Review of “The Impact of Menstrual Side Effects on Contraceptive Discontinuation”

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 [], 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.

Study Findings

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.

Nile Cruise Egypt

A Luxury Nile Cruise boat is a highly appointed, floating, 5-star hotel, with most of the facilities of a normal 5-star hotel, including a relaxing sun deck and swimming pool. All your meals are included, though beverages and bottled water are not included. You will have your own en-suite, air-conditioned cabin (we book upper deck cabins wherever possible), and full use of all the boats facilities (restaurants, ships, sun deck, swimming pool, etc) We use several different cruise boats on the Nile, and we will inform you exactly which boat we will use enough time before your departure, as the boats shuttle back and forth on the Nile between Aswan and Luxor, with regular breaks for cleaning and maintenance. However, we regularly inspect to ensure they are of the same 5-star deluxe standard.

All of the boats offer comfortable accommodation and have mainly twin bedded cabins all of which are air-conditioned and have private facilities. All of the cabins have panoramic windows affording views of the passing river bank. all the boats have added a fridge, internal telephone and TV with local and video channels. Suites are also available if you want to have that little bit of extra comfort.

These cabins are larger than standard berths and have a double or twin beds and are equipped with en-suite facilities, internal telephone, fridge and TV local channel. One of the pleasures of cruising is the food and your Nile cruise operates on a full board basis with buffet breakfast followed by lunch and dinner which can either be a set menu or buffet style. The only additional expenses are drinks, tips, souvenirs and optional excursions available on board. A credit system operates on board the boat whereby all extras will be billed to your cabin. There is limited money exchanging facilities on board, so it is advisable to ensure that you have enough local currency although your guide will allow time for a bank stop during your cruise.

The lounge bar is the perfect place to relax on comfortable sofas and enjoy a cocktail before dinner and entertainment in the evenings.

On the sundeck you will find a plunge pool with sun beds and towels, there are also chairs and tables in a shaded area where you can relax. The reception area has safety deposit boxes and there’s even shop on board where you can buy souvenirs and essentials.

The History of the Human Hair Piece

The use of hair pieces started in ancient Egypt. The earliest known use of a toupee was found in a tomb near the ancient Predynastic Capital of Egypt, Hierakonpolis. The tomb and its contents date to 3200-3100 B.C.E.

It has been stated in history books that the ancient Egyptians wore wigs to shield their hairless heads from the sun, and also to protect their hair from the bleaching effects of the sun. They used beeswax and resin to keep their wigs in place. Wigs were also used as an everyday fashion in other ancient cultures including the Asyrians, Phoenicians, Greeks and Romans. For the Romans, in particular, wigs were often made with hair from slaves.

The use of human hair in wigs dates back to 2700 B.C.E in the Egyptian wigs. These were rare, however, and substitutes using palm leaf fibers and wool were much more commonly used. Wigs in ancient Egypt were worn by both males and females. They were used to protect their heads from the sun, and from vermin. The styles of wigs, and materials they were made of, were used to denote rank, social status, and religious piety. Women’s wigs were adorned with braids and gold, hair rings and ivory ornaments to make them more stylish than men’s wigs. The Egyptians who had wigs that were more elaborate and involved had the highest social status.

After the Roman Empire fell, the use of wigs was diminished. When the Christian influences emerged during the mid-evil era, fashion became more plain. By the Middle Ages (1200-1400 C.E.), the difficult times said goodbye to the use of wigs. Women were required to have their heads covered, and beauty became irrelevant. The feminine hair style once again regained importance as women again started showing their heads at the start of the Renaissance period. (1400-1600) Instead of covering their heads, women took pride in their appearance, and adorned their hairstyles and coiffures (wig fixtures on the tops of their heads) with lustrous veils and sparking jewels. Once again, society saw the importance in women’s wigs and fashion. In the 16th Century, wigs were brought back into use, and were used to compensate for hair loss, or to improve personal appearance. The biggest reason, however, for bringing wigs back, was because people were very unhygienic, and they had a problem with head lice. They would shave their heads to keep lice away, and wear wigs which were much more easily de-loused.

Among the reasons of the common people, the revival of the wig was largely influenced by Royalty. Queen Elizabeth I of England wore a red wig, which was worn in a “Roman” Style of tight elaborate curls. King Louis XIII of France who reigned from 1601 – 1643, started wearing wigs in 1624 when he began to prematurely bald. Thus was the start of wearing wigs for hair loss. His son and successor, Louis XIV of France (1638-1715) largely promoted his fathers wig wearing, which contributed to its spread in European and European-influenced countries.

In 1660, periwigs for men were introduced into the English-speaking world. These wigs were shoulder length or longer, and imitated the long hair that had become fashionable among men since the 1620’s. The English court quickly picked up the use of periwigs and it became increasingly popular.

With the arrival of the 17th century, the wig once again became the height of fashion for both men and women. Many of whom would shave their head underneath for comfort and fit. Hair historian Richard Corson says that the ascendance of King Louis XIV to the French throne was a pivotal point in the full return of the wig. The king had thinning hair, and would supplement it with false pieces until eventually he agreed to have his head shaved and to wear a wig.

The eighteenth century brought wigs to a whole new level. Wigs were once again viewed as a symbol of class. Those who had high finances would purchase large wigs for formal occasions. The larger or more “full bottomed” the wig was, the more expensive. This was a mark of class and income. If someone could not afford a wig, they would make their own natural hair look as “wig-like” as possible.

The mid-eighteenth century brought the term “hair dressing” into terminology. White was the favored color for wigs at this point. Trades were constructed around the care and maintenance of wigs, called hair dressing. The trade was so named, because the hair was dressed instead of being cut. The wigs were greased and then powdered with flour, or a special mixture of starch and plaster. Women did not wear wigs, but wore coiffures which were piled high with artificial hair, powdered and placed with jewels. Women mainly powdered their hair grey or blue-ish grey. From the 1770’s onward, women’s hair was never found bright white like men. At this point, wig powder was made from finely ground starch that was scented with orange flower, lavender, or orris root. Wig powder was most often used as off-white, but it was occasionally colored violet, blue, pink or yellow.

Men’s powdered wigs, and women’s powdered coiffures eventually became essential for formal wear occasions. This continued until almost the end of the 18th century.

At the end of the 18th century, the development of the naturally white or off-white powder-less wig for men, which was made from horsehair, became the new fashion, as powdering wigs was messy and inconvenient.

By the 1780’s, young men started lightly powdering their natural hair just as women had been doing since the 1770’s. After 1790, both wigs and powder were used only for older and more conservative men, and ladies being presented in court. At this point, English women seldom powdered their hair anymore. In 1795, the fashion for wigs and powder disappeared when the British government levied a tax on hair powder.

By the start of the 19th century, the wearing of wigs as a symbol of social status was largely abandoned. In the United States, only the first five presidents, from George Washington to James Monroe wore powdered wigs. In the 19th century, women hardly wore wigs anymore. Full wigs were only worn by older women who had lost their hair.

Today, wigs, referred to in today’s society as hair pieces, are worn by many people on a daily basis in everyday life. They are mostly worn by individuals who are experiencing hair loss due male pattern baldness, or to medical reasons, Most commonly from cancer patients undergoing chemotherapy, or those who are suffering from alopecia. When faced with the troubling idea of hair loss, many individuals will search to see what is the right answer for them. Hair pieces have been around for so long, and are used everyday, going unnoticed by millions of people.

Minimize Maintenance Free With Cedar Railings

Cedar wood allows many advantages among the varieties of wood available in the market. It is almost maintenance free, consider that only needs application of lacquer every three years and to do this just will take just 15 to 20 minutes per 1000 square feet of cedar wood.

Cedar wood has been known to the humanity for thousands of years.Cedar are grown in many areas of the world. It seems to be native to the Himalayan range area, and they can also found in the Mediterranean region as in the South American Wilderness.Trees grow to a height of 50 meter, their evergreen leaves reaches up to 3 feet long. The leaves are comparable to fir tree leaves and the trunk of the cedar wood tree may grow from 1 to 2 feet in diameter,some times bigger. The most common varieties of cedar wood are, Deodar Cedar, Lebanese Cedar, Turkish Cedar, Missioner Cedar (original of Misiones, Argentina) Cyprus Cedar, Or so called Atlas Cedar.

Some facts:

1. Maintains truncated pyramidal silhouette in the extreme for most of his life– The branches grow horizontally, with the apices fallen. The male flowers appear individually. They are cylindrical, 3-6cm in length, pale yellow or pink. The women appear in small pineapples 1cm long, light green or reddish. Flowers fall.

2. Very longevity can reach the millennium

3. The leaves are aciculares because individual or bouquet of 2.5-4cm long, thin, white and flexible, grayish green

The cedars are known for the quality of its wood, resistant to high temperatures, humidity and aging. In ancient times the Lebanese (Phoenician) exported cedar wood mainly to Egypt, where it was used for the construction of ships and sarcophagi. The Egyptians also used cedar oil for mummification

Bible named the Cedar wood many times and the most famous place where scented cedar was extensively used for building is King Solomon temple in Jerusalem. It construction was near the 1000 BC, so the durability of cedar wood is established beyond doubt around the world.

DIY Cedar Railings

If you wish to do a DID railing of Cedar, there are many supplier who can satisfy your requirements on this matter, when a good previous planning, you can acquired the pre cut railings and just installing them in desired place, provide a map stating the dimensions of the area to be enclosed with railings to the wood supplier and other valuable information so that the railings can be manufactured and shipped according to your real needs and may install without problems.

Assemble it as per manufacturer’s indicated recommendation and you will obtain a beautiful Cedar wood railing instantly, if you have to do some trimming to adapt it perfectly it won’t no present any trouble to the DID fan has skills and experience in woodworking.

Cedar maintenance

Cedar railings can be easily maintained if you are aware that your railings must away from moisture, keep dry and clean and the beauty of their will last long years, Cedar, red or white, gives your home not only warm appearance, style and comfort but also spread the soft scent of its perfume, highly appreciated otherwise as part of incense. Let the famous and elegant Cedar be part of your home and of your deck railings, as a sign of good taste