Education on menstruation and fertility can serve as a starting point for discussions
with both women and men about pregnancy, contraception and reproductive health, experts
say.
Providers who teach clients about fertility awareness should explain how family
planning methods affect ovulation and menstruation. Natural family planning methods, male
contraceptive methods and barrier methods do not affect women's menstruation cycles, nor
do they interfere with ovulation. Hormonal methods and the intrauterine device (IUD) can
affect menstruation, and hormonal methods work primarily by interfering with ovulation.
Hormonal methods
Combined oral contraceptives (COCs), which contain estrogen and progestin, suppress
ovulation. COCs can decrease the number of days of menstrual bleeding, decrease menstrual
cramps, and reduce the unpleasant physical and emotional symptoms of premenstrual
syndrome. COCs also can reduce the volume of  menstrual
blood loss. They can cause breakthrough or intermenstrual bleeding, as well as amenorrhea
(missed periods).
Progestin-only contraceptives include the progestin-only oral contraceptive or
mini-pill, Norplant subdermal implants, and some injectables, such as
depot-medroxyprogesterone acetate (DMPA or Depo-Provera). They suppress ovulation in about
half of the menstrual cycles. In all women, they thicken cervical mucous, making it
difficult for sperm to enter the uterus.
Progestin-only contraceptives may reduce menstrual cramps, and they also may cause
bleeding disturbances, such as amenorrhea or intermenstrual bleeding. Amenorrhea occurs
infrequently in women using Norplant but is more likely the longer a woman uses DMPA.
Since bleeding disturbances are often cited by women as a reason for discontinuation of
progestin-only contraceptives, counseling can help women anticipate how methods will
affect their menstrual cycles and whether these changes will be acceptable to them.
Emergency contraception
Fertility awareness can help couples understand better that pregnancy can be prevented
even after unprotected intercourse. Although not as effective as contraceptives used prior
to intercourse, emergency contraception can be used by women who have been sexually
assaulted, who forgot to use a contraceptive method, who used it incorrectly, or who
experienced a condom failure. Emergency contraception is considered safe for all women,
and is about 75 percent effective at preventing pregnancy.
Around the time of ovulation, a woman's cervical mucus changes, protecting sperm from
the normally acidic environment of the vagina and providing nutrients that enable sperm to
survive. Consequently, conception may not occur until several days after intercourse.
Women who use emergency contraception prevent pregnancy before it begins. Certain types of
oral contraceptives can interfere with ovulation or fertilization. Pills also may alter
the uterine lining (endometrium).
An advisory committee of the U.S. Food and Drug Administration, a regulatory agency,
recently endorsed the use of some brands of oral contraceptives for emergency use. Certain
COCs can be taken within 72 hours of unprotected intercourse and repeated 12 hours later
to be effective. Specific brands of progestin-only pills can also be effective, the panel
said, if taken within 48 hours after intercourse and repeated 12 hours later.
IUDs and sterilization
IUDs, such as the Copper T, prevent fertilization by impeding the movement of the sperm
and their viability.
While IUDs do not affect ovarian function, users may experience increased menstrual
bleeding and pain. These side effects typically subside over time, although providers can
give iron supplements to improve hemoglobin levels if bleeding is heavy or the woman is
anemic. Providers also can offer nonsteroidal, anti-inflammatory drugs, such as ibuprofen,
to reduce pain and bleeding. IUDs containing synthetic progestin, which are available in a
few industrialized countries but not in developing nations, can reduce menstrual bleeding
and cramping.
Tubal ligation or the use of clips to achieve female sterilization do not affect
ovulation. Pregnancy is prevented by cutting or clipping the fallopian tubes to keep the
egg and sperm from uniting. Some women who have undergone surgical sterilization report
changes in bleeding patterns or increased dysmenorrhea (painful periods).
Reproductive health
While the average menstrual cycle lasts about 28 days, lengths of cycles vary. Even
within the same woman's lifetime, cycle length, duration of bleeding and volume of
bleeding may vary.
Providers should help clients understand what types of genital symptoms are normal for
them and which are not. For example, many women in less developed countries view purulent
vaginal discharge as natural.1 However, abnormal vaginal
discharge may be a sign of a sexually transmitted disease for a woman. In a man, pain or
abnormal discharge from the urethra may be a sign of STD infection.
Left untreated, some STDs can lead to pelvic inflammatory disease in women, a cause of
infertility. Excess vaginal bleeding or bleeding and pain can be symptoms of ectopic
pregnancy or illness, such as myoma or cancer.
Women taught to be aware of deviations in cervical secretions, such as noticeable
discharge or pain during intercourse, are alerted to seek medical attention, says Dr.
Victoria Jennings of the Institute for Reproductive Health at Georgetown University in
Washington.
"For a woman to be able to note this earlier, rather than later, and describe her
symptoms to a health-care provider, is important" for her reproductive health, says
Dr. Jennings.
-- Barbara Barnett
References
- Zurayk H, Khattab H, Younis N, et al. Comparing women's
reports with medical diagnoses of reproductive morbidity conditions in rural Egypt. Stud
Fam Plann 1995:26(1):14-21.
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