How Women Perceive Menstruation and Their Menstrual Patterns

Women the world over are very aware of their pattern of menstruation and how it affects their lives. Research that was carried out in 10 countries two decades ago led to a comparison of menstrual patterns and women's perceptions of menstruation.¹ That research showed how women generally seem to focus more on the number of days when they are bleeding than on the number of days when they are not. It also showed that many women consider that an increase or decrease in the number of days of bleeding is more important than a change in the number of days without bleeding. Women tend to link the amount of their menstrual bleeding with the length of their menstruation, the research showed. More than two-thirds of the women in the study said they preferred to have one monthly bleed. In the 10 countries, most women (ranging from 53% in the United Kingdom to 91% in India) said that they did not wish to use methods that induced amenorrhoea.

Perceptions of menstruation vary in different cultures. These perceptions may be positive or negative, but service providers need to remember that these perceptions will influence the attitudes of women—and their partners—to changes in bleeding patterns resulting from the use of hormonal contraceptives. Thus, just how acceptable hormonal contraceptives are often depends on how much change in menstrual bleeding a woman experiences and what her perception of menstruation is.

Menstruation may be viewed either positively or negatively. For instance, menstruation may be perceived as a sign of femininity, fertility, youth, or purification of the body, yet at the same time it is also linked with vulnerability and pollution, and with attitudes of disgust and shame. In some societies, these negative perceptions are the basis for restricting women's religious, social and domestic activities while they are menstruating. It is because of religious and social traditions or taboos that menstruation may be looked on as more than just a physiological process; it becomes an event that has social, cultural and psychological implications. "A woman has two perceptions of bleeding: one from her actual experience and the other from her position as a member of society which has attached certain meanings to menstruation," according to the authors of the 10-country study. The interaction of these two elements determines her attitude to menstrual bleeding.

Various studies have examined women's preferences for different patterns of vaginal bleeding, particularly with regard to the use of oral contraceptives. As early as 1977, for instance, research investigated the acceptability to 196 women in Scotland, United Kingdom, of a long period without menstruation followed by a "withdrawal bleed". The women were given a combined oral contraceptive for periods of 84 days followed by 6 days without the pill.² Most of the women (82%) said that they preferred having less frequent periods, and 91% of those who completed the year of follow-up liked the three-monthly regimen so much that they refused to return to the standard monthly regimen of oral contraceptives after the study was over. However, 45% of the women withdrew from the study early, chiefly for medical reasons.

A study published in 1987 tested just how acceptable a seven-week cycle of pill use was to 100 women.³ In this case, the authors of the study concluded that the seven-week cycle was not viable since "the majority of volunteers preferred the inconvenience of a monthly withdrawal bleeding". In contrast, a similar study reported in 1993 that when 198 Swedish women used an even longer cycle (nine weeks of taking the pill followed by one week without it), 63% preferred having a withdrawal bleed every three months.⁴ This was despite some breakthrough bleeding and spotting early in the cycle. Some 26% of women in this Swedish study preferred monthly bleeding.

When 158 women were interviewed about oral contraceptive use and menstrual bleeding in an Australian study, 83% said it was necessary to bleed monthly when taking an oral contraceptive.⁵ However, when they were given a choice of how often to menstruate, 54% said they preferred to bleed monthly, 27% preferred to bleed every three months, 4% preferred to bleed every 6–12 months, and 15% said they preferred not to bleed at all.

A large European study on patterns of bleeding, which was reported in 1996, involved interviews with women in France, Germany and the United Kingdom.⁶ The 1201 women who were interviewed were asked to rank their preferences for bleeding every month, every three months, every six months, or not at all. The most preferred pattern of bleeding was every three months and the least preferred pattern was not at all.

Few studies have researched attitudes to menstruation and patterns of bleeding among women who were using injectable or implanted contraceptives. However, one study involved interviews with 328 young women at three different clinical sites in the USA to find out their attitudes to injectable or implanted contraceptives.⁷ Asked about possible menstrual changes, 74% of the young women said that they would stop using a contraceptive method if it caused irregular bleeding and 66% said they would stop using it if it stopped them bleeding altogether. The responses of the interviewees were not related to education, sexual or menstrual history, previous contraceptive use, and history of pregnancy or of sexually transmitted diseases. Two-thirds of the young women interviewed said that they would prefer a contraceptive method that would reduce their menstrual flow.

In China, a study confirmed the importance of counselling on contraceptive use and menstrual change.⁸ Of 421 users of depot-medroxyproges-terone acetate (DMPA), half were given detailed counselling both before and during treatment while half received only routine counselling. In both groups, women who stopped using DMPA cited menstrual change as the main reason for doing so. However, a year later significantly more women who had received intensive counselling were still using DMPA than were those who received routine counselling only (42% versus 11%).

Recent research in Thailand found that amenorrhoea was seen in a very negative light; it was considered not only to be unhealthy but also to have a negative effect on a woman's appearance.⁹ This perception was held regardless of age or education. Health care providers in Thailand have experienced the same perception, and this prompted a group of Thai researchers to offer DMPA users complaining of amenorrhoea the option to switch to the combined monthly injectable Cyclofem in order to enable them to menstruate. Since Cyclofem contains 25 mg MPA and 5 mg estradiol cypionate, this option does not increase the body's burden of synthetic steroid yet offers continuation with a similar form of contraception. This was tested in a controlled clinical trial that involved 100 women who were DMPA users and had amenorrhoea.¹⁰ In this trial, 82% of women who switched to Cyclofem experienced some vaginal bleeding within six months but almost all of them reported hormonal side-effects. Nevertheless, one-third of the women chose to continue using Cyclofem at the end of the trial, despite the fact that it required a more demanding schedule of administration.

It is clear that many women worldwide see their pattern of menstruation as a sign both of their reproductive health and of their health in general. The natural process of menstruation has taken on such sociocultural, religious and psychological significance that many women refuse to tolerate disturbances to their pattern of vaginal bleeding as a result of using hormonal contraceptives. If their needs are to be met adequately, we need to have a better understanding of the mechanisms that underlie vaginal bleeding and of women's attitudes to menstrual disturbances. Only then can effective and acceptable solutions be found.

References

1. Snowden R, Christian B, eds. Patterns and perceptions of menstruation. New York, St. Martin's Press, 1983.

2. Loudon NB et al. Acceptability of an oral contraceptive that reduces the frequency of menstruation: the tri-cycle pill regimen. British medical journal, 1977, 2:487–490.

3. Hamerlynck JV, et al. Postponement of withdrawal bleeding in women using low-dose combined oral contraceptives. Contraception, 1987, 35(3)199-205.

4. Cachrimanidou A-C et al. Long-interval treatment regimen with a desogestrel-containing oral contraceptive. Contraception, 1993, 48:205–216.

5. Rutter W et al. Women's attitudes to withdrawal bleeding and their knowledge and beliefs about the oral contraceptive pill. Medical journal of Australia, 1988, 149:417–419.

6. Fuchs N, Prinz H, Koch U. Attitudes to current oral contraceptive use and future developments: the women's perspective. European journal of contraception and reproductive health care, 1996, 1:275–284.

7. Gold MA, Coupey SM. Young women's attitudes toward injectable and implantable contraceptives. Journal of pediatrics, adolescence and gynecology, 1998, 11:17–24.

8. Lei ZW et al. Effect of pretreatment counselling on discontinuation rates in Chinese women given depot medroxyprogesterone acetate for contraception. Contraception, 1996, 53:357–361.

9. Supanee J-A. The effects of perceived change in the menstrual pattern on the acceptability of fertility regulating methods. D.Ph. thesis, University of Exeter, United Kingdom, 1998.

10. Manee P-A et al. Effectiveness of Cyclofem in the treatment of depot medroxyprogesterone acetate-induced amenorrhea. Contraception, 1998, 57:23-28.

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