Home > Briefs > Gynecology ObstetricsModern contraceptives can indeed seriously disrupt menstruation, causing heavy, prolonged or irregular bleeding, as well as a total disappearance of menses (amenorrhea).When a provider talks to a client about choosing a method or listens to a woman complain about side effects, he may ignore these disturbances or minimize their importance, because some of these disturbances are admittedly transient or may subside over time.As long as irregular bleeding does not have serious consequences, such as anemia, it is often only a minor health problem.But such changes are not acceptable to some women.According to a study conducted by the World Health Organization (WHO) in 10 countries and among 5,322 women, the latter are sensitive to the slightest variations in their menstruation.In both rural and urban areas, and regardless of socio-economic or religious background, the majority of respondents (well over half in most countries) do not want their menstrual cycle disrupted.1But the notion of "normal periods" varies considerably according to the regions of the world, due in particular to genetic or environmental factors influencing menstrual rhythms.This same WHO study thus showed that, among women not using contraceptives, the quarterly average of bleeding days is, for example, 12 days in Mexico compared to 18 in Great Britain (where menstrual cycles seem to be more short and more prolonged bleeding).Among women using a contraceptive, such regional and ethnic variations in menstrual flow have also been observed.Another WHO survey of more than 5,000 subjects using either a combined oral contraceptive (COC), or an injectable contraceptive, or even a vaginal ring releasing a progestogen, has shown these differences: European women tend to menstruate more often than those in Asia, Latin America, Africa or the Caribbean.And this difference is observed whatever the method used.Women in North Africa using an injectable contraceptive have the shortest periods of bleeding or spotting, the longest amenorrheic intervals, and the most regular rhythms. 2From one region of the world to another, the notion of "normal periods" also depends on religious and cultural factors, which can have a considerable influence on the daily existence of women, whether it is the perception of their state of health, hygiene, sexual life, performance of domestic tasks, participation in social activities or even attendance at places of worship.During their periods, Muslim women no longer have the right to pray, to fast, to touch certain sacred books or to practice various religious rites.They often consider menstrual blood to be polluting.They are afraid of being contagiously unclean and thus avoid getting too close to young children and pregnant women."In Egypt, towels and clothes stained with menstrual blood are washed separately," said Dr. Laila Kafafi, permanent adviser in Cairo for FHI research teams."And even if their religion does not prohibit them from showering during their period, some Muslim women believe that showering like this is bad for their health."Elsewhere, in Yugoslavia for example, Christian women are sometimes forbidden to take part in certain parish activities or to carry out their work in the home when they are menstruating."But modern lifestyles often force women to perform their domestic chores even during their periods and even if they would prefer not to," says Dr Asha Mohamud, a Somali doctor who has studied women's concerns in his country. in health and who is based in Washington where she is a program manager with PATH (Program for Appropriate Technology in Health)."Interestingly, these various prohibitions imposed by religion likely mirror ancient cultural practices aimed at protecting women and easing their burden during menstruation."In the majority of regions studied by the WHO, most women are happy to have their periods.Menstruation attests to their youth, femininity and fertility.It can also relieve the one who feared to be pregnant.Periods are also often interpreted as an indicator of good health, even if this is a false idea: the absence of periods then worries many women, who mistakenly imagine that they will suffer cancer, heart disease, vision problems or mental illness.A study on the acceptability and use of contraceptive methods conducted in five different ethnic groups (Bahamians, Cubans, Haitians, Puerto Ricans and Black Americans) also showed that regular menstrual bleeding is most often considered necessary for good health. health.3Analysis of the responses of participants in the WHO study shows clear trends in the changes in menstrual bleeding considered acceptable by women.For example, the vast majority do not want disturbances in their cycle, but if such disturbances should occur, the women questioned tend to prefer a reduction in bleeding rather than the reverse.These results are valuable to providers because they will allow them to assess the degree of acceptability of menstrual-modifying contraceptive methods.Usual menstrual disorders with contraceptive methodsUsual menstrual disorders with contraceptive methodsCombined injectables (Cyclofem, Mesigyna): Periods regular in most women, but frequent, irregular or prolonged bleeding is possible in some cases.Combined oral contraceptives: reduced number of bleeding days and decreased menstrual flow;small bleeding;amenorrhea.Levonorgestrel IUD: marked decrease in menstrual flow;amenorrhea.Hormonal contraceptives cause menstrual disturbances in the majority of users.This is particularly the case with long-acting progestins-only such as Norplant or with injectables such as depot-medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN), which offer contraceptive protection for three months and two months respectively.Although the number of days of heavy bleeding is only rarely increased by progestins-only, the latter tend to prolong the period of light bleeding (spotting), irregular bleeding and, especially with injectables, amenorrhea .The prospect of such disruptions may frighten some women.For example, in a study conducted in Indonesia, FHI observed the case of a 32-year-old woman, mother of two, living in an urban area, who made the decision not to use Norplant after shared the experience of a relative prone to irregular bleeding: "I saw this friend with her implant bleeding again and again, and I was afraid to use the method."4For the majority of six-capsule Norplant users, these menstrual disturbances occur within the first year.Over time, however, the side effects tend to diminish.Among users of Norplant-II (two-rod implant system), problems are also frequent during the first twelve months: the follow-up of a group of more than 1,000 Indian women using this contraceptive has thus shown that they can occur in 75 percent of cases, mostly as "infrequent bleeding" or "frequent/prolonged bleeding".These side effects later subsided and appear to have persisted in only about a third of the 100 women still followed after five years.5Furthermore, thanks to a study conducted in Singapore with 100 users of Norplant-II, it was observed that, during the first three months, "unusual menstrual bleeding" (most often irregular or prolonged bleeding) had occurred in about 90 percent of cases.But the frequency of the disorders had fallen to 30 percent among the sixty participants still followed by the researchers after five years.6Interestingly, Norplant discontinuation rates among women with menstrual disorders are relatively low.The survey carried out in India showed that while 75 percent of Norplant-II users experienced such problems during the first year, only 8 percent abandoned the method for this reason.Examination of the results of several studies also reveals that discontinuation rates for menstrual disorders range from 4 to 31 percent over five years.7 And in clinical trials conducted by FHI in 11 countries, the rate of dropout due to menstrual disorders reached about 16 percent at five years.8However, relatively low Norplant discontinuation rates do not always reflect user satisfaction.A survey conducted in Senegal showed that many health providers try to convince women to keep their implants,9 probably because the method is relatively expensive."Most of the women whose request for withdrawal was met with resistance actually responded as soon as the first menstrual problems appeared. But providers did not seem to consider these problems serious enough to warrant a immediate intervention,” comments Ms. Elizabeth Tolley of FHI and one of the study’s lead authors.Treatment of menstrual disorders related to Norplant can be effective and should be offered as an option, but the implants should be removed if the woman requests it.Informing clients about the advantages and disadvantages of this method, as well as encouraging them to share their concerns about side effects, are essential points of good counselling.Such counseling can improve both the woman's sense of well-being and the degree of acceptance of the method.Conversely, poor counseling may cause the client unnecessarily distress.Sometimes, as a study in Haiti shows, providers and clients do not sufficiently discuss during counseling the possibility of heavy or prolonged bleeding induced by Norplant.10 The example of a US clinic illustrates the benefits of good preparatory work.In this particular case, the providers were able to carefully describe the potential problems associated with Norplant and discuss with the women the reactions to adopt in the event of side effects (such as the use of less expensive mini sanitary napkins, rather than normal pads or tampons).And, as Ms. Judy Norsigian, program director with the Boston Women's Health Book Collective and member of FHI's Contraceptive Research Advisory Committee, points out, this educational effort has paid off: if the initial rate of adoption of Norplant was lower than that of other dispensaries in the region, that of long-term continuation was much higher.However, good prior counseling is not always sufficient to improve continuation rates.This was shown by a survey carried out in North America among 98 women who had used and then abandoned Norplant between 1991 and 1994. Among these women, counseling had no influence on their decision. to abort the method.Disorders of the menstrual cycle were the main reason for requests for removal of implants.11Knowing how to respond to the concerns of clients with menstrual irregularities could be a priority during follow-up visits.It would also seem that these side effects are better tolerated if the male partners actually participate in the decisions made in family planning.Additionally, providers might rightly point out the benefits of certain contraceptive-induced changes.This is the case, for example, of amenorrhea, which is usually a sign of pregnancy and which can make the woman anxious, but which must be interpreted positively in women using a hormonal method, because it is in fact the consequence of good contraceptive protection.A study of the menstrual characteristics of 234 women using Norplant showed that after one year of use, participants with regular cycles were also those most at risk of contraceptive failure.At five years, the unintended pregnancy rate was 17 percent in this group compared to only 4 percent among those with irregular cycles and 0 percent among amenorrheic women.12Most women using a progestogen-only injectable contraceptive have longer or more irregular periods or amenorrhea during the first year.Between the first three and six months, these contraceptives indeed cause irregular and prolonged bleeding.The menstrual discharge then tends to disappear and about two-thirds of DMPA users become amenorrheic before the end of the second year.NET-EN, however, causes fewer menstrual disturbances than DMPA, and amenorrhea is also less common with this injectable.13 DMPA-related menstrual disturbances cause about 25 percent of method dropouts in the first 12 months .But, according to the results of a WHO study, this rate at one year can vary considerably from one country to another, from 3.5 percent in Jamaica to almost 59 percent in Yugoslavia.14 such differences can be partly explained by cultural differences favoring or condemning the acceptance of menstrual disorders.But they also result from biological differences as evidenced by several studies on these injectables.For example, Thai women absorb and eliminate DMPA faster than Mexican women.15 And in Vietnam, among DMPA users, the frequency of regular cycles is two to three times higher than that of other ethnic groups, a difference no doubt of metabolic origin.16Furthermore, the quality of counseling has an important influence on the continuation rates of DMPA users.This role has been demonstrated by a study conducted with 400 Chinese women.Half of these women received quality counseling before and during method use, while the other half received only superficial help.At the end of the first year, participants in the first group, despite apparently more frequent menstrual disorders (40 percent compared to 26 percent), had only a dropout rate of 11 percent compared to 42 percent for the second. group.17 And a recent survey in Vietnam of some 600 amenorrheic participants using DMPA also showed the importance of counseling on method continuation rates.18 "Women who tend to continue the method are also those who say receive the best advice from not only providers, but also other satisfied users or their families or husbands," says Dr Maxine Whittaker, Australian physician and technical advisor on the part-funded study. by WHO.With monthly injectables combining estrogen and progestin, the menstrual cycle becomes more regular.After several months of use, most women are well regulated and so bleeding occurs once a month predictably.During the first three months, sporadic bleeding occurs in about half of users of these combined injectables.But at one year, less than a third of women using Cyclofem (25 mg DMPA combined with 5 mg estradiol cypionate) or Mesigyna (50 mg NET-EN combined with 5 mg estradiol valerate) complain of such bleeding.19A WHO study in which Cyclofem was introduced into family planning programs in Indonesia, Jamaica, Mexico, Thailand and Tunisia found continuation rates for about 8,000 participants.At one year, the dropout rate for menstrual disorders ranged from 3 percent in Indonesia to 40 percent in Tunisia.20 It is possible that cultural differences explain such variations.Like other progestogen-only methods, progestin-only pills (PP or micropills) usually cause irregular periods or an increase in the duration of light bleeding.They can also cause amenorrhea.Combined oral contraceptives (COCs) are much more widely used than progestin-only pills (PP).They usually reduce the number of days and the amount of bleeding.The decrease in menstrual flow can thus reach 60 percent or more.Sometimes, however, the occasional disappearance of periods and the occurrence of very light bleeding, light bleeding (spotting) or intermenstrual bleeding are poorly tolerated by the woman.Amenorrhea is also a possible side effect, especially in users of low estrogen pills.Women using an intrauterine device (IUD) often complain of pain and heavier menstrual bleeding.According to some studies, the frequency of these side effects could reach up to 80 percent.With copper IUDs, menstrual flow is only moderately increased (30 to 50 percent compared to menstruation observed in women not using modern contraceptive methods).FHI studies in 23 developing countries, however, indicate that the disturbances induced by copper IUDs tend to decrease after the first few months of use.21According to Dr. Patrick Rowe, physician in charge of research on IUDs at the WHO in Geneva, it is difficult to determine for each type of intrauterine device the abandonment rates due to an increase in menstrual flow."Even for a given type of IUD," he says, "there are significant differences in rates from one center or study to another."However, bleeding problems (heavy, prolonged or irregular discharge) remain the main reason for IUD removal: the drop-out rate at one year is between 7 and 15 percent.Hormone-releasing IUDs, on the other hand, greatly reduce menstrual flow.Progestasert, which releases the natural hormone progesterone, is a device with high cost, restricted distribution and authorization for use limited to one year in the United States.In several European and Asian countries, women can use levonorgestrel IUDs (called LNg IUDs).With these devices, the number of days of bleeding and light bleeding (spotting) is significantly reduced compared to that observed in women not using the method.It is not uncommon for their users to become amenorrheic.A series of multicenter studies coordinated by the WHO has followed more than 3,000 women using the IUD.It found that removal rates for pain and/or bleeding or amenorrhea are significantly higher at one year with the LNg IUD than with the copper TCu-380A IUD.22 At three years however, this difference tends to diminish, except in amenorrheic women: the removal rates for pain and/or bleeding were then 17 percent with the LNg IUD and 11 percent with the TCu-IUD. 380A, but 27 percent and 0.2 percent due to amenorrhea, respectively.23 "This WHO work has shown that, despite counseling to reassure women about the disappearance of their periods, a phenomenon that is not a sign of pregnancy, rates of LNg IUD removal due to amenorrhea could not be improved,” comments Dr Rowe.As a general rule, it is always recommended that providers emphasize to potential LNg IUD users that amenorrhea is not a disease.Absence of menstruation is, on the contrary, an indicator of the action of levonorgestrel on the uterine mucosa.In addition, the absence of bleeding can be a medical advantage.Reduced blood loss helps preserve iron stores in women's bodies and this is an important effect in those with anemia.In several countries, LNg IUDs are authorized for use not only for contraception, but also for the treatment of heavy periods.In some cases, these devices can replace surgery.24 Amenorrhea is also sometimes desired by women who, despite normal menstrual flow, find the disappearance of periods more practical and more comfortable.Menstrual disorders related to sterilization have been studied in particular within the framework of the work carried out in Brazil at the Centro de Pesquisas e Controle das Doenças Materno-Infantis de Campinas (CEMICAMP) with the support of FHI.The 236 participants in this study were between the ages of 30 and 49 and had been sterilized for at least five years.Disorders of the cycle ranked first among the physical effects attributed to the surgical intervention.An increase in menstrual flow was thus cited by more than a third of these sterilized women.25 The results of other researchers also indicate that female sterilization can be accompanied by painful periods, heavy bleeding or light bleeding (spotting ), and disturbances in the duration and regularity of the menstrual cycle.But, as some research shows, the menstrual disorders observed after sterilization may in fact result from the abandonment of a contraceptive method rendered useless by the intervention.Users of an oral hormonal contraceptive who have hitherto been used to light menstruation will notice heavier bleeding.Conversely, women who were using an IUD will often experience a decrease in menstrual flow after removal of a device that tends to cause greater discharge.26 These changes in menstruation are therefore unlikely to be a consequence of sterilization, but rather the abandonment of the contraceptive method previously used.The possible consequences of sterilization on menstruation merit further study.But a review of the results of 200 well-designed studies examining the menstrual and hormonal effects of tubal ligation shows that for women undergoing the procedure after the age of 30, the risk of disruption, menstruation pain or premenstrual distress are not increased by the intervention.On the other hand, in younger women who already have menstrual disorders prior to sterilization, these risks sometimes seem higher, although no major hormonal modification seems to occur.27But this management of menstrual disorders is also debatable, especially when oral contraceptives (COCs or estrogen) are used in women already using a hormonal method.For Judy Norsigian, program director at the Boston Women's Health Book Collective and member of FHI's advisory committee on contraceptive research, "It's not always a good idea to play hormonal roulette. Offering something else as an antidote for bleeding isn't necessarily suitable. It's best to offer another method."And for Doctor Carlos Petta, attached to the Brazilian University of Campinas and expert in injectable contraceptives: "As these bleedings do not usually present a health risk, the best approach is perhaps to simply wait for the menstrual cycle to regularizes. But if this approach is impossible, then certainly another method must be proposed."MESH descriptor : Women , Employment , Contraception , Contraceptives , Amenorrhea , Health , Sterilization , Methods , Research , Menstruation , Menstrual cycle , Copper , Levonorgestrel , Labor , Vietnam , Oral contraceptives , Indonesia , Blood , Ethnic groups , Pregnancy , Illness , Jamaica , Religion , Weather , Mexico , Combined oral contraceptives , Tunisia , Boston , Population , Life , Anemia , Africa , Yugoslavia , Progesterone , Programs , Philippines , Ligation , Fear , Reproduction , Risk , Role , Senegal , Singapore , Thailand , Touch , Clothing , Cities , Washington , Pregnant women , AdoptionOccupational medicine in martigues - 13 (Bouches-du-Rhône | Occupational medicine)General practitioner (f/m) (Manche | General medicine)General practitioner (f/m) (Pas-de-Calais | General medicine)Mpr (f/h) (Côtes-d'armor | Physical medicine & rehabilitation)General practitioner (f/m) (Aube | General medicine)General practitioner (f/m) (Manche | General medicine)Occupational physician (f/m) (Paris | Occupational medicine)Intensive care physician (f/m) (Corsica | Medical resuscitation)FOR RENT - NEW CABINET PARIS 17TH TERNES DISTRICTSTANDING MEDICAL AND PARAMEDICAL PRACTICE IN PARIS 16Sharing natural medicine practices in a multidisciplinary center Paris09Sale/rental of premises in a nursing homeSharing of qualitative cabinet PARIS 11, refurbished, private street entranceRental of a consulting room within a multidisciplinary medical centerParamedical offices - Versailles1210 route du puy 33240 LA LANDE DE FRONSACTechnical support caducee@caducee.netRedaction redaction@caducee.netAdvertising and partnerships partnerships@caducee.netCopyright 1997-2021 Caduceus.net.All rights reserved.Legal Notice -Privacy Policy