Why does amenorrhea occur with Freya 28 (ethinyl estradiol and gestodene)?

Amenorrhea with Freya 28 (Ethinyl Estradiol and Gestodene)

Amenorrhea during Freya 28 use is a common, expected side effect that does not require medical treatment and is not harmful to health. 1

Mechanism of Amenorrhea with Combined Hormonal Contraceptives

• Freya 28 contains ethinyl estradiol (synthetic estrogen) and gestodene (progestin), which work together to suppress the hypothalamic-pituitary-gonadal (HPG) axis 1
• This suppression leads to inhibition of gonadotropin-releasing hormone (GnRH) pulsatility, which disrupts normal gonadotropin release 1
• The altered hormonal environment prevents the normal endometrial build-up that would occur in a natural menstrual cycle 1
• Specifically, the continuous hormonal levels maintain a thin endometrial lining that may not shed during the hormone-free interval 2

Prevalence and Clinical Significance

• Amenorrhea occurs in approximately 2.7-2.9% of cycles with low-dose ethinyl estradiol/gestodene combinations 2
• In clinical studies of gestodene-containing pills, amenorrhea was observed in 0.6-0.7% of cycles with higher doses and up to 2.7% with lower doses 3, 2
• The incidence of amenorrhea is similar between gestodene and other progestins like desogestrel (2.7% vs 2.9% of cycles) 2, 4

Clinical Management

• Amenorrhea with Freya 28 does not require any medical treatment - reassurance is the appropriate management 1
• If a woman's regular bleeding pattern changes abruptly to amenorrhea, pregnancy should be ruled out if clinically indicated 1
• No additional examinations are needed if amenorrhea is the only symptom without other concerning clinical signs 5
• If the woman finds amenorrhea unacceptable despite reassurance, counseling on alternative contraceptive methods should be offered 1

Health Implications

• Amenorrhea from hormonal contraceptives does not have the same negative health implications as amenorrhea from hypothalamic dysfunction or energy deficiency 1
• Unlike amenorrhea associated with the female athlete triad or RED-S (Relative Energy Deficiency in Sport), contraceptive-induced amenorrhea does not lead to bone mineral density loss 1
• Contraceptive-induced amenorrhea does not cause the hormonal alterations seen in energy deficiency states (such as decreased estradiol, decreased T3, increased cortisol) 1

Patient Counseling Points

• Amenorrhea should be discussed during contraceptive counseling before starting Freya 28, as understanding expected bleeding patterns reduces discontinuation rates 1, 5
• Patients should be reassured that amenorrhea while on combined hormonal contraceptives is not harmful 1
• Bleeding patterns may change over time with continued use of the contraceptive 5
• The absence of withdrawal bleeding does not indicate decreased contraceptive efficacy 1

When to Consider Further Evaluation

• If amenorrhea is accompanied by other symptoms such as pelvic pain or abnormal vaginal discharge 5
• If there are abrupt changes in bleeding patterns that suggest other pathologies 5
• If amenorrhea persists after discontinuation of the contraceptive 6