Bleeding Changes Affect Contraceptive Choice and Use
Menstruation, the vaginal bleeding that women experience monthly for much of their lives, can mean many different things to women—a sign of femininity, youth, and the ability to reproduce, a reassurance of not being pregnant, and an indicator of health. It also can mean a monthly chore, pain, restricted contact with family and friends, limitations on activities, and feeling and being regarded as "unclean." The onset of monthly bleeding signals the beginning of fertility. Its sudden absence may indicate pregnancy or health problems.
It is no surprise, then, that many women are concerned when a contraceptive method changes monthly bleeding. These bleeding changes differ, depending on the method. Combined hormonal methods—the pill and monthly injectables, for example—tend to make monthly bleeding shorter and more predictable. Progestin-only methods such as long-acting injectables, implants, progestin-only oral contraceptives ("the minipill"), and the hormonal levonorgestrel-releasing IUD (LNG-IUD) all can cause bleeding changes that range from bleeding and spotting at unexpected times to no monthly bleeding.1 Copper IUDs do not change the length of menstrual cycles but do tend to cause somewhat heavier and longer monthly bleeding. Often, the same method can have different effects for different women or different effects over time for the same woman.
|
Bleeding changes are rarely harmful, and they do not signify underlying or impending illness.
|
These bleeding changes are rarely harmful, and they do not signify underlying or impending illness. Nonetheless, bleeding changes constitute women's most commonly reported method-related reason—and sometimes the most common reason overall—for discontinuing hormonal methods and copper IUDs (4, 15, 30, 34, 35, 39, 40, 47, 49, 61, 112, 119, 120, 152, 156).
While many women stop their method due to bleeding changes, other women are less bothered. For example, in a clinical trial of the copper TCu-380A IUD in Nigeria, Peru, and Turkey, only 6% of women reporting menstrual complaints had their IUDs removed for this reason (48). Also, discontinuation rates vary by country. For instance, rates of discontinuation of the TCu-380A IUD due to bleeding changes have varied from 1 per 100 women (in Cameroon) to 17 per 100 women (in Egypt) after 12 months of use (see Quick Look). In Peru 0 per 100 women discontinued the combined monthly injectable because of bleeding changes, whereas in Colombia 9 per 100 women did (15). In Pakistan 11 per 100 women discontinued progestin-only pills as a result of bleeding changes, while 0 per 100 women in Ghana did so (61).
How a woman reacts to bleeding changes and what she tolerates depends on many factors, such as on the type of bleeding change and how severe it is, on whether it interferes with her daily activities or personal relationships, and on traditional beliefs or restrictions surrounding bleeding (see What Shapes Women's Attitudes About Bleeding Changes). How she reacts also depends on what she knows about these bleeding changes—what they mean and what they do not mean.
 |
|
Discontinuation of Contraceptive Methods Due to Bleeding
Changes Varies in Clinical Trialsa
|
| |
Rates of Discontinuation per
100 Women at 12 Months Due to:
|
|
Contraceptive Method
|
No Monthly Bleeding
|
Other Bleeding Changes
|
|
Combined Oral Contraceptives
|
0.2 to 7b
|
|
Combined (Monthly) Injectables
|
0 to 5c
|
0 to 13c
|
|
Progestin-Only Oral Contraceptivesd
|
6 to 26e
|
|
Progestin-Only Injectablesd
|
7 to 13f
|
13 to 15f
|
|
Implantsd
|
0 to 12g
|
|
Hormonal IUDd
|
2 to 5h
|
6h
|
|
Copper IUDs
|
Not applicablei
|
1 to 17j
|
|
a Studies selected for adequate sample size, covering multiple centers or multiple countries, sound study methodology, and discontinuation rates reported as gross cumulative life table rates. (Gross cumulative rates are discontinuation rates for a single event among current users. That is, when the rate is calculated, discontinuations for other reasons are taken into account. These are most appropriate for comparing event rates among different methods.)
b Sources: Dunson 1993 (38), Dunson 1993 (40), McLaurin 1991 (90)
c Sources: Bassol 2000 (15), Cuong 1996 (32), Garza-Flores 1998 (56), Hassan 1999 (66), Koetsawang 1994 (83), Martinez 1998 (88),World Health Organization 1988 (153)
d Breastfeeding women may be more likely than women not breastfeeding to tolerate bleeding changes with progestin-only methods. Discontinuation rates, however, are not reported for breastfeeding women and for other women separately in these studies.
e Sources: Dunson 1993 (39), Sheth 1982 (118)
f Sources: Cuong 1996 (32), Said 1986 (113)
g Sources: Ba 1999 (12), Grubb 1995 (61), Sivin 1998 (120), Sivin 1998 (124), Zheng 1999 (161)
h Sources: Andersson 1994 (9), Luukkainen 1986 (86), Pakarinen 2003 (101), Sivin 1990 (121). For discontinuation rates due to "other bleeding changes," Luukkainen 1986 (86) and Sivin 1990 (121), report rates for bleeding issues and/or pain.
 i No monthly bleeding is uncommon among users of copper IUDs. Thus, discontinuation rates are not reported for this bleeding change.
j Sources: Farr 1994 (47), Farr 1995 (48), Farr 1996 (49), Petta 1994 (103), Reinprayoon 1998 (108), Sivin 1984 (119), World Health Organization 1997 (156)
|
Providers and Programs Can Help
The contraceptives that can cause bleeding changes are the most effective reversible family planning methods, and many women choose them for their effectiveness. Thoroughly discussing possible bleeding changes ahead of time and helping manage any bleeding changes that prove bothersome are among the most important ways that family planning providers can help these women continue to prevent unwanted pregnancy (see Counseling and Treatment Can Help).
Bleeding changes are just one topic that family planning providers need to discuss with clients considering hormonal methods or IUDs. Other key topics include effectiveness, other advantages and disadvantages of the method, how to use the method, when to return, and, as appropriate, prevention of sexually transmitted infections (94).
At a broader level, a better understanding of menstruation can improve women's well-being—not only women's own understanding but the understanding of family members and the community as well. Family planning programs can work with other organizations to improve knowledge and change attitudes about menstruation. Educating adolescent girls, mothers, and other family members about the start of menstruation during adolescence and about hygiene during monthly bleeding is especially important (see box, Better Understanding Menstruation Helps Girls and Women).
Left: Combined and progestin-only contraceptives, copper and hormonal IUDs, injectables, the patch, vaginal ring, and implants all change monthly bleeding to different degrees. Also, the Lactational Amenorrhea Method (LAM)—breastfeeding in a way that reliably postpones the return of fertility—delays the return of monthly bleeding after childbirth. Right: Male and female sterilization, barrier methods (male and female condoms and the diaphragm), spermicides, and fertility-awareness based methods do not change monthly bleeding. Illustrations: Left, Rita Meyer and Fran Mueller/Johns Hopkins' CCP; Right, Rita Meyer and Mark Beisser/Johns Hopkins' CCP
1 In this report the medical term for absence of monthly bleeding—amenorrhea—is used only in relation to pregnancy or disease to make the distinction between medical conditions and a normal and harmless contraceptive side effect.
|
Order this report
Download PDF
E-mail this page 
See companion INFO Reports, "Key Facts About the Menstrual Cycle