Elsevier

Contraception

Volume 67, Issue 1, January 2003, Pages 1-8
Contraception

Original research article
Amenorrhea associated with contraception—an international study on acceptability

https://doi.org/10.1016/S0010-7824(02)00474-2Get rights and content

Abstract

Surveys undertaken in the 1970s and 1980s suggested that amenorrhea was unacceptable to most women, especially in developing countries. More recent research suggests that increasing numbers of women in the developed world prefer to menstruate less often. In a questionnaire survey of 1001 women attending family-planning clinics and 290 contraceptive providers in China, South Africa, Nigeria and Scotland, only among black women in Africa did the majority like having periods. In all other groups, most women disliked periods, which were “inconvenient” and associated with menstrual problems. Given the choice, the majority of Nigerian women would prefer to bleed monthly. Elsewhere, women would opt to bleed only once every 3 months, or not at all. In all except the Chinese centers, the majority of women would be willing to try a contraceptive which induced amenorrhea. Providers tended to overestimate the importance of regular menstruation to their clients. This is an important observation for scientists and funding agencies involved in developing new methods of contraception.

Introduction

When Pincus and colleagues developed the combined oral contraceptive pill, they purposely introduced a regimen which would confer a monthly withdrawal bleed because “these artificial menstrual cycles give assurance to the contraceptive user of ‘normal’ genital function” [1]. In contrast, the 3-monthly injectable method of contraception, depot medroxyprogesterone acetate (Depo Provera®), which became available a decade or more later, inhibits cyclical ovarian activity, doing away with menstrual periods in most users. For many years, amenorrhea was widely regarded as the price women had to pay for the clear advantages of the method in terms of efficacy and duration of action. When the levonorgestrel-releasing intrauterine device (Mirena®) came onto the market in the 1990s, the amenorrhea commonly associated with its use was heralded by the manufacturer, providers and users as a positive benefit of the method. There is no medical advantage to menstruation per se. On the contrary, the morbidity associated with menstruation is impressive. Menstrual dysfunction is one of the most common reasons for which a woman consults her general practitioner and in some countries up to 20% of women will undergo hysterectomy for excessive menstrual bleeding [2].

In the developed world, the gradual acceptance of amenorrhea associated with contraception has recently attracted interest. Surveys suggest that increasing numbers of women welcome methods which induce amenorrhea and indeed many manipulate their pill-taking to achieve it [3], [4]. The debate has been taken a step further recently by the suggestion that whether to menstruate or not should be a matter of choice [5], [6], [7]. However, perceptions of menstruation vary according to culture and religion and women’s attitudes to changes in bleeding patterns associated with contraceptive use vary widely. Research undertaken by the World Health Organization (WHO) published in 1981 suggested that most women (even in the UK, but particularly in the developing world) preferred to have a monthly bleed and were unwilling to use a method of contraception which induced amenorrhea [8]. These findings have strongly influenced not-for-profit agencies involved in contraceptive development, which have tended to shy away from exploring such methods. Since much of the research on attitudes to menstruation was carried out decades ago, we have undertaken a survey among women attending family-planning clinics, and among their providers. The study was designed to explore attitudes towards menstruation and willingness to use a method of contraception which induces amenorrhea.

Section snippets

Materials and methods

The survey was undertaken in two centers in the People’s Republic of China (Shanghai and Hong Kong), two centers in Africa (Sagamu in Nigeria and Cape Town in South Africa), and in one center in Scotland (Edinburgh).

Two questionnaires were developed, one for women attending family-planning clinics (clients) and another for health professionals responsible for providing contraception (providers). Pilot versions of the relevant questionnaire were administered to 20 clients and five health-care

Results

The questionnaire was administered to 200 clients in each of the five centers. In Edinburgh, Shanghai and Nigeria, no one refused to participate. In Hong Kong, 4 women and in Cape Town, 12 women declined to take part, mainly due to lack of time. At least 50 providers in each of the five centers were sent a questionnaire. All questionnaires were returned in Cape Town, Shanghai and Nigeria. In Hong Kong, 50 of 76 questionnaires were returned. In order to obtain 50 returned questionnaires from

Discussion

Regular monthly periods are a relatively recent phenomenon [11]. Until modern contraceptives became available, most women spent much of their lives pregnant or breastfeeding and, therefore, amenorrheic. Menses only returned briefly at weaning, which was rapidly followed by another pregnancy. The epidemic of menstrual cycles coincided with the demographic transition from developing to developed country status with low fertility rates. Faced with the inevitable inconvenience of repeated menstrual

Acknowledgements

The authors would like to thank the following staff for administering the questionnaires: in Edinburgh, Sister Ann Mayo; in Cape Town, Sister Anne Hoffman; in Hong Kong, Miss Sharon Lee; in Shanghai, Dr. Chuanliang Tong, Dr. Aihua Fang and Ms. Meiying Yu; in Sagamu, Sister Stella Ayo Soyombo; in Glasgow, Dr. Alison Bigrigg. We also thank Dr. Rob Elton for statistical advice and Dr. Erin McNeill for valuable discussions. The five centers in this study comprises the Contraceptive Development

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