1. Women’s attitudes to contraception without bleeding (version without illustrations) Dr. Anne Szarewski Senior Clinical Medical Officer, Margaret Pyke Centre, London Clinical Consultant, Hon Senior Lecturer Cancer Research UK

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 Egypt96 India, Hindu, low caste96 India, Hindu, High caste95 Philippines95 Indonesia, Sudanese85 Pakistan, Punjab84 Korea79 Jamaica61 Yugoslavia, Muslim61 Indonesia, Javanese58 Mexico57 Yugoslavia, non-Muslim52 United Kingdom42 Pakistan, Sind33

4. %age unwilling to accept amenorrhoea WHO Stud Fam Plann. 1981 Jan;12(1):3-16 Pakistan, Punjab91 India, Hindu, low caste85 India, Hindu, High caste81 Pakistan, Sind81 Mexico74 Philippines72 Jamaica69 Yugoslavia, Muslim67 Indonesia, Sudanese65 Indonesia, Javanese61 Egypt60 United Kingdom53 Yugoslavia, non-Muslim52 Korea50

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? Rutter W et al. Med Journal of Australia. 1988; 149: 417-419 Interval Female patients % Female Drs % (n = 158) (n = 20) Every month5445 Every 3 months2720 Every 6 or 12 months 4 5 Never1530

8. Shakespeare, J. et al. BMJ 2000;320:291 Prescribing patterns of norethisterone 5 mg for general practitioners in Oxfordshire and the rest of England

9. Preferred frequency of the withdrawal bleed (n = 1005) 1 st pref %2nd Pref %3rd Pref % 4th pref % Monthly 44 7 1435 Every 3/12 14 50 35 1 Every 6/12 9 40 48 3 None at all 34 2 361 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 25-3445-49 (n=321) (n=324) (n=319) Monthly26.233.328.8 Every 3/1238.325.021.3 Every 6/12 7.8 6.8 4.4 Once a year 4.0 3.4 6.6 Never21.825.026.3 Would not use OCs 1.9 6.512.5 den Tonkelaar et al. Contraception. 1999; 59: 357-362

11. OC age category (years) 15-19 25-3445-49 (n=310) (n=295) (n=250) Monthly263526 Every 3/121511 5 Every 6/12 4 3 4 Once a year 8 8 7 Never413746 Wiegratz et al. Contraception 2004; 69: 37-42 Preferred frequency of bleeding on OCs by age

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 Gold MA et al J Pediatr Adolesc Gynecol. 1998 Feb;11(1):17-24. Would stop if had Would stop if had irregular bleeding % amenorrhoea % Elite Women’s College 7963 Co-ed state university 6666 Inner-city clinic 7071

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 amenorrhoea Glasier A et al. Contraception 2003; 67: 1-8 Edin- burgh Cape Town-B Cape Town-W Cape Town-C Hong Kong Shan ghai Nig eria Do you like periods? Yes26753542503381 No74256558516319 How often would you choose to bleed? Monthly33493042 4371 3 monthly20272615393012 Never379293661513 If fertility returned immediately, would you use a method that stopped periods? Yes65526461374873 No25412633323524 Undecided117 632184

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 suppression Strongly agree or agree [N (%)] Even if completely safe, not interested in stopping periods312 (22) It would make me anxious or worried628 (44) It's necessary to have a period every month727 (50) I'd be pleased to use a method of birth control that made my period stop for a certain period of time 859 (60) If I were sure it wouldn't hurt me, I'd do it996 (69) A lot more research should be done on this topic1128 (79) I think stopping periods is a good idea618 (43) I'd be interested in changing my period to make it less painful879 (60) I'd be interested in changing my period to decrease problems I have during my periods 919 (63) I'd be interested in changing my pattern to have lighter periods953 (66)

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