By Madeleine Moore, Consultant & Technical Advisor, PSI-Europe, Judith Elena Brauer, Program Manager & SRHR Technical Adviser, PSI-Europe and Odette Hekster, Managing Director, PSI-Europe
Menstruation is a normal and natural part of the reproductive system, and over half of the world’s population experiences menstruation throughout their lifetime. Women and girls’ experience with menstruation is an important determinant and outcome of sexual and reproductive health and rights (SRHR). Growing evidence exists about the associations between menstrual health and fertility, contraceptive use, reproductive tract infections, maternal health and HIV and AIDS. Despite this, menstrual health and hygiene (MHH) remains a neglected component of SRHR that affects the life course of many women and girls worldwide.
One important linkage between MHH & SRHR is contraceptive-induced menstrual changes (CIMCs), including the absence of menstrual bleeding, reduction of painful menstruation, as well as alleviation of symptoms of Pre-Menstrual Syndrome (PMS) that users of certain contraceptive methods may experience. Menstrual bleeding is a very personal and individualized experience, so CIMCs have the potential to dramatically impact the contraceptive use experience. A negative or unexpected experience of CIMCs can lead to method dissatisfaction or discontinuation, while a positive experience with the non-contraceptive benefits of some methods, such as lighter, easier periods, may potentially lead users to be more satisfied with their chosen contraceptive method. Addressing CIMCs is critical—whether that includes proper counseling about them, incorporating discussion of them into contraceptive method selection, eliminating them, or leveraging the benefits of some CIMCs.
Recognizing and addressing the importance of CIMCs is central to women’s experiences with contraceptive use. PSI was pleased to participate in the groundbreaking Virtual Technical Consultation on Contraceptive-Induced Menstrual Changes, coordinated by FHI 360 through the Envision Family Planning (FP) and Research for Scalable Solutions (R4S) projects with support from USAID.
The two-day technical consultation convened experts in the fields of family planning and menstrual health to review evidence around CIMC, with a focus on user perspectives and experiences across the life course. This consultation was an opportunity to facilitate new and increased connections between the family planning and menstrual health worlds, and to learn about the latest research and programmatic advancements. As PSI has been at the forefront of much of this work; several PSI programs were featured.
Some of the key highlights from the technical consultation were:
MHH is a critical aspect of SRHR: The consultation recognized the many biological and socio-cultural links between menstruation and SRHR. It also highlighted that awareness and understanding of menstruation can lead to greater bodily literacy and is critical to understanding fertility, pregnancy, and contraception.
PSI-Latin America and the Caribbean incorporated menstrual health as a key component of its youth SRHR program aimed at reducing teenage pregnancy rates. The program used a multi-channel strategy to strengthen information delivery and signpost to care through digital channels, while improving delivery of care through a network of providers. The program recognized that misinformation on the menstrual cycle increases the chances of adolescent pregnancy and a lack of information about CIMCs and stigma around it causes girls to fear accessing contraception. In response, the program led with menstruation to deliver the whole reproductive health package for girls in Latin America. This approach resonated with girls—as indicated by the increase in engagement on menstruation-related content—and allowed the program to bridge the information gap and put self-care at girls’ fingertips from the comfort of their phones and homes.
User perspectives shine new light on CIMCs: While “bleeding changes” have long been cited as an undesirable side effect for some contraceptive methods, new research has delved into this to better understand users’ perceptions of different types of bleeding changes—absence of bleeding (amenorrhea), length of bleeding, amount of bleeding, predictability of bleeding, frequency of bleeding—and how they can both positively and negatively impact contraceptive method use, (dis)continuation, and perceived health concerns. Although perceptions of these potential benefits vary based on cultural context, they present an opportunity to explore contraceptive attributes that are desirable to women.
PSI-Madagascar uses an innovative approach to promoting the hormonal intrauterine system (IUS) in Madagascar, leading with bleeding changes as a key attribute of this method and use of the NORMAL tool. The method is offered alongside a wide range of other options. In the first two years of offering the IUS, one of the most common reasons users gave for choosing the IUS was the menstrual bleeding changes offered by the method. Three months after adopting the IUS, continuation rate was very high, at 91%, and those who did not continue the IUS did not give bleeding changes as a reason for discontinuation. The case of Madagascar shows that with the right promotion and training of providers, clients and providers may come to see the menstrual changes associated with the IUS as an advantage rather than a disadvantage for clients who prefer lighter or no periods.
FP counseling should address CIMCs upfront, not only after method provision: Before clients choose and receive their FP method, providers should ask about their preferences regarding CIMCs and explain which methods align with them. This approach can help clients identify which method is the best fit for their individual needs and desires.
Job aids like the NORMAL counseling tool, developed by PSI and FHI360, and counseling approaches like PSI’s evidence-based Counseling for Choice (C4C) approach can help providers to effectively address client’s individual concerns, preferences, and desires for CIMCs and to tailor their counseling to their client’s needs.
Forward-looking innovations are necessary: Product research and development is ongoing to develop new methods and technologies that meet girls and women’s needs and preferences and take into account the desirable and undesirable CIMCs they may experience. PSI’s work outside contraceptive counseling for CIMCs includes, among others, collecting insights to understand clients’ preferences either through market landscaping studies or user-centered design. This insight gathering can help inform the design of new methods and technologies.
PSI, in collaboration with PSI-Europe, is expanding its work of integrating MHH and SRHR, as we lead the way in programmatic implementation, market research, and thought leadership—developing technical briefs, convening donors and other key stakeholders, developing an Investment Case for strategic funding that supports holistic MHH-SRHR programs and addresses current key gaps, as well as building critical partnerships.
PSI and PSI-Europe will continue to collaborate with FHI360 and other partners at both the global and country levels to advance these agendas.
To view the presentation and recordings from the Virtual Technical Consultation on Contraceptive-Induced Menstrual Changes, click here.