Women throughout the world are acutely aware of their menstrual bleeding and are
concerned with bleeding changes. Contraceptive-induced menstrual irregularities can result
in refusal to start or continue using the contraceptive methods.
Modern methods can profoundly affect menstrual
bleeding patterns, with disturbances ranging from heavier bleeding, to prolonged or
irregular bleeding, to no bleeding at all.
Providers may discount or minimize such disturbances when discussing contraceptive
method choices with clients or when women complain about these side effects. Some
disturbances, providers may correctly point out, are transient or can change over time.
Unless bleeding irregularities result in medical problems, such as anemia, they may be
minor health concerns. Some women, however, will
not tolerate bleeding changes that are acceptable to others.
Women notice even minor changes in menstrual bleeding, according to a study conducted
by the World Health Organization (WHO) of 5,322 women in 10 countries. Most women surveyed
(well over half in most of the countries), including rural and urban women from various
socioeconomic strata and various religious groups, did not want their menstrual cycles to
change.1
Yet, women's perceptions of what constitutes normal menstrual bleeding varied
remarkably in different regions of the world due, in part, to natural variations in
menstrual bleeding patterns associated with both environmental and genetic factors. The
WHO study showed that in non-contracepting women throughout the world, for example, the
average number of bleeding days over three months ranged from 12 days for Mexican women to
18 days for English women (the English women's cycles were more frequent, and their
bleeding during each cycle lasted longer).
In contracepting women, such ethnic variations in bleeding patterns have also been
observed. Another WHO analysis of over 5,000 women using combined oral contraceptives
(COCs or OCs), injectables or a progestin-releasing vaginal ring found that European women
tended to have more frequent bleeding than women from Asia, Latin America, Africa or the
Caribbean. This was true regardless of contraceptive method used. In contrast, North
African women using injectables had the shortest bleeding/spotting episodes, longest
bleeding-free intervals and least variable bleeding patterns.2
Cultural influences
Religious and cultural norms in various regions of the world also influence women's
perceptions of normal or acceptable menstrual bleeding and, in many instances,
dramatically affect women's daily lives. They define whether a woman is healthy, can
perform routine domestic tasks, engage in sex or social activities, visit religious sites,
or even bathe.
Menstruating Moslem women are forbidden by their religion to pray, fast, touch various
holy books or conduct some pilgrimage rituals. Moslem women often consider menstrual blood
to be polluting and their uncleanliness to be contagious. While menstruating, they tend to
avoid approaching small infants or pregnant women.
"In Egypt, towels and clothes stained with menstrual blood are washed separately
from other household items," says Dr. Laila Kafafi, FHI senior resident research
advisor in Cairo. "And, although their religion does not forbid women from showering
while menstruating, some Moslem women believe it is unhealthy to do so."
In Yugoslavia, Christian women are sometimes prohibited from attending church festivals
and performing domestic chores while menstruating.
"Given the reality of modern lifestyles, however, many menstruating women simply
must perform domestic activities, even if they prefer not to," says Dr. Asha Mohamud,
a Somali physician who has conducted research on health concerns of Somalian women and is
a Washington-based senior program officer at the Program for Appropriate Technology in
Health. "Interestingly enough, religious prohibitions on various activities probably
evolved as a means of enforcing cultural practices meant to protect and ease the burden of
menstruating women."
Most women in the majority of regions studied by WHO viewed menstruation as a welcome
event. It represents youth, fertility and femininity, and reassures women that they are
not pregnant. It is often perceived as crucial to good health, although this idea is a
misconception. Many women also perceive erroneously that lack of menstruation could cause
cancer, heart disease, vision problems or mental illness. Similarly, an investigation of
the acceptability and use of contraceptive methods in five groups (Bahamians, Cubans,
Haitians, Puerto Ricans and African Americans in the United States) revealed that regular
menstrual bleeding was generally viewed as necessary for good health.3
Women in the WHO study expressed differing, yet clear, opinions about the type of
bleeding that would be acceptable. For example, while the great majority of women
preferred their menstrual cycles not to change, women tended to prefer less, rather than
more, blood loss if changes were to occur. Such differences are essential for providers to
take into account when considering the acceptability of contraceptive methods that change
menstrual patterns.
Common Bleeding
Disturbances from Method Use
| Method |
Bleeding
Disturbance |
| Norplant 
|
Increased days of light
bleeding or spotting/irregular bleeding |
| Injectables 
|
Progestin-only Injectables
(DMPA, NET-EN): Irregular and prolonged bleeding episodes/spotting first three to six
months; later, amenorrhea Combined Injectables (Cyclofem, Mesigyna): Predictable
once-a-month bleeding for most women, but some may experience frequent, irregular or
prolonged bleeding |
| Oral Contraceptives 
|
Progestin-only Pills:
Increased days of light bleeding/irregular bleeding; amenorrhea Combined Pills:
Decreased number of days of bleeding/blood loss; spotting; amenorrhea |
| IUD 
|
Copper IUDs: Increased
menstrual blood loss of 30 to 50 percent LNg IUDs: Significantly decreased bleeding;
amenorrhea |
| Sterilization 
|
More research needed, but
menstrual changes in some women tend to reflect changes caused by discontinuation of a
prior method |
Hormonal methods
Hormonal contraceptives, particularly long-acting progestin-only methods like Norplant,
the three-month injectable depot-medroxyprogesterone acetate (DMPA) and the two-month
injectable norethindrone enanthate (NET-EN) change menstrual bleeding patterns in the
majority of users. Progestin-only methods rarely increase the number of days of heavy
bleeding, but they often increase the number of days of light bleeding or spotting,
irregular bleeding and -- particularly in the case of injectables -- amenorrhea (absence
of bleeding).
The prospect of such changes can frighten women. In an FHI study in Indonesia, for
example, a 32-year-old urban woman with two children decided not to use Norplant after
hearing of her friend's experience with irregular bleeding: "I saw my friend using
the implant. She got bleeding again and again. I was afraid to take this method."4
The majority of women using the six-capsule Norplant implant system experience
disturbances during the first year of use. Over time, these menstrual disturbances tend to
subside. Similarly, about 75 percent of more than 1,000 Indian users of the two-rod
Norplant-II had bleeding disturbances, primarily "infrequent bleeding" or
"frequent/prolonged bleeding," during the first year of use. Bleeding patterns
improved over time, with only about a third of some 100 women who remained in the study at
five years reporting disturbances.5
In a study of 100 Singaporean Norplant-II users, about 90 percent experienced
"abnormal menstrual bleeding" --primarily irregular or prolonged bleeding -- in
the first three months of use; however, among some 60 women who remained in the study at
five years, these changes had decreased to 30 percent.6
Notably, discontinuations among Norplant users due to menstrual irregularities are
relatively few considering the large number of users reporting irregular bleeding
patterns. In the Indian study, while 75 percent of Norplant-II users experienced bleeding
irregularities in their first year of use, only 8 percent discontinued for that reason. In
a review of several studies, reported menstrual-related discontinuations before the end of
five years of treatment have ranged from 4 percent to 31 percent.7
In clinical trials of Norplant conducted by FHI investigators in 11 countries,
approximately 16 percent of subjects had discontinued Norplant due to menstrual problems
at the end of five years.8
Norplant's relatively low discontinuation rates, however, may not always accurately
reflect women's satisfaction with the method. A study in Senegal showed that many
providers strongly encourage continuation,9 perhaps because
the method is relatively expensive. "Most women who had problems obtaining removal of
their implants requested early removal because of bleeding disturbances, but it appears
that these bleeding disturbances were not considered serious enough by providers to grant
immediate removal," says Elizabeth Tolley of FHI, who co-authored the study.
Treatment for Norplant-related bleeding disturbances can be successful and should be
offered as an option. But the implants should be removed if a woman requests removal.
Counseling women about the advantages and disadvantages of Norplant, and encouraging
them to report their concerns about side effects such as menstrual disturbances, can be
crucial to a woman's sense of well-being and may also improve acceptance of the method.
Similarly, poor counseling can cause unnecessary distress.
In a Haitian study, providers and clients alike reported that the
possibility of Norplant-induced prolonged or heavy bleeding was not adequately explained
during counseling.10 In contrast, in a clinic in the United
States, providers carefully described the kind of bleeding that Norplant might cause and
discussed how women might deal with such bleeding changes (including how to lower the
expense of managing bleeding by using minipads rather than larger pads or tampons). As a
result, initial Norplant use was lower but continuation rates were much higher than at
other clinics in the same area, says Judy Norsigian, program director of the Boston
Women's Health Book Collective and a member of an FHI advisory panel on contraceptive
research.
However, even preliminary counseling may be insufficient to boost continuation rates. A
survey of 98 North American women who had Norplant inserted and removed between 1991 and
1994 found that comprehensive pre-implant counseling received by all but one client did
not influence their decisions to remove the implant. Irregular menstrual bleeding was the
main reason given for requesting removal.11 Thus, addressing
women's concerns about menstrual bleeding irregularities during follow-up visits may be
essential. Involving husbands in family planning decisions may also make
contraceptive-induced bleeding disturbances easier to accept.
Providers may justifiably stress the benefits of such menstrual changes as amenorrhea.
Under normal circumstances, the absence of bleeding suggests pregnancy, making women
anxious. However, amenorrhea may be a welcome sign that a contraceptive method is working
effectively. A study of the bleeding patterns of 234 women using Norplant showed that,
after one year of use, those women with regular cycles were at greatest risk for method
failure. The five-year pregnancy rate for users with regular cycles was 17 percent,
compared with 4 percent for users with irregular cycles and none for users with
amenorrhea.12
Progestin-only injectables
The majority of women using progestin-only injectables report prolonged or irregular
menstrual bleeding or amenorrhea in their first year of use. During the first three to six
months of use, progestin-only injectables are associated with episodes of irregular and
prolonged bleeding. Later, they are associated with amenorrhea; approximately two of every
three DMPA users experience amenorrhea by the end of the second year. NET-EN disrupts
bleeding patterns somewhat less than DMPA and is less likely to cause amenorrhea.13
Discontinuation rates due to DMPA-associated menstrual disturbances are approximately
25 percent after one year. However, in a WHO trial, the percentage of women who
discontinued after one year due to bleeding varied widely among seven countries: from 3.5
percent in Jamaica to almost 59 percent in Yugoslavia.14 This
may be due, in part, to cultural differences in the acceptability of bleeding
disturbances. Also, population variations have been observed in studies of progestin-only
injectables. Thai women, for example, absorb and eliminate DMPA more rapidly than do
Mexican women.15 And, in a study of DMPA use by Vietnamese
women, the percentage of DMPA users with a normal menstrual pattern was two to three times
higher than reported in previous DMPA studies in various other populations, probably due
to ethnic differences in the agent's metabolism.16
Furthermore, pretreatment counseling can affect DMPA discontinuation rates. This was
demonstrated in a study of about 400 Chinese women, half of whom received intensive
pretreatment and ongoing counseling about DMPA and half of whom received only brief
counseling. After a year, women in the intensive counseling group reported more menstrual
irregularity (40 percent) than did those in the other counseling group (26percent), but
their discontinuation rate was 11 percent compared with 42 percent for the routine
counseling group.17
In a recent study of about 600 Vietnamese DMPA users, counseling influenced whether
women experiencing amenorrhea continued using DMPA.18
"Women who continued use reported receiving better quantity and quality of advice
from health staff, as well as from other satisfied users, families or husbands," says
Dr. Maxine Whittaker, an Australian-based physician and technical advisor to the
Vietnamese study that was funded in part by WHO.
Monthly injectables
Monthly injectables combining an estrogen with progestin create more regular menstrual
cycles. In most women using these injectables, bleeding tends to occur predictably once a
month after the first few months of use.
In general, about half of women using combined monthly injectables experience irregular
bleeding during the first three months, while less than a third of users of Cyclofem (25mg
DMPA and 5mg estradiol cypionate) and Mesigyna (50mg NET-EN and 5mg estradiol valerate)
reported irregular bleeding patterns after one year.19
In a WHO study in which Cyclofem was introduced into family planning programs in
Indonesia, Jamaica, Mexico, Thailand and Tunisia and given to about 8,000 women,
discontinuation rates associated with menstrual disturbances at one year ranged from about
3 percent in Indonesia to about 40 percent in Tunisia.20
Different cultural attitudes about disturbances may be among reasons why discontinuation
rates vary so widely.
Oral contraceptives
Like other progestin-only methods, progestin-only contraceptive pills (POPs or
minipills) usually produce irregular menses or increased days of light bleeding. They may
cause amenorrhea.
Combined oral contraceptives, which are much more widely used than POPs, commonly
decrease the number of days of bleeding and blood loss, with menstrual flow decreasing by
60 percent or more. However, missed periods, very scanty bleeding, spotting or
breakthrough bleeding may occur and upset women. Amenorrhea also may be a side effect,
especially in women using low-estrogen pills.
IUDs
Increased menstrual bleeding and pain are frequently reported by women using
intrauterine devices (IUDs). In some studies, as many as 80 percent of IUD users complain
of these disturbances. With Copper T IUDs, menstrual blood loss is increased moderately
(defined as a 30 percent to 50 percent increase in bleeding compared with the average loss
for women not using modern contraceptive methods). FHI research conducted in 23 developing
countries, however, indicates that Copper T IUD-related bleeding disturbances tend to
decrease after the first few months of use.21
Determining discontinuation rates due to increased menstrual bleeding for specific IUDs
is difficult, says Dr. Patrick Rowe, medical officer in charge of IUD research at WHO in
Geneva, "because there is great variation in removal rates for pain and/or bleeding
for even the same device between centers and studies." However, bleeding problems --
namely heavy, prolonged or irregular bleeding -- are the main reason for IUD
discontinuation. The bleeding-related discontinuation rate for IUDs, in general, is
approximately 7 percent to 15 percent at one year.
Hormone-releasing IUDs significantly reduce the volume of menstrual bleeding.
Progestasert, which releases the naturally-occurring hormone progesterone, is costly, not
widely available, and is approved for only a year of use in the United States. A
levonorgestrel-releasing IUD, called LNg IUD, is available in several European and Asian
countries. The number of bleeding and spotting days in LNg IUD users is markedly reduced
when compared with non-users. A substantial proportion of users experience amenorrhea.
A multicenter WHO study involving more than 3,000 women indicated that, at one year of
use, the removal rate for pain and/or bleeding -- as well as amenorrhea -- was
significantly higher for the LNg IUD than for the Copper T380A.22
At three years of use, this difference in removal rates for pain and/or bleeding was less
pronounced, but the difference in removal rates for amenorrhea was more pronounced. At
three years of use, removals for pain and/or bleeding for the LNg IUD and the Copper T
380A were 17 percent and 11 percent, respectively. Removal rates for amenorrhea were 27
percent and 0.2 percent, respectively.23
"In the WHO study, counseling subjects that amenorrhea was normal and did not mean
that they were pregnant did not appear to reduce amenorrhea-related LNg IUD removal
rates," says Dr. Rowe. However, it is generally recommended that providers still
counsel potential LNg IUD users that amenorrhea is not a disease. Rather, it is a sign
that levonorgestrel is acting on the lining of the uterus.
Furthermore, the absence of bleeding can have important medical benefits. Reducing
menstrual blood loss, and thereby increasing the body's iron stores, is particularly
important for women with anemia. In several countries, an approved use of the LNg IUD,
besides contraception, is treatment of excessive menstrual bleeding. In some cases, it
offers an alternative to surgical treatment.24 Amenorrhea may
even be welcome relief for women who have normal monthly bleeding, but find it to be
uncomfortable or inconvenient.
Sterilization
In an FHI-sponsored study by Centro de Pesquisas e Controle das Doenças
Materno-Infantis de Campinas (CEMICAMP) in Campinas, Brazil, involving 236 women aged 30
to 49 years who were sterilized at least five years earlier, the most frequently reported
physical change attributed to sterilization was related to menstruation. Over a third of
sterilized women in the study reported increased menstrual flow.25
Other studies suggest that female sterilization may cause such menstrual disturbances as
painful menstruation, heavy bleeding or spotting, and changes in cycle length or
regularity.
However, research has also shown that the contraceptive method used just prior to
sterilization can affect women's reports of bleeding changes after the procedure. For
instance, former OC users, accustomed to method-induced light bleeding, will notice
increased bleeding when they stop taking OCs. Likewise, IUD users, accustomed to
method-induced heavier bleeding, will tend to notice decreased bleeding when they no
longer use an IUD.26 These changes likely are not due to
sterilization, but rather to discontinuation of the previous contraceptive method.
Further research is needed to determine whether sterilization can cause menstrual
disturbances. Meanwhile, a literature review of more than 200 studies on menstrual and
hormonal changes in women who undergo tubal sterilization concluded that, in
well-controlled studies, the procedure was not associated with an increased risk of
menstrual dysfunction, painful menstruation, or increased premenstrual distress in women
who underwent it after age 30. Women in their 20s with histories of menstrual dysfunction
before sterilization may be at higher risk of these disturbances, but do not appear to
have significant hormonal changes.27
-- Kim Best
References
- Snowden R, Christian B, eds. Patterns and Perceptions of
Menstruation, a World Health Organization International Collaborative Study in
Egypt, India, Indonesia, Jamaica, Mexico, Pakistan, Philippines, Republic of Korea, United
Kingdom and Yugoslavia. New York: Croom Helm, Long and Canberra and St. Martin's
Press, 1983.
- Belsey EM. Regional and individual variation in bleeding patterns
associated with steroid contraception. In Snow R, Hall PE, eds. Steroid Contraceptives
and Women's Response: Regional Variability in Side Effects and Pharmacokinetics. (New
York: Plenum Press, 1994)27-53.
- Scott CS. The relationship between beliefs about the menstrual cycle and
choice of fertility regulating methods within five ethnic groups. Int J Gynaecol Obstet
1975;13(3):105-9.
- Dwiyanto A, Faturochman, Suratiyah K, et al. Family Planning, Family
Welfare and Women's Activities in Indonesia, Final Report to the Women's Studies
Project. Research Triangle Park, NC: Population Studies Center, Gadjah Mada University
and Family Health International, 1997.
- Datey S, Gaur LN, Saxena BN. Vaginal bleeding patterns of women using
different contraceptive methods (implants, injectables, IUDs, oral pills) -- an Indian
experience. An ICMR Task Force Study. Contraception 1995;51(3):155-65.
- Biswas A, Leong WP, Ratnam SS, et al. Menstrual bleeding patterns in
Norplant-2 implant users. Contraception 1996;54(2):91-95.
- Coukell AJ, Balfour JA. Levonorgestrel subdermal implants. A review of
contraceptive efficacy and acceptability. Drugs 1998;55(6):861-87.
- Dunson TR, Krueger SL, Amatya RN. Risk factors for discontinuation of
Norplant implant use due to menstrual problems. Adv Contracept 1996;12(3):201-12.
- Tolley E, Nare C. Women's experiences with Norplant removal in four
clinics in Dakar. Unpublished paper. Family Health International, 1997.
- Tolley E, Guy T, Carré-Theodore D, et al. Report of a study to
evaluate the provision of Norplant by non-physicians, Pignon, Haiti. Unpublished paper.
Family Health International and Comité de Bienfaisance de Pignon, 1996.
- Opara JU, Ernst FA, Gaskin H, et al. Factors associated with elective
Norplant removal in black and white women. J Natl Med Assoc 1997;89(4):237-40.
- Shoupe D, Mishell DR Jr, Bopp BL, et al. The significance of bleeding
patterns in Norplant implant users. Obstet Gynecol 1991;77(2):256-60.
- World Health Organization Task Force on Long-acting Agents for the
Regulation of Fertility. Multinational comparative clinical trial of long-acting
injectable contraceptives: norethisterone enanthate given in two dosage regimens and
depot-medroxyprogesterone acetate. Contraception 1983;28(1):1-20.
- World Health Organization. A multicentred phase III comparative trial
of depot-medroxyprogesterone acetate given three-monthly at doses of 100 mg or 150 mg: 1.
Contra- ceptive efficacy and side effects. Contraception 1986;34(3):223-35.
- Garza-Flores J, Guo-wei S, Hall PE. Population and delivery systems:
variability in pharmacokinetics of long-acting injectable contraceptives. In Snow R, Hall
PE, eds. Steroid Contraceptives and Women's Response: Regional Variability in Side
Effects and Pharmacokinetics. (New York: Plenum Press, 1994)69-83.
- Cuong DT, My Huong NT. Comparative phase III clinical trial of two
injectable contraceptive preparations, depot-medroxy- progesterone acetate and Cyclofem,
in Vietnamese Women. Contraception 1996;54(3):169-79.
- Lei Z, Wu S, Garceau RJ. Effect of pretreatment counseling on
discontinuation rates in women given depot-medroxyprogesterone acetate for contraception. Chung
Hua Fu Chan Ko Tsa Chih 1997;32(6):350-53.
- Thom NT, Anh PT, Larson A, et al. Introductory study of DMPA in Vietnam
-- an opportunity to strengthen quality of care in family planning service delivery.
Presentation at Lessons Learned Workshop, Hanoi, October 12, 1998.
- World Health Organization. Facts about once-a-month injectable
contraceptives: memorandum from a WHO meeting. Bull WHO 1993;71(6):677-89.
- Hall P. Task Force on Research on Introduction and Transfer of
Technologies for Fertility Regulation, Special Programme of Research, Development and
Research Training in Human Reproduction, World Health Organization. The introduction of
Cyclofem into national family planning programmes: experience from studies in Indonesia,
Jamaica, Mexico, Thailand and Tunisia. Contraception 1994;49(5):489-507.
- Rivera R, Farr G, Chi I-c. The Copper IUD: Safe and Effective. The
International Experience of Family Health International. Research Triangle Park, NC:
Family Health International, 1992.
- Rowe PJ. Research on intrauterine devices. In Van Look PFA, ed. Annual
Technical Report 1995. (Geneva: World Health Organization, 1996)140-41.
- D'Arcangues C, Griffin PD, von Hertzen H, et al. Technology development
and assessment. In Van Look PFA, ed. Annual Technical Report 1997. (Geneva: World
Health Organization, 1998)79.
- Luukkainen T, Toivonen J. Levonor- gestrel-releasing IUD as a method of
contraception with therapeutic properties. Contraception 1995;52(5):269-76.
- Osis MJM, de Souza MH, Bento SF, et al. Estudo Comparativo Sobre as
Consequencias da Laqueadura na Vida das Mulheres. Research Triangle Park, NC: CEMICAMP
and Family Health International, 1998.
- Chamberlain G, Foulkes J. Long-term effects of laparoscopic
sterilization on menstruation. South Med J 1976;69:1474-75.
- Gentile GP, Kaufman SC, Helbig DW. Is there any evidence for a
post-tubal sterilization syndrome? Fertil Steril 1998;69(2):179-86.
How to Manage Bleeding Disturbances |
Once gynecological disease is ruled out,
the first approach to help women manage contraceptive-induced bleeding disturbances should
be counseling and reassurance that such changes are to be expected. In addition,
recommended approaches to managing bleeding disturbances include the following:
- Combined oral contraceptive pills can be used to treat bleeding problems associated with
progestin-only contraceptives. Pills that contain 50µg ethinyl estradiol and 250µg
levonorgestrel each, taken daily for 20 consecutive days, significantly reduce bleeding
days in Norplant users.1
-
- Estrogen can treat bleeding problems associated with progestin-only contraceptives.
Norplant-induced uterine bleeding also has been controlled by using 50µg ethinyl
estradiol taken daily for 20 days, although estrogen was significantly less effective than
combined oral contraceptive pill use.2
-
- Non-steroidal anti-inflammatory drugs, such as ibuprofen, reduce heavier menstrual
bleeding associated with intrauterine devices (IUDs).
However, the need to manage contraceptive-induced bleeding disturbances is debatable,
especially the use of hormonal treatments (combined pills or estrogen) in women already
using hormonal methods.
"It is not a good idea to play hormonal roulette," says Judy Norsigian,
program director of the Boston Women's Health Book Collective and a member of an FHI
advisory panel on contraceptive research. "Offering something else to counter
bleeding is not necessarily a good idea. It is better to offer her a different
method."
"Since bleeding usually presents no health risk, a little bit of patience to await
regular cycles may be the best approach," adds Dr. Carlos Petta of the University of
Campinas, Brazil, who has conducted extensive research on injectable contraceptives.
"But if that is not possible, certainly another method should be offered."
-- Kim Best
References
- Alvarez-Sánchez F, Brache V, Thevenin F, et al. Hormonal treatment for
bleeding irregularities in Norplant implant users. Am J Obstet Gynecol 1996;174(3):919-22.
- AlvarezSánchez; Díaz S, Croxatto HB, Pavez M, et al. Clinical
assessment of treatments for prolonged bleeding in users of Norplant implants. Contraception
1990;42(1):97-109.
|
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