Counseling and Treatment Can Help
Counseling family planning clients about potential bleeding changes with hormonal methods and IUDs helps them to choose suitable methods, increases their satisfaction with those methods, and encourages continued use of effective methods. Before a woman starts a new method, counseling about these methods includes describing the potential bleeding changes, explaining that these changes are normal and not harmful, and discussing how she would feel about these changes. Preparing clients in advance for potential bleeding changes helps them avoid unnecessary worry if they experience such changes.
Providers can encourage clients to return if they have problems. For the continuing user, bleeding problems often can be managed through counseling and sometimes treatment. Of course, providers should always offer clients the choice of switching methods if they are not satisfied or if their needs or preferences have changed.
Besides good counseling, family planning programs can employ other strategies to help clients continue to use contraception effectively. For example, health care workers can visit clients' homes. Community-based agents or outreach personnel can discuss the client's experience with the method, answer questions, help solve problems, and facilitate clinic visits if needed. This approach can reach clients who might stop a method despite continuing need but do not return to the clinic (76, 80). (A forthcoming issue of Population Reports, "Developing a Continuing Client Strategy," will discuss ways to help clients continue preventing unwanted pregnancies.)
Counseling Improves Client Satisfaction and Continuation
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Preparing clients in advance for potential bleeding changes helps them avoid unnecessary worry.
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Women who know in advance about possible bleeding changes are more satisfied with their method. For example, in Indonesia users of Norplant ® implants who were more knowledgeable about the method and about potential bleeding changes were more satisfied with the method than those who had less knowledge. In the province with the greatest differences in satisfaction, 98% of women with a "high" level of knowledge about the method were satisfied overall compared with 33% of women with a "low" level of knowledge (129). In Finland users of the hormonal levonorgestrel-releasing IUD (LNG-IUD) who reported receiving "a lot" of information about the occasional or complete absence of monthly bleeding with the method were five times more satisfied than LNG-IUD users who reported receiving "very little" information (13). Such findings may suggest both better-informed method choices and better-prepared users.
Evidence from diverse places—Bolivia, China, and Mexico—suggests that in-depth explanatory counseling about bleeding changes and encouragement to return with any problems contributes to longer use of a method. Repeating this information at follow-up visits may help (63).
For example, in a rural area of Yucatan, Mexico, women generally believe that absence of monthly bleeding is bad for health. In a study of Yucatan women who chose the progestin-only DMPA injectable, women who had received in-depth counseling continued using the injectable longer than women who received only routine counseling. Routine counseling consisted of general information about DMPA side effects, given at the first visit only. In-depth counseling consisted of information about the risks, benefits, and overall characteristics of the method, including common side effects such as lack of monthly bleeding, bleeding and spotting at unexpected times, and heavy bleeding. Providers also emphasized that side effects are not harmful, and they encouraged clients to return to the clinic if they had any concerns. These messages were repeated at each reinjection visit, every three months. Among women receiving routine counseling, 27% had discontinued the method at 12 months due to absence of monthly bleeding or bleeding at unexpected times, compared with 6% of women given in-depth and repeated counseling (21).
Similarly, in Sichuan Province, China, women who received in-depth, structured counseling before and during DMPA use were significantly less likely to have discontinued the method because of bleeding irregularities at 12 months than women who received routine counseling—5% compared with 19% (85). The in-depth counseling covered mode of action and common side effects. It made the point that bleeding irregularities would lessen with continued use. Also, these clients watched a video of satisfied DMPA users and received an informational booklet about the method. The group of women who received routine counseling did not receive information about potential side effects unless they asked.
In 30 government health centers in Bolivia, women who said they were told at the first visit that monthly bleeding might stop were more likely to be using DMPA after 12 months than women who said that they did not receive such information (73% compared with 57%) (71). In addition, 71% of women who said they were advised to return to the clinic in case of side effects were still using DMPA at 12 months compared with 42% of women who said they did not receive that advice.
How Providers Can Help
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Counseling about bleeding changes and encouraging clients to return with any problems contributes to longer use.
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A woman's attitude toward bleeding changes caused by her contraceptive method depends on many factors, both personal and social (see What Shapes Women's Attitudes About Bleeding Changes). Providers need not spend a lot of extra time and resources to draw out each client's perceptions and feelings about menstruation and bleeding changes. To help clients choose and use methods that fit their needs and their attitudes toward bleeding changes, providers can take the simple steps, see Useful Steps and Explanations to Help the NEW Client Consider Monthly Bleeding Changes. If a continuing user of a method finds that bleeding changes are a problem, providers can follow the steps on this page (Useful Steps and Explanations to Help the CONTINUING Client Manage Bleeding Changes Caused by Her Method) to help the client. It is a good idea to ask all returning users of hormonal methods and IUDs about bleeding changes. It is not necessary to cover all these steps, however, if a woman's bleeding changes are not bothering her.
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Useful Steps and Explanations To Help the NEW Client
Consider Monthly Bleeding Changes
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Describe common bleeding changes, including how these changes may vary over time (see Counseling Aid).
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- Providers can give information during one-to-one counseling or during group sessions.
- Visual aids (such as flipcharts, wall charts, cue cards, and checklists) are useful tools to help present information. For example, an illustration of the menstrual cycle from the Decision-Making Tool for Family Planning Clients and Providers (150), adapted and reprinted in the companion INFO Reports, "Key Facts About the Menstrual Cycle," can help to explain how menstruation works and how contraceptive methods affect it.
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Explain bleeding changes in ways that clients easily understand.
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- For instance, in India some providers compare absence of monthly bleeding with certain contraceptives to agricultural practices (7): A farmer prepares her field before sowing seeds by tilling the soil so that the seeds can easily take root and grow. In a similar fashion, a woman's body prepares for pregnancy by the thickening of the womb lining (like tilling the soil) so that an egg (seed) that is released can easily implant in the womb and grow. If the farmer does not want to grow anything in her field, however, she will not need to till the soil. Similarly, if a woman uses contraception because she does not want to get pregnant, the egg is not released (with some hormonal methods) and so the womb lining does not need to thicken to prepare for a fertilized egg. Thus, the womb lining does not need to shed as monthly bleeding because it has not thickened.
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Describe how likely the bleeding changes are.
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- Focus first on the most likely bleeding changes (see Counseling Aid).
- Use descriptive terms and comparisons. For instance, absence of monthly bleeding is quite common with progestin-only injectables but uncommon with combined injectables.
- Use both positive and negative statements. For example, almost half of women using DMPA stop having monthly bleeding by the time they have used the method for 12 months, and slightly more than half do not experience absence of monthly bleeding (147).
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Explain that these bleeding changes are normal with these contraceptives.
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- These changes are not signs that something is wrong with her health.
- Providers can dispel common myths about bleeding changes associated with contraceptives (see box).
- To help ensure that providers have up-to-date and accurate knowledge about bleeding changes, initial training and refresher courses can cover this information, and supervisors can repeat it.
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Discuss with the client how she would feel if these bleeding changes happened to her.
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- Would such changes be bothersome or interfere with her daily life? How would they affect the client's sexual relationship with her partner?
- How would she interpret the specific bleeding changes? For instance, with DMPA how would she feel if she did not bleed monthly? Would she welcome it or would she worry that it is a sign of illness or pregnancy? Would she want to change methods if she had these side effects? (It is not the bleeding change itself, but rather how the woman feels about it and interprets it that will determine how she reacts.)
- How would her partner and other family members feel about and interpret the bleeding change? Other family members often play important roles in a woman's contraceptive decision-making process (133, 134).
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If the woman has a medical condition that could be relieved by certain family planning methods, mention that.
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- In some cases bleeding changes with a hormonal method can help relieve existing menstrual problems or reproductive conditions (see Quick Look). For women with these conditions, this could be a factor in their choice of a contraceptive method.
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Once the client has chosen a method, explain all possible bleeding changes and how these changes may vary over time.
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- Stress again that these bleeding changes are normal and not signs of serious illness.
- Encourage the client to return any time that she has concerns.
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Useful Steps and Explanations To Help the CONTINUING Client
Manage Bleeding Changes Caused by Her Method
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In the first few months of use, explain that the changes probably will lessen with time.
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- Common with all hormonal methods and IUDs: Breakthrough bleeding and spotting, bloody vaginal discharge at an unexpected time during the cycle.
- Injectables, implants, copper IUDs, and the LNG-IUD can also cause prolonged or heavy bleeding in the first few months.
- These problems usually lessen or stop with time.
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If the client is using pills for contraception, check that she is taking a pill each day.
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- Skipping or missing pills repeatedly can lead to even more bleeding irregularities and also could make the pills less effective.
- New pill users, particularly, may skip pills, thinking wrongly that this will relieve side effects.
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If the bleeding problems persist or the client asks at any time, offer available treatments (see Provider Guide).
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- Treatment may improve bleeding symptoms and help the client use her method longer (105).
- If there is reason to suspect an underlying medical condition unrelated to the contraceptive, such as pregnancy, infection, or cancer, refer for diagnosis (see Provider Guide).
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If at any time the client finds the bleeding changes unacceptable or is not satisfied with the method for any other reason, help her choose an available method that better suits her.
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- Clients can be counseled to have patience and wait for bleeding problems to lessen. Providing this kind of support is especially important given that the contraceptive methods that cause bleeding changes are also among the most effective methods. Still, no client should feel pressured to keep using a method that she wants to change. Any family planning client having problems with a method should be offered a change of methods as one of her options. Using the Counseling Aid, the provider can counsel the client on other effective methods that are less likely to cause the bleeding changes that she finds unacceptable.
- It is particularly important to ask users of implants and IUDs if they want to switch, since women cannot stop using these methods without a provider's help.
- If the client wants a method that does not affect her menstrual cycle, the client can consider condoms or fertility-awareness based methods, such as the Standard Days Method® or the TwoDay Method®. A client needs to understand that these methods require her partner's cooperation and that their effectiveness is highly dependent on continuing correct use. If a couple is sure that they will want no more children, they can choose vasectomy or female sterilization.
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See companion INFO Reports, "Key Facts About the Menstrual Cycle