Women

1
Womens attitudes to contraception without
bleeding(version without illustrations)
Dr. Anne Szarewski
Clinical Consultant, Hon Senior Lecturer
Cancer Research UK
Senior Clinical Medical Officer,
Margaret Pyke Centre, London
2
The period is used as an indication of
well-being of being normal physically and
sexually in relation to reproductivity and
heterosexual activity It is the means by which
ones health is maintained. The monthly
outflowing of blood provides a cleansing action
and/or removes unnecessary blood, which might
rise and cause headaches or strokes
Scott CS. Int J Gynaecol Obstet 1975 13 105-109
3
Menstruation is necessary for femininity - age
responding yes WHO Stud Fam Plann. 1981
Jan12(1)3-16
Egypt 96 India, Hindu, low caste 96 India,
Hindu, High caste 95 Philippines 95 Indonesi
a, Sudanese 85 Pakistan, Punjab 84 Korea
79 Jamaica 61 Yugoslavia, Muslim 61
Indonesia, Javanese 58 Mexico 57 Yugoslavia
, non-Muslim 52 United Kingdom 42 Pakistan,
Sind 33
4
age unwilling to accept amenorrhoea WHO Stud
Fam Plann. 1981 Jan12(1)3-16
Pakistan, Punjab 91 India, Hindu, low
caste 85 India, Hindu, High caste 81 Pakistan,
Sind 81 Mexico 74 Philippines 72 Jamai
ca 69 Yugoslavia, Muslim 67 Indonesia,
Sudanese 65 Indonesia, Javanese 61 Egypt
60 United Kingdom 53 Yugoslavia,
non-Muslim 52 Korea 50
5
WHO study of menstrual experiences and beliefs
Severy LJ et al, Women Health. 1993 20 (2)
1-20
Women from many backgrounds describe only three
different patterns of menstrual experience.
However, these experiences are interpreted very
differently. There are at least nine different
patterns of beliefs and preferences around
menstruation. Women choose and use
contraceptives as a component of their beliefs
about the menstrual experience, rather than the
experience itself.
6
WHO Stud Fam Plann. 1981 Jan12(1)3-16
The belief systems surrounding menstruation are
handed down from one generation to the next
during the process of socialization.
7
If you could design an OC, how often would you
choose to bleed?
Interval Female patients Female Drs
(n 158) (n 20) Every
month 54 45 Every 3 months 27 20 Every 6
or 12 months 4 5 Never 15 30
Rutter W et al. Med Journal of Australia. 1988
149 417-419
8
Prescribing patterns of norethisterone 5 mg for
general practitioners in Oxfordshire and the rest
of England
Shakespeare, J. et al. BMJ 2000320291
9
Preferred frequency of the withdrawal bleed (n
1005)
1st pref 2nd Pref 3rd Pref 4th pref
Monthly 44 7 14 35 Every 3/12
14 50 35 1 Every 6/12 9
40 48 3 None at all 34 2
3 61
Fuchs et al Europ J Contracep Rep Health Care
1996 1 275-284
10
Preferred frequency of bleeding on OCs by age
OC age category (years) 15-19
25-34 45-49 (n321) (n324)
(n319) Monthly 26.2 33.3 28.8 Every
3/12 38.3 25.0 21.3 Every 6/12 7.8 6.8
4.4 Once a year 4.0 3.4
6.6 Never 21.8 25.0 26.3 Would not use OCs
1.9 6.5 12.5
den Tonkelaar et al. Contraception. 1999 59
357-362
11
Preferred frequency of bleeding on OCs by age
OC age category (years) 15-19
25-34 45-49 (n310) (n295)
(n250) Monthly 26 35 26 Every
3/12 15 11 5 Every 6/12 4 3 4 Once
a year 8 8 7 Never 41 37 46
Wiegratz et al. Contraception 2004 69 37-42
12
Would you use OCs to bleed less frequently?
OC age category (years) 15-19
25-34 45-49 (n 310) (n 295) (n
250) Yes, always 6 5 4 Yes, for a
prolonged time 8 8 7 Yes,
sporadically 54 32 35 Never 26
50 46
Wiegratz et al. Contraception 2004 69 37-42
13
The frequent statement that it is natural seems
to indicate a sense of being in harmony with
nature and the natural rhythm of
life. Irregularity of menstruation serves as a
warning that something is wrong. Her sense of
health and well-being is threatened.
Scott CS. Int J Gynaecol Obstet 1975 13 105-109
14
Tolerance of irregular bleeding and amenorrhoea
in young women
Would stop if had Would stop if had
irregular bleeding amenorrhoea Elite
Womens College 79 63 Co-ed state
university 66 66 Inner-city clinic
70 71
Gold MA et al J Pediatr Adolesc Gynecol. 1998
Feb11(1)17-24.
15
Discontinuation rates of Implanon by specific
reason
Flores JB et al Int J Gynaecol Obstet. 2005
90(3)228-33
16
Attitudes and experience of clients towards
contraception and amenorrhoea Glasier A et
al. Contraception 2003 67 1-8
Edin-burgh Cape Town-B Cape Town-W Cape Town-C Hong Kong Shanghai Nigeria
Do you like periods?
Yes 26 75 35 42 50 33 81
No 74 25 65 58 51 63 19
How often would you choose to bleed?
Monthly 33 49 30 42 42 43 71
3 monthly 20 27 26 15 39 30 12
Never 37 9 29 36 6 15 13
If fertility returned immediately, would you use a method that stopped periods?
Yes 65 52 64 61 37 48 73
No 25 41 26 33 32 35 24
Undecided 11 7 11 6 32 18 4
17
Factors influencing young Malians reluctance to
use hormonal contraceptives
Castle S. Stud Fam Plann. 2003 34 186-199
18
Menstrual disruption, in the form of
amenorrhoea or prolonged bleeding, appeared to
have dire repercussions, including accusations of
witchcraft and immoral behaviour, that could
result in a womans being divorced or in her
husbands acquiring an additional wife.
Castle S. Stud Fam Plann. 2003 34 186-199
19
Infertility is understood not simply as not
having a child, but rather as not having a child
when one is desired Prolonged bleeding or an
absence of bleeding may reveal a womans
clandestine use of a method to her partner.
Prolonged bleeding also has private
consequences in that she cannot have sexual
relations, because if she does, her partner may
become ill. The most dreaded consequence is that
he may take another wife or obtain a divorce
Castle S. Stud Fam Plann. 2003 34 186-199
20
Amenorrhoea may signal menstrual disruption to
family members, who may notice that the
expected four to five day monthly break in the
womans religious or household duties does not
occur. Amenorrhoea is associated with
questions pertaining to the morality of the woman
or to aspersions concerning her fertility
potential. ..She may be socially ostracized and
unable to find a husband
Castle S. Stud Fam Plann. 2003 34 186-199
21
                                      
 
                                      
 
                                      
 
                                      
 
                                      
 

I think that the stopping or the disruption of
periods is due to sorcery or to marabouts (magic
men). They cast a spell on you. In a climate
where the belief in maraboutage persists, even
among the most educated, reversing widespread
misapprehensions concerning hormonal
contraceptive methods is likely to be a difficult
task.
Castle S. Stud Fam Plann. 2003 34 186-199
 
22
Andrist et al. Contraception 2004 70 359-363.
Women's attitudes toward menstrual suppression
Strongly agree or agree N ()
Even if completely safe, not interested in stopping periods 312 (22)
It would make me anxious or worried 628 (44)
It's necessary to have a period every month 727 (50)
I'd be pleased to use a method of birth control that made my period stop for a certain period of time 859 (60)
If I were sure it wouldn't hurt me, I'd do it 996 (69)
A lot more research should be done on this topic 1128 (79)
I think stopping periods is a good idea 618 (43)
I'd be interested in changing my period to make it less painful 879 (60)
I'd be interested in changing my period to decrease problems I have during my periods 919 (63)
I'd be interested in changing my pattern to have lighter periods 953 (66)
23
Studies by Sulak P et al.

• Highly selected women attending a specialist
  gynae clinic
• Complaining of problems in the pill free week
• Very committed practitioner
• High success rates not surprising!

Obstet Gynecol 1997 89 179-83 Am J Obstet
Gynaecol 2002 186 1142-9 Contraception 2004
70 281-287
24
The haphazard nature of science all too often
produces progress in advance of understanding
John Rocks error. Malcolm Gladwell, New Yorker,
March 2000