera, a synthetic derivative of the naturally occurring hormone progesterone, in hopes that it could prevent spontaneous abortion and premature delivery. While DepoProvera failed in that arena, Coutinho discovered that it temporarily prevented ovulation, and he pioneered its use as a contraceptive.Segal, now a Distinguished Scientist at the Population Council in New York, a former director of Population Sciences at the Rockefeller Foundation, and founding director of the Center for Reproductive Law and Policy, worked with Coutinho on Americanizing "Is Menstruation Obsolete?", which was originally published in Portuguese as "Menstruacao, a Sangria Inutil?" (Menstruation, a Useless Bleeding) in 1996.As the Portuguese title suggests in a less delicate fashion than its English counterpart, Coutinho feels no sentimentality when it comes to menstruation, a biological dinosaur in his opinion. As he discusses in his book, continuous menstrual cycles are a late 20th century phenomenon.About 40 years ago, the social climate, thanks in large part to the lingering effects of World War II and the feminist movement, became more conducive to women's independence, while at the same time, mainstream dissemination of the contraceptive pill offered greater control over reproductive choices. Until this revolution was enacted, women spent most of their reproductive lives either pregnant or nursing, which naturally suppressed their menstrual cycles. Coutinho's mother, for instance, had nine children and averaged a period once every two years. In addition, advances in science that prevented illness and improved nutrition further increased the number of menstrual cycles a woman has in her lifetime.But our contemporary bodies have barely budged from their original design, which emerged about 200,000 years ago. And our reproductive systems, quite similar to those of many non-human primates, may very well be the result of a 20 million-year-old template introduced by a creature thought to be the common ancestor of humans and the Great Apes.Coutinho also points out that menstruation as we know it is not a normal occurrence in the animal kingdom. Aside from certain non-human primates and some bats and shrews, human females are reproductive anomalies. We are certainly the only species that bleeds consistently for several decades; modern American women can expect to have approximately 450 periods in their lifetime."It's not natural for a woman to bleed for 30 or 40 years of her reproductive life -- it's not what nature intended," asserted Coutinho, when we reached him by telephone in Brazil. "Nature's idea was for her to ovulate and get pregnant."Dr. Sharon Golub, a professor of psychology active in the women's studies program at the College of New Rochelle, retorted, "We have longer lives now and longer non-pregnant lives, and what the effect of that is, I don't think we know. But should we suppress menstruation chemically because our lives are longer and we used to be pregnant more? I don't think so."Menstruation is the body's response to a reproductively fruitless cycle of ovulation, and as nature would understand it, a symptom of failure. The fact that the majority of modern women spend most of their sexual lives striving for reproductive failure is not really the point. At this juncture in human evolution, our biological and cultural imperatives are at odds for the first time.The effect of this disharmony and the action, if any, it should illicit is the ultimate domain of "Is Menstruation Obsolete?" Coutinho explained that through his research and clinical practice, he has treated thousands of very miserable women. While virtually every woman has some combination of unpleasant cyclical symptoms -- fatigue, irritability, bloating, backache and cramping being the most common -- according to Coutinho, 30 to 40 percent of women experience significant discomfort prior to and during their periods.According to Dr. Segal, about 10 percent of women are completely disabled by their period, and he said of the cramps associated with dysmenorrhea, "If you haven't suffered from them, you can't imagine how bad it can be."In his extensive chapter on the nature of PMS and the myriad research on the subject, Coutinho writes, "The effects of PMS on mood and behavior can create problems in all aspects of a woman's life and can affect not only the woman herself but also those around her." He continues, "Surveys show a correlation between PMS and marital conflicts, mistreatment of children, aggressiveness at work...excessive food intake and alcohol abuse." Segal noted that PMS can be so severe that the American Psychiatric Society has recognized it as a disorder.Coutinho even cites several British cases where PMS has been used successfully as part of a criminal defense and, ludicrously enough, managed to keep one murderer out of jail.Coutinho also addresses serious menstruation-related disorders such as endometriosis, a chronic disease in which portions of the uterine lining are discharged into the pelvic cavity where they attach to organs. Endometriosis affects one in 10 women, according to Coutinho, and can cause extreme pain, infertility and cancer.In his book, he includes the high-profile example of Marilyn Monroe, who suffered from endometriosis at a time when the only treatment was removal of the ovaries. Because she wanted a child, Monroe refused this surgery. "She endured the severe monthly pain by consuming greater and greater quantities of narcotics, ultimately leading to her death by overdose," Coutinho postulates.Other conditions such as anemia, migraine, asthma, insomnia, arthritis and epilepsy can be aggravated by the menstrual cycle. By suppressing menstruation, many of these conditions can be eliminated or better managed.Hormonal methods of birth control, such as the pill and DepoProvera injections, prevent ovulation and true menstruation. In most women, DepoProvera prevents bleeding altogether, though a friend of mine bled for 73 consecutive days while on it. According to Dr. Segal, about 20 percent of users have breakthrough bleeding. And in the case of the pill, the light bleeding a woman experiences echoes menstruation but is not in fact the real thing. Although the pill can be taken continually to completely suppress bleeding, according to Coutinho, pharmaceutical companies developed it to mimic the menstrual cycle believing thatwomen would be apprehensive about not menstruating and would fear pregnancy.Although Coutinho maintains that the health risks associated with hormonal suppression are limited to a relatively small percentage of women, hormones aren't entirely innocuous. "There are some health risks associated with giving exogenous hormones," explained Dr. Corinne de Cholnoky, who practices obstetrics and gynecology with a holistic focus in Stamford and Greenwich, Conn.. "There are some women who can't take estrogen if they have breast cancer or severe liver disease, a history of blood clots, undiagnosed bleeding, and obviously you have to make sure someone's not pregnant." Some women are allergic to exogenous hormones as well.A fertility specialist, de Cholnoky also noted that it can take up to a year for some women to regain their normal cycles after being on DepoProvera, which can interfere with their ability to get pregnant when they want to.While de Cholnoky believes it should be a last resort, she notes that there are cases which do require hormonal manipulation or suppression and that with some menstruation-related disorders like endometriosis, there isn't an effective natural approach. For mild to moderate monthly discomfort, de Cholnoky suggests lifestyle adjustments, including exercise, a reduction in saturated fat intake, purging the diet of dairy and wheat products, and managing pain with over-the-counter medications and homeopathic remedies.Through her practice, de Cholnoky has found that stress and emotional distress are contributing factors in many cases of problematic menstruation and debilitating PMS. By focusing on this psychological aspect and unraveling the source of emotional and ultimately physical pain, the whole individual can be treated. This holistic approach tends to be more effective than masking the problem by treating symptoms with pain medication or hormonal therapy, de Cholnoky said.The potential link between breast cancer and hormones, primarily estrogen, has been the subject of hot debate in the last decade. It's still unclear whether long-term use of the pill increases a woman's risk for developing breast cancer; some research indicates that it does, some that it lowers risk and some that it has no effect. It's generally accepted, however, that the pill can significantly reduce a woman's risk for developing ovarian and endometrial cancer.Coutinho suspects that long-term use of contraceptive pills, which contain either progestin alone or in combination with estrogen, and DepoProvera, a progestin, may lower a woman's risk of breast cancer. Based on research that suggests a correlation between the number of menstrual cycles a woman has and her risk for developing breast cancer, Coutinho believes that hormonal suppression may help limit a woman's exposure to estrogen and thus reduce her risk.Most of the medical community believes that estrogen and its effect on breast cancer is too poorly understood to reach any absolute conclusions, and it's possible that the estrogen in combination contraceptive pills may counteract any benefit of suppressing menstruation. Most physicians don't prescribe estrogen therapies to women with breast cancer or a high hereditary predisposition to it."Although we've had the birth control pill around for a long time, and it's probably the most researched drug in history and looks pretty safe particularly in the smaller doses used today, I still have trouble with a very long-term use of hormones," Dr. Golub commented. "You're muckin' around with old Mother Nature, and I just don't think she likes it." Golub has written six books, the latest of which, "Periods: From Menarche to Menopause", Dr. Segal praises in his introduction to "Is Menstruation Obsolete?"When asked whether his book was written primarily for those with menstruation-related problems or the average woman, Coutinho re-plied, "I don't expect a sudden change in mores so drastic that everyone is going to want to stop menstruating."Noting that menstruation causes serious problems for about 30 percent of the female population, he added, "I think we'll start with suggesting that the women with these conditions try suppressing their periods for a year. And from then on, women will know that they can choose. In the future, very few women will bleed every month when they learn that it brings no benefit to them."The June issue of the American medical journal Contraception contained a Dutch study which concluded that 80 percent of the subjects would prefer a change in bleeding patterns, such as less painful, less frequent, less heavy and for some, not at all. "The majority of these women in all age groups preferred to have a bleeding frequency of less than once a month...and over 30 percent of the women included in this research preferred not to be menstruating at all," Coutinho noted.If the crimson tides are in fact turning, they are not doing so without critics. "I do not think [hormonal suppression of menstruation] is a natural process, and I don't think it's doing a lot of women a service by implying that they don't need to be having periods because it's a big part of who they are and what happens to their bodies," said de Cholnoky.Golub responded, "To suppress periods just for the sake of convenience -- I don't think that's justification for medication. Hormones are powerful things, powerful drugs, and they influence all parts of the body, not just the reproductive system. There's a lot we don't know, so I think proceeding with caution when changing what happens naturally is important."Golub is also sensitive to the psychological ramifications of menstrual suppression. "Both menarche and menopause are landmark experiences in a woman's life, and the onset of menstruation in girls is something that for most girls is eagerly awaited," she explained. "They want it, and they want to be normal. They are not looking forward to periods with dread."Golub cited a 1978 study by Koff, Rierdan & Silverstone originally published in the Journal of Developmental Psychology, which has been reprinted in many textbooks and is included in Golub's latest book. Girls expected to reach menarche within the next school year, around age 12, were asked to draw pictures of themselves before and after they began menstruating.As Golub promised, the results were dramatic. Depictions prior to menstruation had an androgynous, childish sensibility while the post-menarchal portraits acquired the sensuousness of grown women. The girls drew themselves with curvy breasts and hips, jewelry, high-heels and big hair.Recognizing that menstruation's significance transcends the physical sphere, Segal has anticipated womankind's likely response to a man proclaiming that periods are dispensable. "There will be a political reaction on the part of feminists who read this as an attack," he said. "I hope people understand that we're not talking about the psychological role of menstruation here."The progression from girl to woman often triggered by menarche, whether due to hormonal destiny or societal expectation, has prompted Coutinho to suggest postponing the age of menarche via hormonal suppression. According to Coutinho, girls get their first period around the age of 10 in the tropics, which makes them vulnerable to a rash of social problems.Coutinho explained that sexual crimes are a plague in Brazil and other South American cultures, and young girls are often the victims of incest. Because they reach menarche at such an early age, they are rendered even more defenseless, and pregnancy compounds their tragic circumstances.Coutinho noted that about 30,000 full-term pregnancies in girls ages 9 to 14 are reported annually in Brazilian public hospitals, and he estimates the same number of girls miscarry or abort their pregnancies. "Most of these girls were a victim of a family member," Coutinho added."We're disgusted with this, but we can't have a policeman in every house to make sure the father isn't going to rape his daughter," he continued. "So what can we do to protect these girls? Not much, but what we can do is prevent them from getting pregnant." Coutinho also posits that hormonal suppression may delay or mute the expression of secondary sex characteristics such as full breasts, making young girls less sexually attractive.While Coutinho concedes that it's really the fathers who must be stopped, social attitudes are slow to change in Brazil; patriarchal dominance is still intact and while sexual crimes aren't socially sanctioned, they're more readily overlooked. Although education and a system of dealing with sex crimes is desperately needed, this will take time. Coutinho explained that as it stands, it's nearly impossible to prove incest, and the victims generally refuse to report their perpetrator even if a sexual crime is suspected. Coutinho remarked that until a cultural overhaul is accomplished, the most a physician can hope to do is limit the tangible damage to a girl."That's ridiculous," asserted de Cholnoky in response to Coutinho's plan. "There's no reason to introduce estrogen and progesterone in large amounts to 9-year-olds' bodies to alleviate a social problem."It's more important to provide them with effective birth control rather than suppress normal body functions which may be necessary for their maturation." De Cholnoky also doubts whether hormonal therapy would stunt the development of secondary sex characteristics.Even where sexual crimes are not epidemic, Coutinho champions delayed menarche. Noting that most of the young girls he treats are the daughters of doctors, he said, "In the future this is going to be a common practice. If you know that you can do this for your daughter, it's a tremendous benefit for her. It will save her from a lot of trouble -- as long as she's a child, she's not going to be a good mother ... you can imagine what a disaster a pregnancy becomes in her life."Said Golub, "If you could [delay menarche] without messing around with hormones, that would be really great for a lot of reasons. It would give girls a few more years to socially mature and presumably be better able to handle the social and sexual ramifications that come along with reproductive maturity." Coutinho suggests that for some girls, vigorous exercise can naturally delay menarche.Most of the women I know take some pleasure in menstruation, and it's an easy excuse for intimacy between females -- one casual exchange on the hardships of bloating and a foundation of empathy is laid.One colleague said laughing, "I'd rather have my period than not have it -- it's been with me all my life. And I get to be mean and everyone understands, and it gives you the most perfect reason to vent even if you're not angry." This reminded me of a bumper sticker currently in circulation that reads, "PMS gives women an excuse to act like men get to every day."One woman, despite the fact that she was in the throes of menstrual misery, quipped, "Even though periods are a pain in the ass, I don't like the idea of hormonal control or completely not having them anymore." Another rejoined, "You're playing with fire when you screw around with nature. Our bodies were designed a certain way and work a certain way, and I don't think it's wise to artificially change that just because periods are irritating."Remarked Golub, "A good proportion of women think it's a necessary nuisance. A substantial number feel that it's part of being a normal woman, and they're accepting of it without the aura of negativity." Whether a woman feels that her femininity is reliant on menstruation or whether she merely tolerates it, Golub has found in her research that many women are surprised to find they miss menstruation when they reach menopause. And, of course, there are those women who have no sentimental attachment to menses and would rather be done with the inconvenience."I'm not forcing women to stop bleeding," Coutinho countered. "If they enjoy it, and they're healthy then they should keep doing it. But they should be aware of the risks of some diseases associated with menstruation and the benefits of suppression."The fate of menstruation remains to be seen. If I were told it would magically disappear without effort or ill consequence, I would be more than happy to get over any residual nostalgia. But I would not like being told that I should mute my periods without a clear and present medical reason.With "The Handmaid's Tale" lingering in my head, I have to wonder what harbinger of the future this practice could be. Though it's certainly not Coutinho's intention, I wonder if his work could be a seed planted in society that matures into the subjugation of female reproduction. I get a premonitory shiver envisioning women being alternately farmed and left barren for the sake of controlling the population or hereditary disease, and more viciously, for racial cleansing and genetic experimentation. And once relinquished, could women ever depend upon regaining the sovereignty of their bodies?Copyright ©1999 New Mass. Media, Inc. All rights reserved.