Elizabeth Tolley, Sarah Loza, Laila Kafafi and Stirling Cummings published their findings from the study of 259 first time users of the IUD, the hormonal implant or the tri-monthly injectable (DMPA). The aim was to gauge women’s bleeding patterns and perception of changes in their cycles subsequent to adopting their chosen method. Relatively few studies have interrogated women’s perception and tolerance of menstrual changes as a result of adopting a new method of contraception, some of which appear to contradict one another. The findings of this study provide important insights for the improvement of counseling to address women’s perception of bleeding changes.
The study collated both quantitative and qualitative data from surveys over a period of 18 months and from 48 women who participated in six focus group discussions (FGD). The study sought to shed light on the high discontinuation rate (70%) of DMPA users after one year, compared to 34% and 10% of IUD and implant users respectively. At the baseline study, participants reported an average of five bleeding days per cycle. After starting usage of IUD and DMPA [http://www.rho.org/html/cont-injectables.htm], users reported eleven to twelve bleeding days per cycle. The researchers also noted that those women who chose to use the implant differed from IUD and injectable users: They were more experienced mothers who wished for no more children and had prior experience with another method of contraception. On average, implant users were also slightly less educated than those who chose other methods and averaged two to seven years elder to women who used injectables and IUDs. Though not fully explored in this present study, the authors noted that these differences in personal characteristics at the baseline could have influenced women’s choice of IUD, implant or injectables.
In another population based survey of 252 women in New Zealand, bleeding irregularity or heavy bleeding were frequently cited as the primary reason for discontinuation of DMPA within 21 months of first adopting the method. Yet, the same study revealed amenorrhea as the primary reason for discontinuation between two and five years after adopting the method. Another randomized trial of two tri-monthly injectable contraceptives showed amenorrhea to be the cause given for discontinuation within twelve months of adopting DMPA. Another study in Bolivia showed a correlation between discontinuation and fewer (less than or equal to four) children or the belief that menstruation is important for the maintenance of good health.
A 1996 study in Egypt looked at counseling on injectables that women received from physicians, nurses and midwives. More than 50% of those providers and counselors believed that long-term amenorrhea could lead to sterility among other health complications. Many of those providers reported their belief that only couples seeking to effectively limit their family size should adopt DMPA. Such misconceptions may introduce biases when counseling and educating women and couples about the variety of available methods of contraception, including DMPA.
One fallout of provider bias in counseling comes in the conveyance of advantages and disadvantages of the various methods of contraception. IUD and implant users were given counseling that weighed heavily upon the advantages of those methods. In some cases, inaccurate or false information was given. By contrast, the same FGD revealed that many providers were more likely to explain disadvantages of DMPA rather than advantages. One provider explained in detail to those women who chose the implant or DMPA that they should expect their menstrual cycles to stop. When actual experiences deviated from the counseling, women were admittedly surprised, at best; many were alarmed.
Though implants caused many women to bleed heavily or led to amenorrhea altogether, injectables users reported nearly thrice the spotting as IUD users and over 60% more than the implant insofar as number of bleeding days. The unpredictability of bleeding days and patterns of bleeding (heavy, light, etc.) means that what was once a ‘cycle’ is rendered a variegated appearance of “traces” or “signs.” By the second month just over one third had felt changes in their cycles and expressed concern over these changes.
In this study, women who chose DMPA reported “dramatic increases in the length of bleeding episodes” during the first months. Subsequent reports revealed “sharp declines” in bleeding among women who continued the method. These same women reported further declines in average number of bleeding days between the twelve and eighteen month period. One woman explained her understanding of the injectable after having used this method for two years:
“Two or three drops, then it stopped for four months. And it came again for a while, and then stopped. I mean that when the injectable is due, it gives me a sign. It comes down as a drop or two….The first two cycles I had spotting. Then it stopped altogether.”
Among the women who discontinued use of DMPA, nearly one third cited amenorrhea as their primary cause for concern while only 7% did so due to other non-contraceptive effects. Notably, none mentioned a desire to return to normal fertility as a reason for discontinuation.
The menstrual diaries recorded by study participants revealed no significant statistical difference among women who continued versus discontinued use of DMPA insofar as “the proportion of total days recorded for each level of bleeding.” This reinforces the idea that the unpredictability of the menstrual cycle is the most disconcerting aspect of DMPA use- not cessation of the menstrual cycle. The study found that while correcting for “personal characteristics, spousal attitudes or knowledge,” bleeding inconsistency/length predicted likelihood of discontinuation of DMPA users at a rate of 4% per additional day above the average of five bleeding days per cycle reported at the baseline study.
The authors conclude that: “Our findings raise the possibility that counseling about bleeding and other side effects should be tailored to the personal and contraceptive experiences of women, and that partners may play an important role in how well some women tolerate contraceptive-related bleeding.” To mitigate these concerns, DMPA providers should discuss the immediate, short-term and long-term changes in adopting this unique method of contraception. Pre DMPA Counseling* should address the specific experience of women with their menstrual cycles in order to better prepare them for the potential changes to her cycle. Spotting and various other forms of irregular bleeding are the greatest indicators of continued use. Addressing these concerns will normalize the experience and reassure women so that they know exactly what to expect from adopting DMPA.
*Pre DMPA Counseling:
– Adheres to pelvic screening guidelines
– Plans injections relative to menstrual cycle and childbirth
– Evaluates medical history including diabetes risk
– Assesses intensity and typical number of bleeding days per cycle
– Addresses perception and misconceptions of menstrual changes
– Incorporates Behavior Change Communication strategies to gain familial support of adoption of family planning
Review of “The Impact of Menstrual Side Effects on Contraceptive Discontinuation: Findings from a Longitudinal Study In Cairo, Egypt.” Published in: International Family Planning Perspectives, Vol. 31, No. 1, March 2005
Hubacher D et al., Factors affecting continuation rates of DMPA, Contraception, 1999, 60(6):345-351.
Rivera R, Chen-Mok M and McMullen S, Analysis of client characteristics that may affect early discontinuation of the TCu-380A IUD, Contraception, 1999, 60(3):155-160.
Tolley E and Nare C, Access to Norplant removal: an issue of informed consent, African Journal of Reproductive Health, 2001, 5(1):90-99.