This episode will dig deeper into a topic that we touched on briefly in our last episode—contraceptive-induced menstrual changes. To explore this topic, we will hear from guests as well as anonymous contraceptive users giving their own testimonies.
www.knowledgesuccess.org/inside-the-fp-story
From Knowledge SUCCESS and FHI 360, this is Season 6 of Inside the FP Story—a podcast developed with the family planning workforce, for the family planning workforce.
Each season, we hear directly from implementers and decision makers from around the world on issues that matter to our programs and services. Through these honest conversations, we learn how we can improve our family planning programs as we work together to build a better future for all.
I am Sarah Harlan, Partnerships Team Lead with the Knowledge SUCCESS project. I am pleased to introduce our narrator, XXXX
Narrator Welcome to Season 6 of Inside the FP Story. This season, we are moving beyond a narrow definition of “family planning” to explore the larger context of sexual and reproductive health (or SRH).
As we heard in our previous episode, menstrual health has many linkages with family planning and reproductive health programs—and these are often under-funded and under-represented within health systems and services. This episode will dig deeper into a topic that we touched on briefly in our last episode—contraceptive-induced menstrual changes. To explore this topic, we will hear from guests as well as anonymous contraceptive users giving their own testimonies.
Narrator While each contraceptive method has potential side effects that can be managed, they also have potential benefits, beyond their use in preventing unintended pregnancies. For example, oral contraceptive pills can help treat conditions like anemia, polycystic ovary syndrome, and endometriosis. In this episode, we will further explore changes to menstruation related to contraceptive use.
The definition we are using for Contraceptive-Induced Menstrual Changes—or CIMCs for short—is “all changes to a user’s menstrual cycle caused by contraception.” This is a broad definition that encompasses changes in how much and how often a person bleeds; changes in uterine cramping and pain, changes in menstrual and gynecological disorders and symptoms; and short-term changes to the menstrual cycle after discontinuing contraception.
Funmi Olaolarun, who you heard from in our last episode, is a community health physician, researcher, and senior lecturer in the Department of Community Medicine at the University of Ibadan in Southwest Nigeria. Here she is talking about menstrual changes.
Funmi Olaolarun So contraceptive induced menstrual changes are changes that occur due to women using contraception, especially hormonal contraception.
And these changes are often the reason why women refuse to use modern contraception to space or limit births, or they stop using a hormonal method after a short time because of the fact that these bleeding or pain related changes, these contraceptive induced menstrual changes, affect their quality of life. And so if they stop using a method, it could inadvertently lead to an unplanned or a mistimed pregnancy.
Narrator As Funmi mentioned, contraceptive-induced menstrual changes can be undesirable. For example, clients may experience heavier or unpredictable bleeding patterns, or pain. As a result, users may start feeling dissatisfied with a method. They could begin using it inconsistently—for example, skipping daily pills or delaying injection appointments. They could even discontinue their method altogether.
These menstrual changes can affect the contraceptive user’s quality of life—causing physical or emotional distress. They may also need to seek health care or purchase menstrual supplies—leading to financial consequences. And there can even be consequences to relationships and families.
For this episode, in addition to hearing from our featured guests, we are sharing quotes from anonymous contraceptive users. These are actual quotes, but to protect anonymity, they were recorded by voice actors. Let’s hear from our first user now, about their experience with injectable contraception.
Anonymous #1 My contraception journey started late last year when I got into this relationship and we had plans not to have a baby. So we opted for a three-month injectable that is hormonal. I had my period in the first month but it never came again until the three months were over. Three weeks after the effective period of contraception I got my period that lasted for two weeks. Then the period went away for a week and came again for another week. I had periods for three good weeks and by this, I mean heavy periods. I thought of going to my doctor but I felt the need to listen to my body first. The greatest lesson that I learned is: There is a need to understand the side effects before choosing contraception and making sure that it is compatible with your body.
Narrator As this user pointed out, some side effects can lead to dissatisfaction with certain contraceptive methods. It is important for users to understand these menstrual changes are safe, normal, and can be temporary. They should be encouraged to seek care if they have concerns or would like to change methods. Here is Funmi with more on what she has seen in her work.
Funmi Olaolarun I have encountered CIMCs, contraceptive induced menstrual changes, in the context of my clinical work. Usually it's an irregularity of bleeding or a change in the nature of the blood they observe, or more cramps or more pain than usual.
Those are the complaints that I have heard. And oftentimes by the time they come to me, they have already stopped using the hormonal method and we have to go through counseling to explain to them the importance of switching to another method if they're not able to tolerate what they consider to be side effects of the hormonal method they had been using so that they do not end up with an unplanned pregnancy.
Narrator Contraceptive-induced menstrual changes are often associated with hormonal methods (for example, injectable contraception, implants, oral contraceptive pills, or hormonal IUDs)—but significant changes can also happen when using the copper IUD as well.
Arundati Muralidharan, who you also heard from in our last episode, is the founder of the Menstrual Health Alliance India (or MHAI) and the coordinator of the Global Menstrual Collective. She talked to us about contraceptive-induced menstrual changes in the context of India, where rates of hormonal contraceptive users are still low, but growing.
Arundati Muralidharan When we are looking at these hormone based contraceptives, I think it's even more essential that women who are considering them or on them would understand what the effect of those methods will be on their bodies. We know from research globally that the effects of contraceptives, of these hormonal contraceptives, on bleeding patterns on the menstrual cycle can lead to discontinuation and poor adherence to that particular method, and that can be problematic.
Narrator While methods, like oral contraceptive pills, injectables, implants, hormonal IUDs are effective modern methods of contraception—their associated bleeding and menstrual changes often lead to discontinuation, especially if these changes are unexpected or misunderstood by users. It is therefore essential that providers address these topics in counseling sessions prior to users starting a method, so they are better prepared for how they can work with their health provider or community health worker to mitigate and manage these changes. It is also important for users to know that many of these menstrual changes go away within a few months of starting a new contraceptive method. Being prepared for these changes, and knowing how long they may last, can help improve contraceptive continuation.
In addition, since individuals often rely on the experiences of others when choosing their method, quality counseling should discuss the range of side effects they could expect. Two individuals could use the exact same method for the same amount of time, and experience very different bleeding patterns. Since contraceptive-induced menstrual changes vary widely by method and by user, it is important that healthcare providers emphasize that the fact that each individual’s body is unique—and their experiences using a particular contraceptive method may be completely different than those of their friends or relatives.
Providers should also address myths and misconceptions in counseling, which can sometimes lead to hesitancy among users. Here is Funmi.
Funmi Olaolarun Some women, when you encourage them to go to the family planning clinic will tell you about the contraceptive induced menstrual changes that a friend or a colleague or a sister had experienced, and that that's why they're not interested in using a contraceptive method.
Narrator Fears and misconceptions about menstrual bleeding frequently contribute to contraceptive discontinuation, or not starting a method at all. Potential menstrual changes—including amenorrhea, which is the absence of bleeding—are often not emphasized in family planning counseling sessions. However, one tool that can help family planning counselors deliver this information is called the NORMAL job aid, developed by FHI 360. This contains guidance for providers to counsel family planning clients on bleeding changes associated with hormonal contraception and the copper IUD. The NORMAL tool is considered a self-care tool because it can help women feel assured that they are experiencing menstrual changes due to contraceptives. We will dive into the topic of self-care in the next episode.
As Funmi explained, it is particularly important to explain that these bleeding patterns are normal, safe, and often temporary and to weigh the risks of unintended pregnancy against the side effects of various contraceptives.
Funmi Olaolarun So these are the two different perspectives that I have gleaned from the different patients I have seen over time. But usually most of them respond to good counseling, especially when it's one-on-one with a provider, and they're able to understand the implications of not having any protection when they remain sexually active, and therefore they're willing to at least try another method if they're not willing to continue using the method they're having problems with.
Narrator Now we will hear from a contraceptive user who experienced some side effects, but because she had the information and counseling she needed, felt comfortable waiting for the side effects to improve.
Anonymous #2 In 2018, I was in a relationship with a partner to whom we both agreed on having sexual benefits as we plan to formalize the friendship in marriage. We went for counseling and settled for non hormonal IUD.I experienced mild cramping and spotting for 7 days. Thereafter had periodic heavy bleeding for three months with mid period spotting and had to be on a panty liner or a pad on some occasions during the month with associated back pain and cramping. After about 5 months my period flow returned to normalcy with no back pain and no cramps during my periods. Gradually my skin tone changed, saw reduced acne and relaxed mind during sexual intercourse. 4 years down the line , I am confident, bold and proud of my choice of contraception and happy for the plan on having children by plan that my partner and I took. Professional counseling is the best pathway to determining the right contraception method to go for as women and men.
Narrator Contraceptive side effects, including menstrual changes, have significant impacts on users’ lives—and while contraceptives are generally not harmful to one’s health, individuals often discontinue or decide not to adopt modern contraception as a result.
In many cases, women make a logical calculation as to whether side effects outweigh the desire to prevent an unintended pregnancy. But what if instead of just focusing on contraceptive side effects, we also considered potential “side benefits”?
Many methods have potential non-contraceptive health and lifestyle benefits—including those related to menstruation—which might not be adequately discussed or appreciated. For example, contraceptives can sometimes improve the symptoms of menstrual disorders like endometriosis, reduce cramping, or lead to lighter or paused periods.
Here is a user discussing her positive experience with the hormonal IUD.
Anonymous #3 I did not consider an IUD until after I had my first child. Since then and over the last 8 or so years with the Mirena, a hormonal IUD, I have experienced rare, minimal bleeding. So little that I don’t even consider using a pad or tampon. For me, that has been an important selling point on this method, of course in addition to its effectiveness. It seems that this method has been perceived as most appropriate for those who have had children but it seems like it would be a great option for anyone, and specifically those with heavy bleeding.
Narrator While there are often non-contraceptive benefits to many methods, they are not emphasized in family planning counseling sessions. Here is Funmi with more on these benefits.
Funmi Olaolarun Yeah, so there could be benefits. For instance, some women would be happy with amenorrhea, where the periods stop or they come much less frequently. And that's a benefit that some women could appreciate. Also for some women, for instance, if they use oral contraceptive pills, it could be beneficial in the sense that their periods could be lighter than usual.
Narrator You may remember Francisco Ruiloba, an OB-GYN based in Mexico City, from our first episode this season. He also spoke to us about the intersection of menstrual health and family planning—specifically, the ability to use certain contraceptive methods to also treat concerns related to menstruation.
Francisco Ruiloba Women come to me because sometimes they have an issue with their menstruation. They have heavy menstrual bleeding or they have irregular periods and they want to take a look at that. But then they sometimes ask for contraception. So it's sometimes very satisfying to hit two birds with one stone and offer them contraceptive services that also work for their own menstrual cycles.
So sometimes, let's say I have a woman that comes to me that has very heavy periods and this has impacted her quality of life. She has to go to the bathroom frequently to change her menstrual towel or change her tampon. She might have symptoms of anemia. It impacts her quality of life, either in the physical or emotional, psychological well being and she also wants contraception.
Narrator Francisco spoke a bit more about why it is important for providers to pay attention to anemia when treating family planning clients.
Francisco Ruiloba I think iron deficiency anemia is an undertalked topic. One out of three women will have abnormal uterine bleeding of some kind in her life. And when you have a heavy menstrual bleeding, when you have periods that are increased in volume or duration, well, you start to run out of iron.
Iron deficiency is the most common nutritional deficiency in the world. And of course, like with so many things, the underprivileged, the underserved communities and countries are the ones who are most affected. And they sometimes don't get enough iron supplementation. They sometimes don't get treated for their heavy menstrual bleeding.
And what's going on there is that she's anemic because she has heavy menstrual bleeding that has never been treated. It's something that has to be addressed.
Well, sometimes in order to treat heavy menstrual bleeding and in order to treat a prolonged bleeding well, contraception might be the best way to do it. It can either be a long acting reversible contraception, it can be oral contraceptives. All of those are not only preventing unwanted pregnancies, but they also are effective in treating the symptoms of heavy menstrual bleeding and iron deficiency anemia.
Narrator These side-benefits are exciting for future contraceptive users; however, this is also a topic that needs more research in order to understand how to best use contraceptives to manage something like anemia. Let’s hear from a user now who experienced heavy bleeding prior to using contraception.
Anonymous #4 From when I was 15 I started bleeding pretty well daily…sometimes a couple of days off but never more than 3 in a row. Led to anemia and just exhaustion. I tried many different pills and they helped some then started depo shots every 3 months and finally barely have a period anymore.
The last period I had was a surprise a few weeks before my next shot was due. It was a nightmare as I don’t keep pads or tampons around anymore and it was in the middle of an all day workshop. Having to try to leave to get to a shop was hard…. It was also the first time I bought pads in years and they are super expensive so I’m very glad I haven’t needed hygiene supplies for every day for 25 years!
Narrator Changes in bleeding can be broad, and can vary by user. It is also important to acknowledge that not all methods will have the same benefits for everyone—and that what is even considered a benefit or a barrier varies widely by individual and by culture. Marni Sommer, a professor of Social Medical Sciences at the Mailman School of Public Health at Columbia University in New York City, was featured in our last episode. She also spoke to us about the topic of contraceptive-induced menstrual changes, and specifically how this relates to cultural beliefs and practices.
Marni Sommer I do think the family planning community has for sure done a lot of work on thinking about menstrual changes. There is deep knowledge that this impacts use of contraceptives, that's not new information for anybody. But I think perhaps we have to do a much better job at understanding the cultural beliefs around menstruation.
Menstruation is so imbued in many societies with sort of very deep meaning around fertility. There's cultural meanings, there's social meanings. It really has sort of a– it holds a place. Not for everybody, but in many parts of the world, it just comes imbued with so many things and also expectations around how it's supposed to be. And when that changes, when there is unexpected bleeding, or different amounts of bleeding, or no bleeding, that can really be emotionally upsetting or confusing or disturbing for folks to the point that they'll stop using the contraceptives or they won't use them the way they're intended to be used. And then of course they're not able, you're not able to use them for preventing pregnancy as you'd like.
Narrator It is also important to recognize how bleeding patterns may affect LGBTQI+ individuals. For example, unwanted uterine bleeding can induce gender dysphoria, and can be a major source of distress for transmasculine individuals. Hormonal contraceptives can be one way to offer relief for those experiencing this.
Because individuals may have different bleeding preferences and considerations due to reasons related to culture, sexuality, gender identity, or other factors—it is imperative that providers consider this when counseling clients on their contraceptive choices.
Francisco Ruiloba I never just give a contraceptive method to a patient without knowing them, knowing what their preferences are, knowing what their values are, knowing what they want, because it's very important.
So if I have a patient that really likes to have her menstrual cycles, like in very orderly fashion to have it like I want to menstruate every month. Because if I don't do that, then maybe I don't feel like a woman. Or maybe I get worried, I believe I might be pregnant. For me, I can't have a menstruation that's irregular. I can't have spotting. Well, I tell those patients maybe a good method for you and we could try it and see if it works are the oral contraceptives or the patch or the vaginal ring. But if instead the woman lets you know that they like to just to not have the responsibility themselves. They say that they are very bad at taking one pill each day and they would like to have method that you administer it and then you don't have to do anything about it for years and that it may involve a like a a clear reduction in the volume of the menstrual cycle and the frequency, well then long acting reversible contraception is for them and then that's when we might offer them hormonal IUD or a contraceptive implant. There's lots of choices and really you have to consider patients where they are. You have to consider their religion.
You have to consider their culture.
It's just all about delivering good information and becoming the tool that patients need in order for them to be their own owners of their own sexual and reproductive health.
Narrator As we heard from our guests—as well as the contraceptive users featured in this episode, there can be substantial non-contraceptive benefits associated with many methods. These methods can reduce the cost associated with menstrual health materials like pads and tampons; reduce pain, cramping, and bleeding; affirm transgender individuals’ identities; and provide more freedom for the users to engage in daily activities. These advantages should not be overlooked—and instead, can be promoted and considered within integrated sexual and reproductive health programs.
Narrator Our guests in this episode, as well as our previous one, make a convincing case for integrating menstrual health and family planning counseling and services. Making sure that users are prepared for potential bleeding changes, supported if they have issues with their method, and counseled on all of their available options can help empower people to make the best choice for themselves. Join us in our next episode, where we will discuss another important consideration that can further empower individuals–self-care in SRH.
Season 6 of Inside the FP Story is produced by Knowledge SUCCESS and FHI 360. This episode was written by Sarah Harlan and edited and mixed by Elizabeth Tully. It was supported by an additional team, including Emily Hoppes, Catherine Packer, and Brittany Goetsch.
Special thanks to our guests Arundati Muralidharan, Francisco Ruiloba, Funmi Olaolarun, and Marni Sommer. We also are grateful to the individuals who shared their stories of contraceptive-induced menstrual changes that we used in this episode.
To download episodes, please subscribe to Inside the FP Story on Apple Podcasts or Spotify; and visit knowledgesuccess.org for additional links and materials.
The opinions in this podcast do not necessarily reflect the views of USAID or the United States Government.
If you have any questions or suggestions for future episodes, feel free to reach out to us at info@knowledgesuccess.org.
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