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763
CHAPTER 56
Not a “Real” Period?: Social and Material
Constructions of Menstruation
Katie Ann Hasson
Menstruation, as a “natural” bodily process, seems self-evident; this allows
it to work as an enduring and central marker of difference in essentialist
conceptions of sex and gender.1 Considered to be a nearly universal female
experience,2 it functions as a literal and symbolic marker of sex and sexual-
ity, fertility, age, and health. Challenging essentialism, feminist scholarship
has analyzed the varying social construction of menstruation in different
places and times (Bobel 2010; Buckley and Gottlieb 1988; Delaney, Lupton,
and Toth 1988; Fingerson 2006; Freidenfelds 2009; Lee and Sasser-Coen
1996; Martin [1987] 2001). This research has focused most often on rep-
resentations and individual experiences of menstruation, mirroring the ana-
lytic split between sex as biological and gender as cultural and social, which
often leaves the biological outside the range of feminists’ critical examination
(Fausto-Sterling 2005; Roberts 2007). The cultural and scientic catego-
ries with which we categorize and study menstruation are important to how
we understand, experience, and intervene in it. Drawing on analyses of the
material aspects of hormones and the menstrual cycle, recent feminist schol-
arship has brought necessary attention to the ways biology interacts with and
is dynamically shaped by social and cultural environments (Fausto-Sterling
2000; Roberts 2007). Overall, feminist scholars have paid more attention
to the cultural meanings and norms that govern menstruation than to what
menstruation is or how it is dened. In doing so, what counts as menstruation
© The Author(s) 2020
C. Bobel et al. (eds.), The Palgrave Handbook of Critical Menstruation
Studies, https://doi.org/10.1007/978-981-15-0614-7_56
764 K. A. HASSON
is taken for granted, and the complex choreography that can alternately shift
or stabilize denitions of menstruation is overlooked.
Despite seeming self-evident, menstruation is not always easily dened.
When technologies alter whether or when menstruation occurs, they often
raise denitional questions, and menstruation’s close links to reproduction
raise the stakes. We can see this, for example, when asking whether medi-
cations to “bring on blocked menses” act on menstruation or pregnancy.
Scholars have questioned whether the bleeding produced by these medica-
tions should be considered menstruation, miscarriage, or abortion (Luker
1984; van de Walle and Renne 2001). It took signicant, coordinated effort
by nineteenth-century physicians and politicians in the United States to shift
the understanding of their use; what had been generally accepted as the resto-
ration of healthy menstruation was redened as illegal abortion (Luker 1984;
Reagan 1997). Similarly, the feminist self-help health technique of “menstrual
extraction,”3 developed by U.S. women’s health activists in the 1970s, pur-
posely occupied an ambiguous position between regulating menstruation and
regulating reproduction (Mamo and Fosket 2009; Murphy 2012). Historical
cases like these provide examples of how denitions of menstruation have
been negotiated and institutionalized in conjunction with technologies that
materially alter bleeding.
Although it is rarely discussed in this way, hormonal birth control is a
prime site for the elision of regulating reproduction and regulating menstru-
ation. When oral contraceptives were rst approved by the Food and Drug
Administration (FDA) and introduced in the United States, they beneted
from the ambiguity of the effects exogenous hormones have on bleeding and
conception. Enovid, the rst hormonal birth control pill, was FDA approved
in 1957 not as a contraceptive but rather as a medication for treating men-
strual symptoms; it was accompanied by a warning that it had the side effect
of stopping ovulation (Watkins 1998). As a treatment for menstrual symp-
toms, Enovid could pass through FDA scrutiny and enter the market, side-
stepping (some) moral debates on birth control while maintaining the
possibility of its off-label use as contraception. It was not until 1960 that
Enovid’s producer requested and received FDA approval for its use as a con-
traceptive (Junod and Marks 2002; Watkins 1998). The initial developers of
the birth control pill knew that the hormones in the pill suppressed both ovu-
lation and menstruation (Marks 2001). To emphasize the “naturalness” of
the pill and increase its acceptability (to users, pharmaceutical executives, and
religious ofcials), they designed a regimen with a pill-free break that pro-
duced bleeding similar to a menstrual period (Marks 2001; Watkins 1998).
Menstrual suppression was thus always a possible use for the pill, but deliber-
ate decisions by developers obscured these effects on bleeding.
The introduction of menstrual suppression birth control pills—oral con-
traceptives such as Seasonale, Seasonique, and Lybrel, which are taken in an
extended regimen to produce fewer periods per year—made the ways that
oral contraceptives regulate bleeding highly visible. Menstrual suppression
56 NOT A “REAL” PERIOD?: SOCIAL AND MATERIAL CONSTRUCTIONS … 765
birth control pills are nearly identical to existing hormonal birth control,
changing only the regimen of how many pills with active hormones are taken
before a “break” from hormones that allows bleeding to occur (Watkins
2012). This change incorporates previously known but little-mentioned ways
that all hormonal birth control changes bleeding and widely practiced but
“unofcial” or “off-label” uses, recreating oral contraceptives as menstrual
suppression in the process. Available since 2003 in the United States, men-
strual suppression birth control has attracted a great deal of attention; how-
ever, the focus on suppressing menstruation as a novel feature of birth control
has precluded attention to both the continuities present in regulating men-
struation and the way menstrual suppression includes a redenition of men-
struation itself. To make birth control into “menstrual suppression,” monthly
bleeding—once relied on to emphasize the naturalness of hormonal birth
control—has been redened as a side effect with no relation to “natural”
menstruation. How were these understandings and denitions of menstrua-
tion changed following the introduction of menstrual suppression birth con-
trol? What are the implications of these changes for gendered embodiment?
The redenition of menstruation, including how it is understood in rela-
tion to birth control hormones, is central to understanding menstrual sup-
pression birth control and its effects on gendered embodiment. I argue that,
following the introduction of menstrual suppression, menstruation itself was
redened, proliferating new categories of bleeding across clinical, regula-
tory, and popular discourse. New denitions and terminology for menstrua-
tion explicitly aimed to change women’s understandings of menstruation and
normalize menstrual suppression. The case of menstrual suppression birth
control pills provides an opportunity to study the work of redening a bio-
logical process understood as quintessentially natural and deeply signicant
for gendered embodiment. Further, this case provides a challenge to gender
scholarship to consider both the social and material construction of gendered
bodies. What material aspects of menstruation—what interactions of bodies
and hormones, what timing and sources of bleeding—are drawn on to dene
and redene menstruation and menstrual suppression?
In what follows, I rst present a brief discussion of the literature on gen-
dered bodies and technologies, particularly as they relate to menstruation and
menstrual technologies. After introducing my data and methods, I turn to
an examination of how menstruation was redened in two key sites: the rst
is the creation and institutionalization of new scientic categories describing
bleeding, and the second is the promotion of new frameworks for under-
standing bleeding through marketing websites directed at potential users.
The rst site shows how previously known distinctions related to bleed-
ing were made newly salient as clinical categories. The second site, market-
ing websites, shows how changed denitions of bleeding were conveyed to
women. I conclude by exploring how studying both the social and mate-
rial construction of menstruation enhances our understanding of gendered
embodiment.
766 K. A. HASSON
Gendered Bodies, TechnoloGy, and MensTruaTion
There is a rich body of feminist research on gender, bodies, and technologies.
In this section, I bring together feminist literature on the social and material
construction of gendered bodies with technology studies literature emphasizing
how technologies, inscribed with gendered ideologies, are actively used in the
performance of gender. Together, this work explains why promoters of men-
strual suppression would seek to change beliefs that monthly menstruation is
natural and necessary (Mamo and Fosket 2009). Past research has shown that
when gender identities or behaviors inscribed in technologies do not match
dominant gender norms, developers can attempt to change those norms
(Oudshoorn 2003a). The introduction of menstrual suppression prompted not
only a challenge to norms of gendered embodiment, but also a redenition of
menstruation itself.
Feminist studies of bodies and embodiment have provided key tools for
this analysis by showing the ways in which gender norms and ideologies
shape how individuals display and “do” gender using their bodies (Butler
1990; West and Zimmerman 1987); how sexed and gendered bodies are per-
ceived (Friedman 2013); and the appearance, capacities, and biology of bod-
ies themselves (Fausto-Sterling 2005; Young 1990). These scholars theorize
the body as neither purely biological/natural nor purely cultural/ social, but
rather as disrupting these boundaries (Fausto-Sterling 2005; Grosz 1994;
Haraway 1991). Technologies, especially those (like medications) that change
the body invisibly from within, make clear the simultaneously social and
material construction of bodies and the dynamic nature of biology (Mamo
and Fosket 2009; Roberts 2007). Recent feminist theories of materiality go
even further, showing that bodies take shape and shift in relation to both the
material conditions that surround them and the conceptual tools that shape
our understanding of and interventions into biology (Frost 2014; Pitts-Taylor
2016; Roberts 2007; Wilson 2010).
Because menstruation is so closely associated with biological femaleness,
technologies that change menstruation make visible the construction of gen-
dered bodies and challenge the equation of gender and biological sex (Mamo
and Fosket 2009). Menstruation has long served as a central aspect of essen-
tialized, biological understandings of sex difference (at least since the nine-
teenth century) (Laqueur 1992; Martin [1987] 2001), serving as a marker
of biological sex and thus a site of the production of gender on the body.
Since the early twentieth century, the hormonal model of sex has dominated
medical understandings of menstruation (Oudshoorn 1994). Under the hor-
monal model, monthly cycles dene both female biology and sexual differ-
ence. “Unexamined assumptions that normal equals periodically regular”
(Martin 1999, 104) meant that any disruption to or absence of regular cycles
was considered a pathological deviation from the female norm and in need
of medical intervention. Menopause has thus been considered doubly prob-
lematic, with medical literature equating the lack of menstrual cycles to both
56 NOT A “REAL” PERIOD?: SOCIAL AND MATERIAL CONSTRUCTIONS … 767
maleness and a breakdown of communication among bodily systems (Martin
[1987] 2001; Roberts 2007).
One of the rst uses of exogenous sex hormones for women was to correct
menstrual irregularity (Oudshoorn 1994). Later, when oral contraceptives
were rst introduced, they were designed to include regular bleeding, a deci-
sion that most accounts explain was intended to make the pill more accept-
able (to women, the church, and pharmaceutical executives) (Marks 2001;
Watkins 1998). The idea that monthly bleeding would make oral contracep-
tives more acceptable depends on the medical and popular belief that regular
menstrual cycles dene “normal” women’s bodies. By building an approxima-
tion of menstruation into hormonal contraceptives, developers simultaneously
made birth control seem more natural and reinforced the idea that monthly
periods should be the norm by physically producing them in women’s bodies
(Oudshoorn 1994).
Menstruation is just one of many examples that feminist scholars have
drawn on to show how ideologies of gender work through technologies to
shape bodies and subjectivities (Balsamo 1995; De Lauretis 1987; Mamo
and Fosket 2009) and how individuals use technologies to perform gender
(Oudshoorn and Pinch 2003b). “Technologies of gendered bodies” con-
struct the body both materially and discursively to bring them in line with
ideologies of gender (Balsamo 1995; Mamo and Fishman 2001). One way
this happens is through the process of conguration, in which developers
“congure” or “script” gendered users as they anticipate—and, ultimately,
produce—the knowledge, identities, and behaviors ideal users will bring to
their interactions with technologies (Akrich 1992; Oudshoorn and Pinch
2003a; Woolgar 1991). Gendered identities and behaviors can be inscribed
in technologies in ways that “invite or inhibit specic performances of gender
identities and relations,” but users must enact these performances through
active use; in doing so, they can accept, reject, or modify gendered scripts
(Oudshoorn and Pinch 2003b, 10). Attention to technology is a necessary
component of theorizing how individuals do gender and how bodies materi-
alize sex/gender (Oudshoorn 2003b; Roberts 2007).
Users are more likely to take up gendered scripts if they align with dom-
inant gender norms and culturally prevalent embodiments (Oudshoorn
2003b; Roberts 2007, 155). When new technologies challenge hegem-
onic gender identities, the conguration process may be used to shift gen-
der norms (Oudshoorn 2003b). In the case of menstrual suppression birth
control, transforming the body to eliminate menstruation challenges several
aspects of dominant understandings of menstruation and women’s bodies.
Medical and popular understandings identify regular monthly bleeding as
a dening feature of the menstrual cycle and of female bodies; normalizing
menstrual suppression, therefore, meant shifting prominent beliefs about
menstruation across multiple discourses.
One way to shift popular beliefs is through advertising campaigns.
Advertisements for menstrual products signicantly shaped popular discourse
768 K. A. HASSON
and understandings of menstruation across the twentieth century. Emerging
scientic understandings of menstruation and new public discourses of the
body coincided with the mass-production of disposable personal products
and the advertising intended to popularize them (Freidenfelds 2009). Early
ads for pads and tampons sought to instill in women new “modern” under-
standings of the body and menstruation, emphasizing hygienic practices and
secrecy. They worked to persuade women that they did not need to restrict
their activities during menstruation—particularly with the assistance of com-
mercially produced menstrual products that would allow them to conceal
evidence of menstruation (Freidenfelds 2009; Vostral 2008). Later adver-
tisements emphasized freedom, empowerment, and continuous productiv-
ity (Vostral 2008). Other popular culture depictions have furthered ideas of
menstruation as a source of shame and embarrassment, requiring vigilant
self-surveillance to hide all signs of bleeding (Kissling 2006).
These cultural understandings and expectations of menstruation affect
women’s embodied experiences (Martin [1987] 2001). They are critical com-
ponents of culturally prevalent embodiments, particular to a certain place and
time (Lock 1993). As shown by Freidenfelds (2009), U.S. women’s under-
standings and experiences of menstruation changed throughout the twen-
tieth century as they embodied the shift to modernity through the use of
new menstrual technologies. These products facilitated (and were required
by) new norms of embodiment, although their use was taken up unevenly
in ways that reected and exacerbated stratication by class, race, and eth-
nicity. Menstrual technologies and the discourse of “the modern period”
also initiated the “body project” of menstrual surveillance and management
(Brumberg 1998; Freidenfelds 2009). As women increased their activity
outside the home during menstruation amid prevailing norms insisting that
bleeding be hidden, women became responsible for an increasing range of
self-monitoring and body-management tasks. Stigma and secrecy meant that
for many women menarche and menstruation were characterized by shame
and embarrassment (Lee and Sasser-Coen 1996), even as the body project of
managing menstruation could also provide a site of agency, pride, and resist-
ance (Bobel 2010; Fingerson 2006).
While feminists hold a range of positions on menstruation and menstrual
technology, a key focus of many feminist engagements has been valuing
women’s experiential ways of knowing and diminishing stigma (Aengst and
Layne 2010; Bobel 2010). In addition to critiquing scientic representa-
tions of menstruation, feminist researchers have worked to generate new
ones (Dan and Lewis 1992; Fausto-Sterling 2000; Martin 1991). Women’s
health activists have challenged regulatory stances on hormonal birth control
and tampon regulation, innovated new ways of producing knowledge about
women’s bodies through self-help health, and developed new technologies of
menstrual management such as menstrual extraction (Bobel 2010; Morgen
2002). Feminist challenges to dominant understandings of menstruation have
56 NOT A “REAL” PERIOD?: SOCIAL AND MATERIAL CONSTRUCTIONS … 769
emphasized valuing monthly menstruation as a sign of good health, chal-
lenging shame and secrecy, and highlighting how the prot-driven menstrual
product industry risks women’s health (Bobel 2010).
Despite their signicant differences, feminist challenges share with main-
stream medical and popular understandings the belief that regular, monthly
bleeding denes healthy menstruation. The introduction of menstrual sup-
pression birth control challenged this belief, which cyclic hormonal birth
control had played a signicant role in reproducing and reinforcing. By trans-
forming the body to eliminate both visible and experienced signs of men-
strual cycles, menstrual suppression challenges cyclicity as a dening feature
of female bodies. If medical technologies must align with culturally prevalent
embodiments (Roberts 2007) and gender norms and identities (Oudshoorn
2003b), how was menstrual suppression birth control introduced and pro-
moted? I argue that denitions of menstruation were reworked across clinical,
regulatory, and popular discourse. While the taken-for-granted naturalness of
menstruation had allowed the periodic bleeding built into the Pill to natu-
ralize hormonal contraception, the task of normalizing menstrual suppres-
sion required redening menstruation to exclude some forms of bleeding.
This explicit renegotiation of the denition of menstruation provides a clear
view of the social construction of menstruation, as well as an opportunity to
explore how its social construction matters to what menstruation is and its
relation to gendered embodiment.
MeThods
For this research, I analyzed two sets of texts through which new denitions
of bleeding were institutionalized and disseminated. This analysis is situated
in a larger project examining medical, advertising, and regulatory discourses
surrounding menstrual suppression pills and practices more broadly, as well
as how prescribers and women engage these technologies. In this article, I
focus specically on changing denitions of menstruation in regulatory dis-
cussions and advertising for menstrual suppression pills. The rst part of
this article demonstrates the creation and institutionalization of new clinical
denitions of menstrual bleeding, drawing on two sources: transcripts from
the January 23-24, 2007, meeting of the FDA’s Reproductive Health Drug
Advisory Committee, and two articles published in the January 2007 issue
of the journal Contraception that discussed terminology and standards for
measuring bleeding in clinical trials of combined hormonal contraceptives
(CHCs) (Mishell et al. 2007a, 2007b). The second examines new denitions
and terminology for menstruation used on websites promoting menstrual
suppression.
First, I focused on a public meeting of the FDA’s Reproductive Health
Drugs Advisory Committee that convened to discuss the testing and approval
of hormonal contraceptives. This meeting stands as the only public regulatory
770 K. A. HASSON
discussion of extended regimen birth control. The Advisory Committee con-
vened to discuss clinical trial procedures and regulatory guidelines for the
approval of new hormonal contraceptives, including issues pertaining spe-
cically to extended regimen birth control. FDA advisory committee meet-
ings are convened periodically to provide an additional level of review for the
approval of new products, to evaluate safety data and reconsider previously
approved drugs, or to address general questions about the drug approval
process (as in this case) (Institute of Medicine et al. 1992; Leiter and White
2015). Advisory committees supplement the FDA’s in-house expertise
and provide additional scientic legitimacy to FDA decisions that are “too
political” to be decided internally (Jasanoff 1994). The FDA determines in
advance a specic set of questions the committee will address. At the January
2007 meeting, the committee was made up of 20 members, mainly academic
physicians (primarily specialists in obstetrics/gynecology), statisticians, and
epidemiologists, along with one representative each for consumers, patients,
and the pharmaceutical industry. Eight FDA employees also participated in
the meetings (but did not vote). The topics on the meeting agenda included
clinical trial design issues, contraceptive efcacy and risk/benet analysis,
cycle control, extended-dosing regimens, and product labeling.
The meeting agenda, transcripts, and materials are available on the FDA
website.4 I downloaded the meeting transcripts and coded and analyzed
them using Atlas.ti. Through a recursive process of open coding, I identied
categories and themes in the transcripts, such as dening bleeding, patient
responsibility, physician counseling, and providing information. My analysis
here focuses on denitions of menstruation and bleeding, which appeared
primarily in discussions of “cycle control” (i.e., the ability of hormonal con-
traception to produce bleeding at scheduled times and not at other times)
and how to dene, measure, and analyze bleeding data in clinical trials.
In the agenda and questions posed to the advisory committee, the FDA
specically asked for guidance on new guidelines proposed by a group of clin-
ical trial researchers for dening, measuring, and analyzing bleeding in clini-
cal trials of hormonal contraceptives. For this reason, I have included in my
analysis the two journal articles proposing these guidelines. Published in the
January 2007 issue of Contraception, the articles examined bleeding deni-
tions and measures used in previous clinical trials for CHCs and proposed
guidelines for future trials (Mishell et al. 2007a, 2007b). I analyzed these
articles with a particular focus on their discussion of why new guidelines were
necessary, the importance of studying bleeding related to CHCs, and their
specic proposals for dening, measuring, and analyzing bleeding in clinical
trials.
Second, to assess how denitions of menstruation were conveyed to poten-
tial users of menstrual suppression birth control, I analyzed websites promot-
ing menstrual suppression pills and practices. As individuals increasingly turn
to the Internet for health information, pharmaceutical companies have fea-
tured websites as a central component of their direct-to-consumer marketing
56 NOT A “REAL” PERIOD?: SOCIAL AND MATERIAL CONSTRUCTIONS … 771
(Ebeling 2011). These include websites that advertise specic products, as
well as those that are part of “disease education campaigns” meant to raise
awareness of particular diseases while “branding” their association with a
particular medication (Dumit 2012). To examine the meanings circulated
to users, I studied the websites of the available brands of menstrual suppres-
sion pills and those promoting the practice of menstrual suppression more
generally. I draw here on analysis of ve websites accessed in January and
February of 2009. Three were websites for the brands of extended-cycle
and continuous-use oral contraceptives available at that time: Seasonique,
Seasonale, and Lybrel. The fourth was fewerperiods.com, an unbranded web-
site promoting the use of hormonal contraceptives (of all kinds) to suppress
menstruation. Although it did not promote any particular brand or prod-
uct, the website was produced by DuraMed/Barr Laboratories, Inc., mak-
ers of Seasonale and Seasonique, and the company logo could be found at
the bottom of the page.5 Finally, I included materials from the website of the
Association of Reproductive Health Professionals,6 including the interactive
tool, “Menstrual Suppression: What It Is, and How to Do It,” and the fact
sheet, “Health Matters: Understanding Menstrual Suppression.” Both were
developed using unrestricted grants from both Barr and Wyeth.7
These websites represent the web-based marketing for all of the available
brands of menstrual suppression pills at the time of analysis, plus two prom-
inent sites explicitly promoting the practice of menstrual suppression that
purported to provide independent, authoritative, medically sanctioned infor-
mation. While this analysis does not include all online discussions of men-
strual suppression, it does provide a sample of sites that were highly visible
and that were presented as authoritative information about menstrual sup-
pression (vs. blogs or forums). In analyzing the text and images on the web-
site, I examined how menstruation was portrayed, how the websites described
what menstrual suppression birth control is and what it does, and how the
websites constructed potential or ideal users of menstrual suppression birth
control.
redefininG MensTruaTion
Scientic Categories and Institutionalization
In January 2007, members of the FDA’s Reproductive Health Drug Advisory
Committee met to discuss a range of issues affecting clinical trials, FDA
approval, and postapproval follow-up for new hormonal contraceptives.8
Cycle control was one of seven main topics on the meeting agenda. Two
points were provided to frame the discussion: (1) New birth control pills
approved in recent years (including one under FDA review at the time of the
meeting) were taken in an extended cycle that postponed bleeding and prom-
ised women fewer periods; however, users complained of frequent and unpre-
dictable bleeding. (2) Changes in the hormonal makeup of contraceptives,
772 K. A. HASSON
especially lower doses of estrogen, made breakthrough bleeding more com-
mon. The FDA posed two questions related to cycle control. The rst was
how researchers should assess bleeding patterns and cycle control in clinical
trials—specically, whether the FDA should adopt in their clinical trial guide-
lines a recently published proposal for dening and measuring bleeding. The
second question was whether the FDA ought to ensure that extended reg-
imen pills actually produced fewer overall days of bleeding. To prepare the
committee for discussing the rst question, Dr. James Trussell, one of the
authors, presented the research and proposed guidelines to his fellow com-
mittee members. Because they were at the center of the advisory committee’s
discussion, I analyze the proposed guidelines in detail before returning to the
committee meeting.
The guidelines were developed at the 2005 Hormonal Contraceptives
Trial Methodology Consensus Conference (Mishell et al. 2007a, 2007b).
Consensus conferences such as this one are often convened to develop and
agree on new diagnoses, assessments of medical technologies, or guidelines
for clinical decision making (Fishman 2004). This particular conference was
funded by an unrestricted educational grant from Duramed Pharmaceuticals,
which was at that time in the midst of clinical trials for Seasonique, a
follow-up product to Seasonale. Two articles, coauthored by several clinical
trial researchers, were published to convey the results of the conference. Of
the seven coauthors, six disclosed nancial and other ties to Duramed and
Wyeth, the two companies with menstrual suppression birth control pills
on the market or under FDA review (Mishell et al. 2007a).9 These ties to
Duramed and Wyeth suggest that, while the guidelines do not explicitly refer-
ence extended regimen pills, the authors were likely aware that their propos-
als could affect clinical trials and FDA review of menstrual suppression pills
under review or in development.
The rst of the two articles examined the methods of evaluating bleeding
used in clinical trials of CHCs approved between 1975 and 2003 (Mishell
et al. 2007a). Explaining that lower hormone doses in more recent contra-
ceptives resulted in higher rates of breakthrough bleeding and spotting, the
authors argued that physicians need better data on how CHCs affect bleed-
ing patterns to inform their prescribing decisions and patient counseling. The
information available to physicians and consumers is, in some ways, limited to
the information requested and reviewed by the FDA in the process of approv-
ing a new drug. Therefore, changing the information requested by regula-
tors would also change the data collected by clinical trials and the information
available to prescribing physicians and consumers. The FDA reviews drugs
based on criteria of safety and efcacy; because bleeding patterns had not
previously been considered relevant, the FDA had not required companies to
provide information on cycle control when applying for approval of a new
hormonal contraceptive. The article showed that individual regulators had at
times asked for and evaluated information on bleeding patterns according to
56 NOT A “REAL” PERIOD?: SOCIAL AND MATERIAL CONSTRUCTIONS … 773
their own interest and expertise, but that the amount and format of informa-
tion included in the reviews varied widely—and thus so had the information
available to physicians and consumers as they decided which hormonal con-
traceptives to use (Mishell et al. 2007a).
The authors’ review of existing clinical trials focused on the lack of consist-
ent measures for bleeding and the shortcomings of the most commonly used
terminology. Previous clinical trials and New Drug Applications for CHCs
varied widely in how they dened bleeding, how they collected informa-
tion about it, and how they analyzed and reported their data. Despite over-
all inconsistency, the most commonly used bleeding categories were those
dened by the “Belsey criteria,” introduced by World Health Organization
researchers in the 1980s. Half of the studies used the criteria in some form
(Mishell et al. 2007a, 6). The Belsey criteria established two categories:
“bleeding” and “spotting.” Bleeding is dened as “any bloody vaginal dis-
charge that requires the use of such protection as pads or tampons,” and
“spotting” as “any bloody vaginal discharge that is not sufcient to require
protection” (Belsey, Machines, and d’Arcangues 1986, 255). The main dis-
tinction between these categories is the amount of bleeding, determined by
whether menstrual products would be used to manage it.
The authors critiqued the Belsey criteria for not accounting for the timing
of bleeding and not distinguishing between bleeding produced by the with-
drawal of contraceptive hormones and menstruation occurring in the absence
of exogenous hormones. For these reasons, the authors argued that the
Belsey criteria were not well suited to describing bleeding in studies of CHCs,
despite their frequent use. They stated:
While valuable for providing denitions and global descriptions of bleeding pat-
terns associated with various methods of contraception, these criteria are not . .
. particularly useful for the reporting of cyclic bleeding in women using CHCs.
. . . [T]he unmodied criteria do not differentiate bleeding occurring during
active hormone therapy from that occurring during placebo interval, making
the determination of the incidence of unscheduled bleeding/spotting difcult.
(Mishell et al. 2007a, 9)
To address these shortcomings, the authors put forth in a second article new
guidelines for dening, measuring, and reporting bleeding patterns (Mishell
et al. 2007b). They proposed that researchers track the timing of bleeding,
particularly with respect to whether it occurs during “placebo intervals” or
while taking active hormones. The new guidelines stressed that researchers
concerned with bleeding patterns related to hormonal contraception must
distinguish bleeding from menstruation, and provided new terminology for
doing so:
The use of traditional terminology (“periods” or “menses”) should be aban-
doned with regards to CHCs and replaced by the use of “scheduled bleeding”
774 K. A. HASSON
or “withdrawal bleeding.” E.g., any bleeding or spotting that occurs during
hormone-free intervals regardless of the duration of the regimen. “Scheduled
bleeding” emphasizes to the woman that her bleeding with hormonal methods
is not the same as menstruation. (Mishell et al. 2007b, 13)
The authors proposed replacing the “traditional terminology” of periods and
menses with new terminology that “emphasizes to the woman” the differences
between hormonally produced bleeding and menstruation. In accordance
with pill developers’ intentions, many pill users recognize the familiar expe-
rience of monthly bleeding as a period, regardless of its physiological differ-
ences from menstruation. In contrast, the proposed terminology emphasizes
bleeding as a side effect of birth control hormones that is “not the same as
menstruation.” While the published recommendations are directed to clinical
researchers, here the authors specically focus on changing how women think
about their bleeding patterns.
Since before the introduction of the rst hormonal contraceptive, researchers
had known the distinction between bleeding produced by the withdrawal of
birth control hormones and menstruation in the absence of synthetic hormones
(Marks 2001). Specifying in the proposed guidelines that the terminology would
apply to regimens of any duration suggests that this distinction is particularly
important in the context of extended regimen contraceptives. The introduction
of birth control pills intended for menstrual suppression provided the conditions
in which this distinction became newly salient, prompting efforts to convince
researchers of its signicance.
At this point, my analysis returns to the FDA, where these new guide-
lines and categories structured the advisory committee’s discussion of cycle
control. In setting the agenda for the advisory committee meeting, the FDA
directly asked the committee to evaluate the proposed guidelines and make
a recommendation about whether the FDA should adopt them. Following a
presentation of the guidelines, the committee’s discussion focused primarily
on the proposed terminology. Many committee members concurred that new
terminology would communicate to women that withdrawal bleeding is not
menstruation. Committee chair Lockwood, for example, praised the recom-
mended language for emphasizing the differences between bleeding on and
off hormonal contraceptives, stating that the new vocabulary “moves away
from mixing metaphors with both physiologic and pharmacological pro-
cesses” (U.S. FDA transcript, January 24, 2007, 15-16). Committee mem-
ber Johnson favored the new standards because “both physicians and patients
need to know what we mean when we say bleeding and spotting” (U.S. FDA
transcript, January 24, 2007, 15).
However, not everyone at the meeting agreed that the new language
would be easier to understand. One senior FDA ofcial asked the committee
to revisit the question of how to convey cycle control information to consum-
ers. Scott Monroe, acting director of the FDA Division of Reproductive and
Urologic Products, asked whether moving away from familiar language for
56 NOT A “REAL” PERIOD?: SOCIAL AND MATERIAL CONSTRUCTIONS … 775
describing bleeding might cause more, rather than less, confusion for con-
sumers. Specically, he asked how to describe bleeding patterns produced by
extended regimen pills:
When we think in terms of a traditional monthly cycle, it is fairly easy to con-
ceptualize things [bleeding patterns]. . . . But then when you are talking about
longer intervals . . . let’s say it is an 84/7 [extended regimen] or a continuous
[regimen] . . . then you have to start doing all this mental sort of arithmetic if
you are trying to go back and relate it to a more traditional pill. We wondered if
. . . everybody can instantly do the mental mathematics . . . ? I don’t think your
average person thinks in terms of numbers of anticipated bleeding days over a
year, the numbers of withdrawals, and so on. (U.S. FDA transcript, January 24,
2007, 42-43)
Monroe highlighted that shifting to the language of withdrawals or antici-
pated bleeding days, instead of “periods,” might make it more difcult for
women to understand and compare extended and traditional pill regimens
and their effects on bleeding.
The advisory committee voted to approve the proposed guidelines. In
doing so, they institutionalized new categories for different types of bleeding.
Because FDA guidelines dictate the information that future clinical trials will
collect, they can determine what information the FDA can provide to phy-
sicians and consumers. Adopting these guidelines meant that potential users
would also need to adopt—or at least under-stand—these categories to make
sense of the information available about hormonal contraceptives.
The proposal and discussion of new guidelines for measuring and evaluat-
ing bleeding demonstrates the work required to make the known distinction
between menstruation and withdrawal bleeding salient for clinical researchers,
regulators, and physicians. Further, the discussion of terminology highlights
that both researchers and regulators were explicitly concerned with changing
how women think about bleeding. Establishing and institutionalizing new
terminology and clinical categories of bleeding facilitated the normalization
of menstrual suppression by changing the object on which menstrual suppres-
sion birth control acts: not menstruation, but “scheduled” or “withdrawal”
bleeding.
Not a “Real” Period
Prior to the initial consensus conference and ensuing FDA discussions, phar-
maceutical advertising campaigns had already been working to change popu-
lar understandings of menstruation as they introduced menstrual suppression
birth control (Mamo and Fosket 2009). On their websites and in print cam-
paigns, the companies introduced potential users to menstrual suppression
through images of an idealized lifestyle achievable with menstrual suppression
and information that preempted questions about what is normal, natural, and
776 K. A. HASSON
safe. They presented detailed explanations of the menstrual cycle and intro-
duced women to the “pill period”—a new term for the “scheduled” bleed-
ing that occurs when women are taking cyclic hormonal birth control. In this
section, I focus on these explanations of menstruation and the distinctions
made between different kinds of periods.10 Although the websites continued
to use the language of “periods,” they stressed the same distinction between
bleeding on and off the pill that was highlighted in the clinical guidelines.
Promoting a new understanding of the experience of menstruation, this dis-
tinction brought attention to the ways that all hormonal birth control alters
menstruation. In this way, pharmaceutical companies pioneered efforts to
change how women understand menstruation that researchers and regulators
took up later.
The language of “pill periods” is specically tailored to the context of
menstrual suppression; it is therefore important to examine closely how the
websites construct these kinds of periods. The work of redening menstru-
ation gured prominently on the websites: all ve devoted signicant space
to describing how the menstrual cycle works with and without the effects of
hormonal birth control. The descriptions were structured around the distinc-
tion between bleeding on and off the pill, divided into three categories: the
“regular” or “basic” menstrual cycle, the cycle when taking hormonal con-
traceptives, and the cycle when using hormonal birth control to suppress
menstruation.11 See Figure 56.1 for a representative example from the Lybrel
website.
As described in Figure 56.1, the “regular monthly period” occurs when
hormones “naturally rise and fall.” In contrast, the “traditional birth control
period,” or “pill period,” results from the withdrawal of hormones during
the placebo week. The new intermediary category of the “pill period” is built
on the assumption of a fundamental difference between bleeding that occurs
“naturally” and bleeding that occurs when taking hormonal contraceptives.
The “pill period” is explained as a side effect of the pill itself. Finally, the web-
site states that with Lybrel women “do not have regular menstrual periods
or ‘pill periods,’” because the pills provide continuous levels of hormones.
Distinguishing between types of bleeding takes on new importance with
the existence of menstrual suppression technology: “pill periods” are sup-
pressed, not “regular periods.” The purpose of introducing the “pill period,”
then, is to promote its suppression. As an intermediary between the “natu-
ral” menstrual cycle and menstrual suppression, the “pill period” normalizes
menstrual suppression and repositions some forms of monthly bleeding as
articial, rather than natural.
The idea that women “do not have regular menstrual periods” seems rel-
atively clear in the case of Lybrel, which is taken continuously to suppress
both “regular” menstruation and “pill periods.” However, the websites for
Seasonale and Seasonique make similar claims, even though they are designed
to produce four bleeding periods per year. How do these websites dene
menstruation in a way that distinguishes the periodic bleeding they produce
56 NOT A “REAL” PERIOD?: SOCIAL AND MATERIAL CONSTRUCTIONS … 777
from “regular menstrual periods”? As seen in this quote from seasonique.
com, one approach is to deemphasize menstruation as the key event of the
menstrual cycle:
When you take a birth control pill, you don’t have a menstrual cycle—your
body doesn’t prepare for pregnancy because you don’t ovulate. As a result, your
uterine lining doesn’t build up, so there’s no need to shed it. This is the reason
you don’t need to bleed every month when you take the Pill.12
To say that women taking birth control pills “don’t have a menstrual cycle,”
the websites identify ovulation as the dening feature of the menstrual cycle.
Because all hormonal birth control suppresses ovulation, by focusing on
ovulation they suggest that all birth control pills are already suppressing the
menstrual cycle. The fewerperiods.com website makes this point explicitly,
stating that the “pill period” is “the reason having fewer periods is possible
when you use hormonal birth control.” In other words, all hormonal birth
control pills suppress “real” periods, but “traditional” pills produce unnec-
essary bleeding as a side effect and disguise it as a “pill period.” These state-
ments assume that potential users already use hormonal birth control and will
Fig. 56.1 “How Lybrel Works” from www.lybrel.com. (Source https://www.lybrel.
com/works/. Credit: Wyeth Pharmaceuticals)
778 K. A. HASSON
accept menstrual suppression once they learn that they are already suppress-
ing their menstrual cycles and inducing a “fake” pill period.
In this way the websites work to revise—and perhaps even delegitimize—
women’s knowledge and experiences of menstruation. The “Fewer Periods”
website addresses how hormonal contraceptive users experience menstrua-
tion when it says, “The light, short bleeding that you experience on the Pill
isn’t a real menstrual period—it’s actually a ‘Pill period,’ which is due to
the withdrawal of hormones in your active pills.”13 Women taking hormo-
nal birth control who experience regular monthly bleeding often understand
that bleeding to be a menstrual period (as developers intended), and some
might nd this distinction irrelevant if the bodily sensations and effects are
the same. Menstrual suppression websites encourage users to question this
embodied experience of monthly bleeding, reinterpreting it as a “pill period.”
Redening menstrual cycles around uctuating hormone levels and ovulation
shifts the dening event from something women feel and see—bleeding—to
something (most) women experience less directly.
The “pill period” narrative revises existing knowledge about menstruation
and provides a new interpretation for current and past experiences of bleed-
ing. It encourages pill users to reinterpret all previous experiences of bleeding
while on the pill, applying a new understanding that these were never “real
periods.” Like the clinical guidelines, the websites focus on changing how
women think about menstruation, emphasizing that the bleeding that occurs
when taking hormonal birth control is not actually menstruation, and thereby
introducing new categories of bleeding. While this information is technically
more accurate, it is important to ask why it appears only in conjunction with
discussions of menstrual suppression.
Menstruation as Multiple
What work does this proliferation of bleeding categories do to undermine the
seemingly obvious naturalness of menstruation? The revision of clinical, reg-
ulatory, and popular understandings of menstruation reversed the efforts of
hormonal contraceptive developers, who built in regular monthly bleeding
intending that it would be perceived as a period and that the assumed nat-
uralness of menstruation would extend to birth control itself. To the extent
that the experience of withdrawal bleeding has been considered a “period,”
normalizing menstrual suppression birth control necessitates denatural-
izing bleeding by breaking the automatic association of monthly bleeding
with “natural” menstruation. To redene menstruation, researchers, regu-
lators, and advertisers identied and highlighted certain material differences
in bleeding—the presence or absence of “naturally” uctuating hormones or
ovulation, for example—to create new categories of bleeding.
Proliferating types of bleeding reveals as many and changeable what
seemed to be a single natural phenomenon. Introducing the idea that
many kinds of bleeding have been and continue to be misrecognized as
56 NOT A “REAL” PERIOD?: SOCIAL AND MATERIAL CONSTRUCTIONS … 779
menstruation made visible “the coexistence of multiple entities that go by the
same name” (Mol 2002, 151). Menstruation was revealed as “multiple,” “a
single [bodily process] that in practice appears to be more than one— with-
out being fragmented into many” (Mol 2002, 151). This multiplicity had
been made coherent and stable through the socially meaningful experience
of bleeding once per month and the taken-for-granted naturalness of men-
struation. As Mol notes, when conicting multiples of the body become
apparent, “one reality wins” (2002, 55). Coherence could be (re) achieved by
instituting hierarchy—“real” menstruation as dened by “natural” hormonal
uctuations was placed above the newer categories of “scheduled” or “with-
drawal” bleeding and “pill periods,” which would no longer be considered
menstruation.
In this case, the proliferation of bleeding categories was re-hierarchized
and used to narrow the denition of menstruation and support its suppres-
sion. However, there is opportunity for gender scholars in recognizing men-
struation as multiple by taking seriously the material differences in bleeding
that were mobilized to redene menstruation. The hormone levels pro-
duced by hormonal contraceptives and the effects on the uterine lining of
their abrupt withdrawal during a placebo week do differ from a menstrual
cycle unaffected by external hormones. In what ways does it matter—and to
whom—that withdrawal bleeding is different from menstruation? Examining
“multiple” menstruation as revealed in this process of its redenition allows
feminist scholars to theorize how this particular “meeting of the conceptual
and the biological has material effects” (Pitts-Taylor 2016, 42).
conclusion
Cultural associations of menstruation with biological sex, nature, reproduc-
tion, and femininity make it an overdetermined site for the examination of
gendered embodiment. Considering technologies that intervene in gendered
bodies provides a vantage point from which to reconsider aspects of embod-
iment taken for granted as xed, as they are socially and materially recon-
structed. While we often take for granted what menstruation is, this case
reveals coordinated effort across multiple realms to redene menstruation
by disaggregating the many types of bleeding that have been understood as
menstruation.
This article has shown how categories of bleeding developed for use
in clinical trials and institutionalized by the FDA aligned with online mar-
keting campaigns for menstrual suppression by emphasizing the distinction
between menstruation and withdrawal bleeding. This distinction challenges
a longstanding equation of menstruation with both nature and biological
sex that has been central to the relationship between birth control hormones
and bleeding. Almost 50 years after the development of oral contraceptives,
with the introduction of menstrual suppression birth control, pharmaceu-
tical companies worked to undo the acceptance of all monthly bleeding as
780 K. A. HASSON
menstruation. They disclosed that oral contraceptives produced a “pill
period” that was not a “real” period, and therefore unnecessary. Advertising
campaigns promoted this new denition for reinterpreting the familiar experi-
ence of monthly bleeding. Scientists and regulators also took aim at the mis-
recognition as menstruation of multiple forms of bleeding. They proposed
using the category of “scheduled” or “withdrawal” bleeding to distinguish it
from menstruation.
The redenition of menstruation undoubtedly provides another example
of the social construction of the body and gender, and a further rejection of
biological essentialism. The explicit re-negotiation of biological facts across
a wide range of institutions—scientic research, medicine, pharmaceutical
industry, federal regulators—offers further evidence that even the most irre-
ducibly biological processes have been and continue to be subject to rein-
scription with new meanings. And yet, stopping here would again shy away
from grappling with biology, with what is going on materially in the body.
What response can feminist scholars and advocates give to the claim that “pill
periods” are not “real” periods and are therefore unnecessary? Without the-
oretical tools to address material differences in bleeding, some may be left to
call on something like a “natural” period and its importance to women’s biol-
ogy to critique or reject menstrual suppression.
In past encounters with these “interactions between the social and the bio-
logical that are not, or not only, linguistic or discursive” (Frost 2014, 316),
feminist scholars have missed chances to analyze how “the meeting of the
conceptual and the biological has material effects” (Pitts-Taylor 2016, 42).
Feminist science studies scholars continue to argue that the dynamic multi-
plicity of biology undermines and explodes essentialist categories and bio-
logical determinism (Fausto-Sterling 2005; Frost 2014; Pitts-Taylor 2016;
Roberts 2007; Wilson 2010). Taking seriously the material differences high-
lighted here in the process of redening menstruation allows feminist scholars
to theorize menstruation—and gendered embodiment—as multiple, high-
lighting the variation and dynamism of biology in its interactions with tech-
nology (Pitts-Taylor 2016).
The axiom of menstrual activism that “not all women menstruate, and
not all menstruators are women” does not need to be taken as a rejection
of biology and its relationship to gendered embodiment. It can be a call to
investigate the interrelated social and material construction of menstruation
and gender, exploring and highlighting “the capacity of biological substance
to forge complex alliances and diverse forms” (Wilson 2010, 197). Complex
arrangements of organs, tissues, hormones—produced in the body or taken
in from outside—generate embodied experiences of regular, irregular, or
absent bleeding. These occur in the context of gender binaries and cultural
norms that demand management and concealment of bleeding, along with
menstrual technologies that facilitate this. We can analyze these “complex alli-
ances” that produce women that do or do not menstruate, menstruators who
56 NOT A “REAL” PERIOD?: SOCIAL AND MATERIAL CONSTRUCTIONS … 781
may or may not be women. Taking for granted what menstruation is and how
it is dened obscures what can be learned by remaining open to menstrua-
tion’s multiplicity and its relationship to gendered embodiment. Sociologists
of gender and embodiment can enhance and strengthen our analysis by theo-
retically and empirically engaging the material aspects of biology as always in
relation and interaction with their representations in specic social and histor-
ical contexts.14
noTes
1. “Not a Real Period?”: Social and Material Constructions of Menstruation by
Katie Ann Hasson was rst published in 2016 in Gender & Society 30 (6):
958–983. Reprinted with permission. No further reproduction or distribution
of the material is allowed without permission from the publisher.
2. Menstrual activists challenge this belief, pointing out that not all women
menstruate and not all who menstruate are women, and use the term
“menstruator” rather than women (Bobel 2010).
3. Menstrual extraction is a technique developed by feminist self-help health activ-
ists for removing the contents of the uterus at the (expected) start of a wom-
an’s period (Murphy 2012).
4. http://www.fda.gov/ohrms/dockets/ac/cder07.htm#rhdac.
5. The fewerperiods.com website is now defunct and the URL redirects to sea-
sonique.com. DuraMed Pharmaceuticals and its parent company, Barr
Laboratories, have been acquired by Teva Women’s Health, Inc.
6. ARHP was founded as “the education arm of Planned Parenthood Federation
of America (PPFA) and incorporated as an independent organization in 1972”
(http://www.arhp.org/about-us/about-arhp).
7. These websites were part of Duramed’s advertising strategy for Seasonique
(Saul 2007).
8. The discussion included oral contraceptives as well as transdermal and vagi-
nal rings, but excluded injectable contraceptives (DepoProvera) and implants
(Implanon, etc.).
9. The only author who did not report nancial conicts of interest was James
Trussell. These connections do not necessarily indicate sinister intent. Clinical
trial researchers are structurally positioned between drug developers, regula-
tors, and prescribers (Fishman 2004). However, nancial ties to pharmaceutical
companies have been shown to affect study outcomes (Sismondo 2008).
10. Elsewhere I explore how depictions of menstrual suppression’s ideal users and
lifestyles convey classed and racialized meanings that reect and reinforce strat-
ied access to reproductive technologies.
11. In contrast, websites for cyclic birth control pills (e.g., Ortho TriCyclen Lo
and LoEstrin) did not present detailed information about the menstrual cycle
or discuss “pill periods” and how they differ from “regular” periods. Cyclic
pills have little to gain from making a distinction between different kinds of
periods.
12. http://seasonique.com/Consumer/BodyAndPeriod/FewerPeriodsPossible.
aspx [emphasis added].
782 K. A. HASSON
13. http://fewerperiods.com/FewerPeriodsPossible/Default.aspx.
14. I would like to thank Rene Almeling, Kate Darling, Dawn Dow, Hannah
Landecker, Martine Lappe, Sarah Macdonald, Theresa MacPhail, Silvia Pasquetti,
Leslie Salzinger, Jade Sasser, Rachel Washburn, Raka Ray and the members of
her gender working group, and the USC Sociology Social Organization reading
group for their feedback on earlier versions of this paper, with special thanks to Jo
Reger and the anonymous reviewers from Gender & Society for their generous
comments. This work has also beneted from feedback provided after presenta-
tions to the Body and Embodiment Section at the 2013 ASA Annual Meeting
and the Center for Feminist Research at USC.
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