What Shapes Women's Attitudes About Bleeding Changes
Health care providers can find it useful to understand what shapes women's attitudes toward bleeding changes caused by contraceptive methods. A general understanding of local beliefs and behavior can help providers be sensitive to clients' points of view.
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Understanding local beliefs and behavior can help providers be sensitive to clients' points of view.
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As menstruation has monthly practical consequences for a woman, her personal experience with menstruation of course influences her attitude towards contraceptive-related bleeding changes, as does the nature and severity of the changes she experiences. But she sees these changes through the lens of her beliefs and understanding about menstruation. Her partner, family, and community usually share and shape these beliefs about the meaning and significance of menstruation, which include social restrictions placed on menstruating women. Common beliefs and restrictions do not necessarily apply to each and every woman, however. Women's attitudes differ and each woman's attitude tends to be mixed (for example, see box, Would More Women Use a Family Planning Method That Stops Monthly Bleeding?).
Menstrual Conditions Are Common
Painful menstruation (dysmenorrhea)—usually cramping in the lower abdomen—is the most common menstrual problem that women face. Prostaglandins, naturally occurring fatty acids that stimulate uterine contractions, cause the cramping pain (126). About one-fourth to one-half of women of reproductive age and about three-fourths of adolescents report having had menstrual pain in the previous three months (64, 65). Severe menstrual pain can keep women from work, school, and daily activities (65, 97, 143). Migraine headaches, which can be disabling, are among the most frequent symptoms accompanying monthly bleeding. They are due to changing levels of reproductive hormones (87). About half of migraines in women of reproductive age occur around the time of monthly bleeding (17).
Excessive or prolonged menstrual bleeding (menorrhagia) affects between 5% and 30% of women of reproductive age (65, 75). It is more common among women under age 20 and over age 40 than among other women. Dealing with excessive blood flow can be particularly difficult where women wear and wash menstrual cloths made from old sarongs, towels, t-shirts, or the like or where purchasing commercial menstrual products can become costly (19).
Excessive or prolonged bleeding may bring about or worsen anemia, a common disorder around the world. It is estimated that in developing countries more than 40% of women ages 15 to 59 are anemic (149). In developed countries about 10% of women in this age group are anemic.
Societal Beliefs Influence and Restrict Menstruating Women
Women's attitudes about menstruation are shaped not only by experience but also by beliefs about the social and cultural meaning of menstruation and what is acceptable monthly bleeding, taboos, and behavioral restrictions (117, 154).
Despite the high value that many societies place on menstruation and its perceived necessity, the names for menstruation in different languages and cultures suggest how societies also view this monthly event with disfavor. Terms in many cultures describe menstrual blood as "polluting." These terms reflect the common misbelief that the purpose of menstruation is to rid the woman of "bad blood" that is building up inside her body. For example, in Niger menstruation is referred to as "women's dirt," and in northern Ghana, as "washing of the stomach" (98). British women often refer to menstruation as "the curse" (154).
Another common set of names refers to menstruation in terms of the behavioral restrictions placed on menstruating women. For example, in Nepal menstruation is referred to as para-sarne (moving off a distance from her usual space) because in many areas menstruating women are isolated from other people (3).
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Women's attitudes about menstruation are shaped by experience, beliefs about the meaning of menstruation and what is acceptable monthly bleeding, taboos, and behavioral restrictions.
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Although not all beliefs are reflected in practice, in many places cultural and religious beliefs prevent menstruating women from participating in worship, sex, domestic chores, and many social activities (3, 62, 93). Most of these restrictions reflect the mistaken belief that menstruation is unclean and therefore a menstruating woman should limit her contact with others. These beliefs also can restrict women's diets and bathing (96). Thus, contraceptive methods that prolong bleeding or cause bleeding at unexpected times may hinder a woman's personal relationships and limit her daily activities.
Worship. In a survey conducted by the World Health Organization (WHO) in the 1980s, nearly all women in Egypt, India, Indonesia, and Pakistan said that menstruating women should not visit places of worship (154). Smaller, more recent studies confirm that many women of different faiths avoid praying, touching religious texts, or visiting religious places during their monthly bleeding (3, 5, 24, 55, 136).
Sexual relations. In the absence of HIV or other sexually transmitted infection, vaginal intercourse during monthly bleeding causes no harm to either partner, and the risk of pregnancy is slight. Still, in societies around the world most women and men avoid sexual relations during a woman's monthly bleeding, and some, even for a few days after.
Some 95% of women surveyed in the 1980s in Egypt, India, Indonesia, Jamaica, Korea, Mexico, Pakistan, the Philippines, and what was then Yugoslavia said that sexual intercourse should be avoided during monthly bleeding (154). In contrast, only about half of women in the United Kingdom, the only developed country in the study, believed sex should be avoided during monthly bleeding. Even among women who thought that it was acceptable, however, many did not have sex then as a matter of personal choice. In some cultures husbands and wives sleep in separate beds while the woman is menstruating (3, 5).
Social activities. Menstruating women often face restrictions on their social activities. Over half of women surveyed in Egypt and India and more than one-fourth in Jamaica, the Philippines, and former Yugoslavia believed that menstruating women should not visit female friends or relatives. This was particularly important when the friend or relative was pregnant or newly delivered. Women believed that the menstruating woman could harm her friend's reproductive health or fertility (154). Among high-caste Hindu families in Nepal, it is customary to send adolescent girls who start to menstruate to relatives' homes during their first three menstrual cycles (3). Fathers and brothers are not allowed to see a newly menstruating girl's face during this time.
Domestic chores. In some Asian countries menstruating women are not allowed to perform their domestic chores such as cooking and washing clothes (3, 5, 62, 154). Some women appreciate this relief from chores for a few days each month (3, 16). Many women living in urban areas without family or friends close by to help them cannot avoid chores, however (55).
Women Have Mixed Perceptions
Given that menstruation can cause inconvenience and pain and limit women's activities, it is not surprising that many women see menstruation as a nuisance. The WHO multi-country study from the 1980s, involving more than 5,000 women, found that women generally saw the physical, social, and behavioral consequences of menstruation as negative (154). They complained that menstruation was uncomfortable, messy, and inconvenient.
The onset of menstruation during puberty evokes generally negative reactions, perhaps because many girls are not prepared for it ahead of time (136, 159). Few are told that menstruation is a normal part of growing up, and that it is preceded by other changes to their bodies such as hair growth in new places, breast growth, and mood swings (see box, Better Understanding Menstruation Helps Girls and Women).
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Contraceptive methods that prolong bleeding or cause bleeding at unexpected times may hinder a woman's personal relationships and limit her daily activities.
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In contrast, many women welcome the end of menstruation and fertility (menopause) (84, 148, 158). Generally, menopause improves women's lives, freeing them from the risks of childbirth and from cultural restrictions on their social and religious activities (148).
Even if most women find menstruation a nuisance, they still consider menstruation a natural and positive event and a sign of continuing youth, fertility, and femininity. According to the WHO study, women saw regular bleeding as necessary for good health, and excessive bleeding as damaging to health. Recent small surveys and focus-group discussions in such countries as Nepal and The Gambia reveal similar perceptions (3, 143). During focus-group discussions in São Paulo, Brazil, one woman explained, "We damn menstruation, but on the other hand we want to menstruate, because we want to feel as a woman, feminine" (43). Therefore, it is understandable that many women do not want a contraceptive method that stops monthly bleeding, even though they may complain about the physical and social consequences of bleeding.
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See companion INFO Reports, "Key Facts About the Menstrual Cycle