Can a Benzodiazepine, or a Benzodiazepine Taper, Change a Woman’s Period?

Can a benzodiazepine, or a taper, change a woman’s period?

Yes, in some women, although the evidence is limited. Some notice irregular, late, heavier, lighter, or missed periods while taking a benzodiazepine such as alprazolam (Xanax), clonazepam (Klonopin), lorazepam (Ativan), or diazepam (Valium). Others notice the change only after a taper begins. The mechanism is unknown, but the cycle often settles during or after a slow taper.

Most women who ask this question took the medication exactly as prescribed, often for years. The nervous system adapted to it, which is called physical dependence, and dependence is not addiction. It is a medical condition caused by a prescription, and it deserves a medical answer.

So, what is actually known, what is not, and what should a woman do when her cycle changes in the middle of a taper?

What does the Ashton Manual say about periods?

It says more than most prescribers know, and less than patients would like. In Chapter III of the Ashton Manual (benzo.org.uk), Professor C. Heather Ashton included “menstrual difficulties” in Table 1, her list of benzodiazepine withdrawal symptoms. In the same chapter she wrote that benzodiazepines “undoubtedly have effects on the endocrine system,” the body’s network of hormone-producing glands, but that these effects “have not been closely studied in humans.”

She was just as careful about cause. Many women complain of menstrual problems, she wrote, yet such problems are common in the general population, and there is “no clear evidence” that they are directly attributable to benzodiazepines. She also cautioned that few if any of the symptoms in her table are specific to benzodiazepine withdrawal.

The picture has not sharpened much since. Benzodiazepines strengthen the effect of gamma-aminobutyric acid (GABA), the brain’s main calming chemical, and the Manual’s opening chapter lists endocrine gland secretions among the functions that may be impaired as a result. The menstrual cycle is timed by hormone signals that begin in the brain, so an effect is plausible.

In fact, how it would happen, and in whom, is not known. Anyone who says that a benzodiazepine raises or lowers estrogen or progesterone in a predictable way is claiming more than has been shown.

Unfortunately, the prescription is rarely the first suspect.

When a period goes missing or turns erratic, a gynecologist works through a sensible list. Pregnancy, thyroid problems, a change in weight, heavy stress, polycystic ovary syndrome, and perimenopause, the years leading up to menopause, are all on it. A benzodiazepine that the patient has taken for years, exactly as directed, usually is not.

Patients often describe the same sequence. The cycle changed, the tests came back normal, and nobody asked about the benzodiazepine that another doctor had called safe for long-term use.

That sequence is not proof of anything. While a benzodiazepine should not be blamed for every change in a cycle, it should not be left off the list either. Both mistakes are easy to make.

Why can periods change during the taper itself?

Withdrawal is one possible reason. Both the Ashton Manual and the Maudsley Deprescribing Guidelines list menstrual changes among withdrawal symptoms. Yet, Professor Ashton found no clear evidence that they are directly caused by the medication. As the dose comes down, the nervous system has to readjust, and the body systems it helps to regulate can be unsettled for a while. Professor Ashton’s table places “menstrual difficulties” on the same list as flushing, sweating, palpitations, and insomnia.

Patients describe late or skipped periods, cycles that shorten and then lengthen again, and flow that is heavier or lighter than usual. Some had these changes before the taper began, because withdrawal symptoms can appear at a steady dose, a pattern known as tolerance withdrawal.

The influence also seems to run the other way. Many patients report that withdrawal symptoms flare around the time of a period. Many also say that perimenopause can set off a stretch of worse symptoms, known as a wave. The Ashton Manual does not address this, but the Maudsley Deprescribing Guidelines do. The Guidelines describe many women reporting worse withdrawal symptoms at the time of their period. They also explain that sex hormones such as progesterone strengthen the effect of benzodiazepines. So, the natural rise and fall of these hormones through the cycle, and in menopause, can add to withdrawal symptoms.

Perimenopause and withdrawal also resemble each other, since hot flashes, night sweats, a pounding heart, and broken sleep belong to both. A taper has room for all of this. The pace belongs to the patient, and holding the dose through a hard premenstrual week, instead of reducing into it, is a legitimate choice.

Do periods go back to normal after a slow taper?

Is the change permanent? That is the fear, and it is a reasonable one for a woman who has already been surprised by a medication once. From what is known, it is not.

Professor Ashton’s sentence on the subject is short: “Endocrine symptoms that are due to benzodiazepines improve after withdrawal.” Patients often describe cycles returning to their usual pattern during a slow taper or some time after it ends. Nothing in the Manual supports the claim that long-term use leaves lasting harm to the cycle.

Yet, her sentence carries a condition: “that are due to benzodiazepines.” A cycle that does not settle, or that was never disturbed by the medication in the first place, needs its own evaluation. No one can promise a date.

What should happen before hormones or a procedure are accepted?

Both doctors should hear about the change. The physician guiding the taper needs to know that the cycle has shifted, and the gynecologist needs to know about the benzodiazepine, how long it has been taken, and where the taper stands. When the United States Food and Drug Administration (FDA) updated the benzodiazepine boxed warning in 2020, its advice to patients included telling their health care professionals about every medicine they take.

This matters most when a treatment is offered. A hormonal contraceptive, another hormone prescription, or a procedure may be the right choice, but it is a second change made in the middle of the first. It is like changing two ingredients in a recipe at the same time. If the result is different, nobody can say which change did it.

Hormonal contraceptives can also change how quickly the body clears some benzodiazepines, which is another reason for both doctors to know the timing. Informed consent applies here as much as it should have applied to the original prescription. Risks come first, then the alternatives, including waiting where that is safe, then a plan for how the treatment would be stopped, and the patient keeps the right to decline.

Professor Ashton also noted that a proportion of women who were long-term benzodiazepine users had had hysterectomies, and she added that there was no evidence of a direct link with benzodiazepine use. The practical point is simpler: the gynecologist should know about the benzodiazepine before a procedure is accepted.

None of this is a reason to avoid care. Very heavy bleeding, bleeding after menopause, severe pelvic pain, or a possible pregnancy should be evaluated promptly, whatever the taper is doing.

A simple calendar helps. Marking each period, each dose reduction, and the worst symptom days on the same page shows both doctors what followed what. Regular meals, sleep, and gentle movement are reasonable, though none of them will regulate a cycle, and supplements sold for hormone balance are a per-patient decision with a physician who understands the pharmacology, because the evidence for them is limited and responses vary.

What if a pregnancy is planned, or a period is missed?

A missed period during a taper calls for a pregnancy test before any other explanation. Withdrawal may delay a period. Pregnancy certainly does.

A woman who is planning a pregnancy, or who learns that she is pregnant, should tell the physician guiding her taper as early as possible. In the Manual’s opening chapter, Professor Ashton wrote that a benzodiazepine taken regularly in late pregnancy, even at prescribed doses, can cause complications for the newborn. That is a reason to plan early. It is never a reason to stop suddenly.

The FDA’s 2020 update warns that stopping a benzodiazepine abruptly, or reducing the dose too quickly, can cause withdrawal reactions, including seizures, which can be life-threatening. Call emergency services for a seizure or any other medical emergency. What to do next about the taper is an individual decision, made by the patient with her taper physician and her obstetric doctor together.

Fortunately, the answer is still a slow taper.

What settles withdrawal symptoms, menstrual or otherwise, is time and a gradual taper that is directed by the patient and adapted to the person. In Chapter II of the Ashton Manual, Professor Ashton described reductions of up to one tenth of the dose at each step, with the patient as the best judge of the pace, and a crossover taper to diazepam where a longer-acting medication helps. The Maudsley Deprescribing Guidelines add that the steps should get smaller as the dose gets lower, a pattern called hyperbolic tapering.

Of course, that takes months, sometimes longer, and the FDA’s update says plainly that no standard tapering schedule suits every patient. A cycle that drifts during the taper is information for the plan. It is not a reason to rush.

Dr. Mark Leeds is an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida. His practice’s primary service is medically supervised benzodiazepine and z-drug tapering for patients in Florida, and a change in the menstrual cycle is part of that taper conversation, alongside whatever the patient’s gynecologist finds. Contact the office to ask about a slow, supervised taper.

This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.