PocketGuide: Client Assessment - Menstrual Bleeding Patterns

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PocketGuide for Family Planning Service Providers

Client Assessment

Menstrual Bleeding Patterns with Hormonal Contraceptives and IUDs

Most modern contraceptive methods (pills, injectables, implants and IUDs) affect the menstrual bleeding pattern. In general, methods in which the bleeding pattern closely mimics that of noncontracepting women are more acceptable to women. Unfortunately, all of the reversible, modern methods may alter the menstrual bleeding pattern relative to:

the number of bleeding/spotting days,
the number of bleeding/spotting periods, or
a combination of the two.

Vaginal Bleeding: Definitions

Throughout the PocketGuide, in describing changes in menstrual bleeding patterns for each contraceptive method, the characteristics of vaginal bleeding have been defined as follows:

Bleeding: Any bloody vaginal discharge requiring use of sanitary protection (pads, cloths or tampons)³

Heavy: Twice as long or twice as much as normal
Prolonged: More than 8 days (duration)

Spotting: Minimal pink, brown or red discharge which requires no sanitary protection

Amenorrhea:

Primary: No uterine bleeding/spotting by age 16 (if no secondary sexual development) or by age 18 (if secondary sexual development)
Secondary: No uterine bleeding/spotting for at least 3 consecutive months

Oligomenorrhea: Menstrual interval > 35 days but <3 months (may or may not be ovulatory)

Polymenorrhea: Menstrual interval 21 days or less (strongly suggests anovulation)

Because of the direct association between vaginal bleeding patterns and reasons for stopping a contraceptive, a clear understanding of the types of bleeding changes is important in order to counsel clients adequately and to manage bleeding problems better in continuing users.

To help clinicians better appreciate the impact of modern contraceptive methods on menstrual bleeding patterns, their varying effects are illustrated in Figure 1. For the figure, the 5 types of clinically important bleeding changes (amenorrhea, infrequent bleeding, frequent bleeding, irregular bleeding and prolonged bleeding) for each method were compared to those of nearly 4000 noncontracepting, menstruating women (controls).

As shown in Figure 1, 85–90% of the control group had an “acceptable” bleeding pattern (cycle control).⁴ As shown in this figure, continued use of low-dose COCs improved cycle control to nearly 95% by the end of the first year of use (gray bars) whereas for DMPA users only 8–9% had an “acceptable” bleeding pattern. It is important to note that some patterns considered unacceptable (e.g., amenorrhea or infrequent bleeding) may be considered acceptable, and even desirable, to some women. In addition, by the fourth reference period 50–60% of DMPA users were amenorrheic or had infrequent bleeding rather than the irregular or prolonged bleeding which characterized the bleeding during the first 90-day reference period.

Understanding the effect of each contraceptive method on cycle control is important because it enables clients to make a better selection of a contraceptive method, thus increasing client satisfaction.

³ The amount of blood lost during a normal menstrual period is about 50–80 ml.
⁴ An acceptable cycle is defined as the absence of the clinically important bleeding changes during consecutive 90-day reference periods.

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