Women’s attitudes to contraception without bleeding (version without illustrations)

1. Women’s 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 one’s 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 Jan;12(1):3-16 Egypt 96 India, Hindu, low caste 96 India, Hindu, High caste 95 Philippines 95 Indonesia, 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 Jan;12(1):3-16 Pakistan, Punjab 91 India, Hindu, low caste 85 India, Hindu, High caste 81 Pakistan, Sind 81 Mexico 74 Philippines 72 Jamaica 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 Jan;12(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 2000;320:291

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 (n=321) (n=324) (n=319) 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 (n=310) (n=295) (n=250) 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 Women’s College 79 63 Co-ed state university 66 66 Inner-city clinic 70 71 Gold MA et al J Pediatr Adolesc Gynecol. 1998 Feb;11(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 amenorrhoeaGlasier A et al. Contraception 2003; 67: 1-8

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 woman’s being divorced or in her husband’s 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 woman’s 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 woman’s 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 suppressionStrongly agree or agree [N (%)]

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 Rock’s error. Malcolm Gladwell, New Yorker, March 2000