How to have a Period-Free Hajj

by Dr. Sameena Rahman

“As-Salaam-alaikum Doctor, I’m wondering if I can get your advice. I’m planning to go for Hajj (Muslim pilgrimage to Mecca), and I want to make sure I don’t get my period while I’m there. What are my options?”

For the last few weeks, I’ve been bombarded with patients making appointments to seek my guidance as they prepare to embark on this journey of a lifetime. I have a private gynecology practice in downtown Chicago, where a number of Muslim patients seek my care as an unapologetically Muslim woman. Usually, patients visit my office for routine care, contraception, or gynecologic issues. However, immediately following Eid-al-Fitr, my office fills with patients who have decided to perform Hajj, fulfilling one of the five pillars of Islam, and wondering whether or not they’ll be on their period at that time. I decided to write this article in order to provide additional guidance to my audience as they venture out to their own gynecologist or other health care provider to seek menses suppression.

However, this article is not meant for the utilization of a universal treatment paradigm for all readers, as each patient should be considered within the context of their medical and family history. Additionally, this is not meant to provide religious guidance or reflect any fatwas or decrees from religious authorities about whether or not it is permissible to take medication, modify menses, or enter sacred areas when menstruating.

That being said, for a woman with normal monthly menstruation to obtain optimal results, I recommend seeking medical advice from a gynecologist 2-3 months prior to the trip. For premenopausal women, attempting to eliminate menses can be successfully achieved with a combination oral contraceptive pill containing both estrogen and progestin components. Please speak with your health care provider if you have any contraindications to estrogen administration, including previous thromboembolic events or strokes, a history of estrogen-dependent tumors, active liver disease, undiagnosed abnormal uterine bleeding, or any comorbidities, such as simultaneously being over 35 years old, a cigarette smoker, and obese.

For my patients, I usually recommend a monophasic combined oral contraceptive pill, meaning that there is a consistent amount of progestin and estrogen delivered everyday throughout the cycle. This monophasic option comes in a pack of 28 pills per cycle, with the last 7 pills being the placebo, or “sugar pill.” In order to prevent getting their period while on Hajj, I advise my patients to skip the placebo pills and start the next pack of contraceptive pills immediately. I also advise my patients to take an extra pack of pills with them on the trip. For some, the mental and physical stress that comes from traveling and performing the rites of Hajj can cause intermittent bleeding. Because of this, I usually avoid low-dose monophasic pills. My preferred prescriptions include ethinyl estradiol doses of at least 30-micrograms and a variety of progestins, such as Ocella, Zarah, Yasmine, Ortho-cept, Ortho-cyclen, Apri, Microgestin. The pills should be taken around the same time daily, as missing one or two doses can lead to breakthrough bleeding and irregular spotting, often causing some panic and distress for female hajj participants. Another viable option is Seasonique, a pack of 84 active hormone tablets, which is specifically utilized for extended elimination of menstrual flow. However, unscheduled bleeding often occurs during the first few months of use, and therefore it might not be ideal for women preparing just a few months prior to Hajj.

Other options include the transdermal contraceptive patch, Xulane, which is applied every week for 3 weeks, and the vaginal contraceptive ring, NuvaRing, which is inserted vaginally once every 3 weeks. Both of these are combination estrogen and progestin methods and can be utilized continuously to prevent menstrual flow, rather than skipping a week of placebo pills to achieve the same effect. However, the transdermal patch is known to produce higher levels of estrogen in blood circulation, so it is generally avoided for the potential risk of blood clotting in the extremities or lungs. The data on the effectiveness of using the vaginal ring continuously is conflicting; however, I have had many patients utilize the ring continuously with great success and no unexpected bleeding on their trips! Some of my patients are uncomfortable inserting or leaving a contraceptive ring in their vagina, and so It is not always my “go-to” treatment option.

For those who are unable to take estrogen pills, taking a continuous dose of the progestin-only pill can reduce their flow, but limited success is seen in eliminating breakthrough bleeding. This can be discussed with your physician on a case-by-case basis. There are also progestin-only intrauterine devices, like the Mirena. In high enough doses, or if inserted early enough, approximately 6 month prior to Hajj, these can be helpful in eliminating menstrual cycles. While careful guidance regarding the risks and benefits of the device and its long-term use should be discussed with your physician at length, it is a great contraceptive method and menstrual suppressant when inserted in advance. Many women have uterine pathology such as fibroids or polyps, or medical conditions, such as Polycystic Ovarian Syndrome (PCOS), or other diagnoses that lead to heavy or irregular menstrual flow. This should be evaluated and discussed before attempting menstrual suppression with standard methods. In these situations, menstrual suppression can still be obtained, but other methods or a combination of medications or procedures may be needed in order to achieve a bleeding free interval during your pilgrimage!

I believe that if you convey to your gynecologist or health care provider that you are embarking on a special, once in a lifetime experience and ensure a full evaluation of any abnormal bleeding problems, one of the options above could be the right choice for you.

Dr. Sameena Rahman is a gynecologist-obstetrician in Chicago.