Menstrual Bleeding Changes Are NORMAL: Proposed Counseling Tool to Address Common Reasons for Non-Use and Discontinuation of Contraception

A new family planning counseling tool uses the simple mnemonic device “NORMAL” to help family planning counselors and providers communicate to their clients key messages about menstrual bleeding changes associated with use of hormonal contraception and the copper IUD.


BACKGROUND
I n 2017, an estimated 214 million women of reproductive age living in low-resource settings wanted to avoid pregnancy but were not using a modern method of contraception. 1 Data from Demographic and Health Surveys conducted between 2005 and 2014 reveal that almost one-third of women cite concerns about side effects or fear of health risks as a reason for non-use of modern contraception. 2 In addition, nearly 40% of women who want to avoid pregnancy report they used a contraceptive in the past but discontinued use because of method-related issues. 3][6][7][8][9][10] Many women fear that menstrual changes-such as heavier bleeding, prolonged bleeding, irregular bleeding, spotting, and absence of bleeding (amenorrhea)-can lead to negative health consequences, including infertility.In addition, women often perceive that menstruation is a natural sign of femininity; they worry absence of bleeding is a sign of pregnancy; and they fear a build-up of "dirty" or "bad" blood in their bodies.][12][13][14][15][16][17][18] Helping women understand the typical bleeding changes associated with the use of modern contraceptive methods could lead to greater acceptance of these changes, increased method uptake, improved satisfaction, and higher continuation rates. 10,19In particular, both health care providers and contraceptive users should understand that changes to menstrual bleeding-including absence of bleeding-due to the use of contraceptive methods will not negatively impact women's health. 20,21A clearer understanding of potential bleeding changes associated with a given contraceptive method and anticipated lifestyle implications may also help women make well-informed decisions about the specific method that best meets their needs. 22n addition, amenorrhea and oligomenorrhea (infrequent bleeding) associated with certain hormonal contraceptive methods can have important noncontraceptive health benefits as well as lifestyle advantages for some women. 20,21Positioning noncontraceptive attributes as having potential advantages for women, rather than characterizing all menstrual bleeding changes as unpleasant side effects, could potentially lead to increased demand for and satisfaction with hormonal contraceptive methods. 23espite the potential advantages of providing highquality counseling on these topics to family planning clients, it is unclear the extent to which this happens in the field and what impact these types of messages might have on method uptake or continued use.A recent review by Polis et al. 10 found few studies that have evaluated whether counseling clients on changes to menses influences method choice or improves continuation rates.The authors noted that development of a counseling tool could help health care providers better communicate with clients about potential bleeding changes associated with contraceptive use.The work described here was undertaken to address this gap.
5][26][27][28][29][30][31][32][33][34] Two clinicians independently reviewed each resource to evaluate if and how menstrual bleeding changes were addressed.They examined 6 parameters to determine whether providers were instructed to (1) describe bleeding changes clients should expect with specific contraceptive methods; (2) compare typical bleeding changes among different contraceptive methods; (3) reassure women about menstrual bleeding changes, either general or detailed reassurance; (4) describe strategies to manage inconvenient menstrual changes; (5) provide basic information about menstruation and/or menstrual hygiene; and (6) explain the potential health benefits of oligomenorrhea or amenorrhea.In addition, reviewers also noted whether providers were instructed to describe typical menstrual changes before or after a client selected a specific contraceptive method, and whether tailored information was included for special populations, such as youth or postpartum women.The information was evaluated for 4 contraceptive methods-implants, injectables, the copper intrauterine device (IUD), and the levonorgestrel intrauterine system (LNG IUS)because of the high likelihood of these methods to change menstrual bleeding patterns.
A key finding from the assessment was that menstrual bleeding changes are insufficiently addressed in the resources reviewed.In general, common bleeding changes, such as heavier or decreased bleeding, and the potential benefits of reduced or no bleeding are addressed in all of the resources evaluated; however, these topics either do not receive much emphasis or little detail is provided.Although resources often instruct providers to reassure women that bleeding changes are not a sign of illness, global evidence demonstrates that women's concerns about bleeding changes are more varied and nuanced. 10As such, family planning counselors need to be able to provide clients with general information about bleeding changes as well as communicate information tailored to clients' individual concerns.Results from the assessment of training, counseling, and reference materials are summarized in the Table.

PROPOSED TOOL
To address gaps in existing guidance and training materials, a multidisciplinary project team from FHI 360 and Population Services International (PSI) developed a simple set of counseling messages about menstrual bleeding changes associated with contraceptive use.The objective of this project, which was funded by the United States Agency for International Development (USAID), was to develop a resource that health care providers could easily incorporate into counseling sessions without substantially increasing time or effort requirements.The primary goals of the tool are to prompt providers to (1) educate women on bleeding changes associated with use of contraception, (2) address common misconceptions and fears about menstrual changes, and (3) increase women's awareness of the potential advantages of reduced menstrual bleeding and/ or amenorrhea.
The tool uses the simple mnemonic device "NORMAL"-Normal, Opportunities, Return, Methods, Absence of Menses, and Limit-to help practitioners remember brief messages about menstrual bleeding changes associated with hormonal contraception and the copper IUD and address typical concerns and questions women often have.The NORMAL tool prompts providers to address the following 6 points: 1. NORMAL -Changes to your menses are NORMAL when you use a contraceptive method.With this point, providers are encouraged to describe the different types of bleeding changes that women can expectspecifically, changes in volume, duration, and predictability of menses-with use of hormonal contraception and the copper IUD.Providers are also instructed to tell clients that menstrual changes can vary over time with continued use of hormonal contraception. 33 OPPORTUNITIES -Lighter or no menses can provide OPPORTUNITIES that may benefit your health and personal life.
Providers are prompted to inform clients of the potential health benefits and lifestyle advantages associated with reduced bleeding or amenorrhea.For example, all hormonal contraceptives offer some protection from iron-deficiency anemia, and some methodssuch as oral contraceptive pills and the LNG IUS-are used as effective treatments for heavy menstrual bleeding (menorrhagia). 33lso, the absence of bleeding or infrequent bleeding can be convenient for women by increasing their ability to participate in educational or work activities, lowering financial

Continued
costs and the burden of menstrual hygiene management, and reducing disruption of sexual activity. 21,35 RETURN -Once you stop using a method, your menses will RETURN to your usual pattern, and your chances of getting pregnant will RETURN to normal.Providers are encouraged to reassure women that menstrual bleeding changes are not permanent and will not harm their future fertility.For most contraceptive methods, fertility will return rapidly after use of contraception is discontinued.In the case of injectable contraception, return to fertility will likely be delayed for several months after stopping use.33 4. METHODS -Different contraceptive METHODS can lead to different bleeding changes.Providers should ask a woman about her preferences regarding bleeding changes when she is selecting a method.Bleeding profiles differ across methods, and women's preferences should inform a tailored counseling approach and be incorporated into deciding which method to select.22 5. ABSENCE OF MENSES -If you are using a hormonal method, ABSENCE OF MENSES does not mean that you are pregnant.Providers should reassure users of hormonal contraception that they should not assume absence of menstrual bleeding is, by itself, a sign of pregnancy.If a woman has other signs of pregnancy while using a hormonal method, or if she misses her menses while using copper IUD, she should talk with her provider or take a pregnancy test.33 6.LIMIT -If changes to your menses LIMIT your daily activities, there are simple treatments available.If a woman perceives bleeding changes as unpleasant or worrisome, she should be encouraged to talk with her provider about options before she decides to discontinue a method.For example, irregular or heavy bleeding may interfere with women's daily lives or increase their menstrual hygiene management burden. 10mple treatment options are available that can help alleviate troubling physical symptoms.33,36 Additional education and reassurance can also be helpful.37 Evidence shows that use of acronyms and mnemonic devices can improve clinical practice in a range of fields, and that the introduction of simple evidence-based checklists and job aids for family planning providers can lead to increased contraceptive use in low-resource settings.[38][39][40][41] Two mnemonic devices have been commonly used in international family planning programs to e Information about the LNG IUS is not included in all resources because it is not widely available in developing countries.The ICA Foundation donates free LNG IUS units and has LNG IUS training resources for providers on their website.The ICA Foundation materials were reviewed for information on the LNG IUS specifically and did not include information on implants, DMPA, or the copper IUD.
train providers on appropriate sequencing of counseling steps: GATHER, which stands for Greet, Ask, Tell, Help, Explain, and Return, and REDI, which stands for Rapport building, Exploration, Decision making, and Implementing the decision. 42,43he NORMAL tool complements these frameworks as well as other commonly used counseling approaches.
Research has demonstrated that when delivering information about a health intervention, there is a risk of inadvertently reinforcing misconceptions among the target population. 44,45As such, all messages included in the NORMAL tool are framed in positive language that avoids repeating inaccurate information.Although only a subset of contraceptive methods was included in the initial review of international counseling and training resources described earlier, the NORMAL tool was designed to be relevant and applicable for all hormonal methods and the copper IUD.Providers who use the tool are instructed to use it both before and after a client selects a contraceptive method; they are also prompted to remind their clients to return for additional counseling and/or treatment if they have concerns about bleeding changes after method initiation.
In 2017, the team that developed the NORMAL tool solicited feedback on a preliminary draft from private-and public-sector health care providers in Haiti and Zambia during family planning training workshops, and from PSI and FHI 360 reproductive health staff in Nigeria and Zambia during project meetings.The format and content of the tool were then revised based on the input received.A final version of the NORMAL tool (Figure ) is also available in French, Portuguese, and Spanish; the term "NORMAL" is used in all 3 translated versions, with minor adjustments to ensure the translated content is accurate and appropriate.(To download the English and translated versions, see www.fhi360.org/resource/normal-counseling-tool-menstrualbleeding-changes-job-aid.)Because the tool is meant to prompt providers to address key points and is not intended to be a script that is read verbatim, the expectation is that providers will be able to address the same topics using local languages with clients.

NEXT STEPS
Changing women's knowledge and attitudes about menstrual bleeding changes associated with contraceptive use may enhance acceptability of modern contraceptive methods, reduce discontinuation rates among current users, and increase use among women with unmet need for contraception.The NORMAL counseling tool is designed to reduce common myths and misconceptions among women, improve women's knowledge of bleeding changes, and increase women's interest in the noncontraceptive benefits associated with oligomenorrhea or amenorrhea.This tool could be incorporated into facility-or communitybased provision of family planning, and could be included in preservice and on-the-job training for providers.
Before the tool is implemented on a wide scale, additional research is needed to further evaluate the feasibility and effectiveness of incorporating the NORMAL tool into family planning counseling sessions, women's comprehension of these messages, and the ultimate impact on changing providers' and women's attitudes and behaviors.In 2018, the NORMAL tool will be evaluated as part of a USAID-funded study in Malawi.Additionally, development of the tool was based on the initial review of counseling and training tools developed by international groups; an important next step would be to review national family planning guidelines and training curricula to determine if and how menstrual bleeding changes are addressed in those documents.Following that review, national stakeholders could be encouraged to incorporate the NORMAL tool into these resources, pending positive evaluation results.

TABLE .
Content Related to Menstrual Bleeding Changes in Key International Family Planning Counseling and Training Resources

TABLE . Continued
Abbreviations: CCP, Center for Communication Programs; DMPA, depot medroxyprogesterone acetate; ICA, International Contraceptive Access; IUD, intrauterine device; LNG IUS, levonorgestrel intrauterine system; K4Health, Knowledge for Health; MCSP, Maternal and Child Survival Program; UNFPA, United Nations Population Fund; USAID, United States Agency for International Development; WHO, World Health Organization.a 1=none; 2=general "no harm" message; 3=detailed "no harm" message.b Special populations include youth and postpartum women.c Method-specific information on the LNG IUS is not included in this resource.d Method-specific information on DMPA is not included in this resource.