Research Paper Title

Making the Case for Menstrual Suppression for Military Women.

Background

Women account for nearly 17% of the soldiers serving in the US Army. As of 2016, all combat jobs are open to women, and females are now assigned to every combat arms military occupational specialty. While serving with demonstrated success, women are uniquely impacted by menstrual-related conditions and unplanned pregnancy. Many of these issues can be addressed or eliminated with the use of available and accepted contraceptive therapies, which would provide a reduction of significant medical events by 66–99%. Although military women report a desire to use contraceptives for menstrual control, the rates remain low. Every deploying soldier is mandated to have a predeployment Soldier Readiness Programme (SRP) appointment to assure appropriate vaccines, vision, and medical issues are addressed, however, there is no policy for predeployment consultation regarding menstrual suppression or contraception. Service members may or may not receive counselling and treatment based on the individual training and preferences of their primary care provider.

Department of Defense policy (CENTCOM MOD14-TAB A) states “evaluating providers must consider that in addition to the individual’s assigned duties, severe environmental conditions, extremes of temperature, high physiologic demands (water, mineral, salt, and heat management), poor air quality (especially particulates), limited dietary options, sleep deprivation/disruption, and emotional stress may all impact the individual’s health. If maintaining an individual’s health requires avoidance of these extremes or conditions, they should not deploy.” CENTCOM MOD 14 Tab A reviews the minimal standards for fitness and outline medical conditions that limit deployment, however, this document does not currently include any gynaecologic conditions outside of pregnancy. The authors propose establishing a mandated predeployment consultation for this population. Further, the consultation should provide access to health care professionals knowledgeable in the use of contraceptives for menstrual suppression and aware of the unique challenges of deployed women in austere environments. The establishment of such a policy would improve readiness of our forces, as well as alleviate many of these barriers to care, and is in line with Department of Defence policy. Since the benefits and barriers discussed in this article extend to both women and transgendered individuals who have maintained female anatomy, the language used throughout should be read as inclusive of this entire population.

There are numerous non-contraceptive benefits to hormonal contraception (See Figure 1 in the reference for a full list). Despite this, there is no standardised SRP or predeployment visit that provides education concerning safe therapies for contraceptive methods to prevent pregnancy or education on menstrual suppression. Up to 68% of servicewomen cite that their primary health care provider is a medic or corpsman, many of whom are not trained in menstrual management. Only a third of servicewomen reported receiving any predeployment counselling on menstrual cycle control, with only 13.5% reporting being offered pharmacological menstrual regulation.

Powell–Dunford et al. (2020) report that 86% of those surveyed desired amenorrhea during deployments; however, 54% were unaware that oral contraceptives could induce amenorrhea and only 7% used this practice during deployment. In this same analysis, 66% of women surveyed had a strong desire for hormonally induced amenorrhea during deployment. Of women who used hormonal contraception for menstrual suppression during deployment, 57% reported satisfaction.

Beyond the inability to practice menstrual control, the lack of contraception during deployment has other consequences including risk of unplanned pregnancies. Unplanned pregnancy is reported to be higher in military women than in civilian women and is a barrier to deployment. Additionally, unplanned pregnancies during deployment are associated with a significant expense and impact on military operations. As evidence, pregnancy represented the single largest reason for evacuation because of a policy requiring all pregnant service members to be administratively redeployed back to the US. During Operation Iraqi Freedom, females had higher rates of becoming non-battle injury casualty requiring medical evacuation – 74% of female medical evacuations out of theatre were for pregnancy-related issues.

Barriers to contraceptive access may contribute to unintended pregnancy. Research indicates that in deployed settings, some servicewomen experience a lack of routine counselling on contraceptive options, care-seeking stigma, logistical obstacles to medical care, and confusion or concerns related to policies on sexual activity that may deter them from seeking contraception. Only 63% of those surveyed received any form of contraception during deployment, and only 41% spoke to a military provider about contraception before deployment. Specific methods, such as Long-Acting Reversible Contraception (LARC), are reportedly discouraged by SRP medical providers and there are a limited range of contraceptive methods available in theatre. According to Grindlay et al., 41% of women who required refills found them difficult to obtain while deployed. It is unclear as to why this LARC is not routinely offered at predeployment medical visits. It could be that the medical providers staffing SRP sites are not trained in the procedures for LARC placement or that LARCs are unavailable in this setting.

In addition to unintended pregnancies while deployed, menstrual irregularities, heavy menstrual bleeding, and painful periods are common sick call visits. Up to 15% of women suffer from absenteeism because of painful menstrual cycles, which can be reduced or eliminated with contraception. An assessment of Gulf War data determined that women generated 1,792 sick call visits with over 25% because of conditions that could have been prevented with contraceptives. Another study of 397 deployed women reported that 35% had at least one gynaecologic problem during their deployment, with irregular menstrual bleeding cited as the most common. Between 2012 and 2016, theatre records documented 941 menorrhagia-related medical encounters affecting 718 unique individuals during deployment to a US Central Command area of responsibility and an additional nine women were evacuated from theatre because of heavy menstrual bleeding.

Iron deficiency and iron deficiency anaemia adversely impact multiple aspects of service member performance including work and cognitive performance. Menstrual disorders left untreated can lead to iron deficiency anaemia. Among females with a diagnosis of iron deficiency anaemia, the most common associated diagnosis is “disorders of menstruation and other abnormal bleeding from the female genital tract” (15.2%). Amaenorrhea is associated with improved iron status. In a population of female service members deployed to Afghanistan, haemoglobin concentration was 14.1 and serum ferritin 55.9 in amaenorrheic individuals compared to haemoglobin of 13.6 and serum ferritin of 34.8 in those menstruating. Cycle management and treatment of menstrual disorders impact female iron status. Given the implications of poor iron status for individual performance, education about iron status and options for amaenorrhea should be incorporated into the comprehensive female exam and part of predeployment counselling.

Failure to address menstrual suppression and unplanned pregnancy in a deliberate manner poses risks in terms of personal health and hygiene, force readiness, mission accomplishment, and financial loss to the military. In order to improve the readiness of this population, the authors recommend a dedicated predeployment appointment with a health care professional trained in contraception and menstrual cycle management at least 90 days before deployment. Contraception interventions require up to 3 months to ensure the desired outcomes of elimination or reduction in the menstrual cycle. In addition, all women who desire oral contraception should be dispensed a full-year supply before deployment thereby eliminating the need for prescription refills and related logistical challenges. As evidence of efficacy, one study showed that prescribing and dispensing a full-year of oral contraceptive pills (rather than 3 months of pills) resulted in 583 unintended pregnancies averted annually in a population of 24,309 women. Department of Defence policy, CENTCOM MOD 14, specifically states that personnel who require medication and are deploying will deploy with no less than a 180 day supply of their maintenance medication. Oral contraceptives should be included in this policy. Since dispensing and carrying a year’s supply of contraceptives could be a logistical burden on these service members, trained clinicians would also have the opportunity to discuss the option of LARC during this predeployment session. The establishment of this session at 90 days predeployment would allow the necessary time to start or change a patient’s contraceptive routine with appropriate time for monitoring and addressing any side effects in accordance with CENTCOM MOD 14 Tab A for deployment to CENTCOM AOR.

In conclusion, a mandated predeployment appointment for women with a clinician knowledgeable in the use of contraceptives for menstrual suppression and aware of the unique challenges women face downrange would alleviate many problems. Predeployment counselling on effective contraception and menstrual suppression will help to eliminate unplanned pregnancies that prevent deployment, decrease unintended pregnancy rates, decrease the number of sick call visits, and lost duty days because of menstrual-related issues, decrease evacuation from theatre because of pregnancy or menstrual related issues and ultimately has the potential to improve women’s health overall by decreasing anaemia. Of course, the authors are not advocating for mandatory menstrual suppression in military women. Instead, the authors offer that the autonomy of these women should be enhanced through universal counselling on menstrual suppression and its possible benefits. Specifically, they propose a universally mandated women’s health SRP executed at least 90 days in advance of a deployment as an ideal venue to benefit military women down range.

Reference

Keyser, E.A., Westerfield, K., Eagan, S., Hall, A., Yauger, B. & Powell-Dunford, N. (2020) Making the Case for Menstrual Suppression for Military Women. Military Medicine. usaa036, https://doi.org/10.1093/milmed/usaa036.