Written by Gunjan Khorgade, Snehal Sinha and Pramila Sharma, Action Research and Training for Health (ARTH)

“It feels good when your periods stop. You don’t have to worry while travelling, you become tension-free”,

said 35-year-old Fefli Bai¹ with a smile, triggering peals of infectious laughter among the assembled women. On World Contraception Day (26 Sep 2023), Action Research and Training for Health (ARTH), a non-profit working on SRHR in rural and tribal communities of Rajasthan, India, convened a consultation with twenty-six women to discuss their experiences around menstrual bleeding changes triggered by the use of locally available contraceptives. The government health system in the area provides combined oral pills, Copper-Ts, and injectables, while ARTH clinics provide oral pills, injectables, Copper-Ts and hormonal IUDs. All facilities also provide male condoms. Contraceptive-induced menstrual changes (CIMCs) are known to be a major reason for discontinuation of contraceptive use. We therefore felt that it would help our intervention to recognize and understand how women perceive these changes and how they react. Every woman is likely to respond in her own way to menstrual changes, hence understanding her perceptions should help a provider address her concerns.

In a systematic review titled “There Might Be Blood: a scoping review on Women’s responses to contraceptive-induced menstrual bleeding changes”², Chelsea Polis and co-authors explain the role of contraceptive-induced menstrual bleeding changes in triggering dissatisfaction and discontinuation. They analyse how menstrual changes can impact women’s daily routines, including participation in domestic work, school, sports, or religious activities along with other domains including emotional relationships. Their paper concludes that that contraceptive-induced menstrual bleeding changes are a key facet of women’s and their partners’ experience of contraception, and a key determinant of satisfaction, discontinuation or switch.

Most contraceptives are known to trigger menstrual changes as per a pattern – injectables, hormonal IUDs, and implants lead over some months to scanty periods and then amenorrhoea. However, some women might initially have irregular bleeding, which even if scanty, is unpredictable. Combined oral pills bring on regular but scanty withdrawal bleeding each month, while Copper-Ts can trigger pain and heavier periods. In the absence of adequate counselling and post-adoption support by health providers, women are left to deal with such menstrual changes on their own. While many women feel relieved that a monthly period indicates non-pregnancy, several others tolerate amenorrhoea well, appreciating the advantages of avoiding monthly blood loss. However, most are averse to spotting, staining, unpredictable or painful bleeding.

“When my child was a year and a half old, I used Antara (injectable contraceptive) once. The next month my periods lasted a day or two. Over time, my periods stopped and I was worried. What if blood was accumulating inside my body? So I stopped taking the injection”

For several women using injectables, the menstrual changes did not last for long, because after three to four doses the government auxiliary nurse midwife withheld further injections and advised them undergo sterilization. Gopi, 30-year-old mother of two worried about weakening eyesight as a result of irregular or no periods. Recalling her experience with injectable contraception, she said,

“My eyes will become weak and I might become blind if I don’t get periods”.

When asked if any had actually experienced weakening of eyesight, the assembled women denied it. They had heard it from older women in the community and hence were apprehensive.

On a very different note, several other women appreciated the benefits of not getting periods after using contraceptives. They said that without periods they were free to pursue their daily chores and felt more energetic – reduction of anaemia and cessation of menstrual pain or cramps due to scanty menses or amenorrhoea are among the known non-contraceptive benefits of hormonal methods.

“You know, I don’t feel tired now. When I used Mukti (hormonal IUD) my periods stopped after some months. I was afraid at first but soon started to see its benefits. I feel stronger now, I don’t get tired easily. And you know the best thing? I don’t have to worry about changing pads each month,” said 28 year old Indira, when asked about her experience with amenorrhoea.

A look of relief crossed 32 year old Savita’s face as she remarked,

“It is good that I get a double benefit from Antara (injectable). I don’t get pregnant and have no periods – no worries about spotting or staining while travelling anywhere”.

Some women in the consultation however had clear notions about wanting periods each month – for them, it signified not becoming pregnant. Most women disclosed that they would like to have “a bit of monthly period”. Moreover, the flow of blood each month was perceived as a cleansing procedure that the rid the body of impure blood.

Women also talked about home-level restrictions during periods and how that influenced their use of contraceptives. When a woman “sits separately” at home and doesn’t enter the kitchen, she signals to those around that she is on her period. After contraceptive induced amenorrhoea, some women did not “sit separately”, their mothers-in-law wondered why, and uncovered the reason. Other women shared apprehensions about sudden or unexpected bleeding that caught them unprepared – this particular effect of contraception was especially unwelcome.

“When I started using injections, my periods became irregular. They didn’t come for two months and then suddenly one day there was spotting. I was not prepared — how was I to cook or worship? So I stopped the injection and started using oral pills. Now I get regular periods”, said 28 year old Seeta, who lived in a remote village in the foothills of the Aravali range.

When asked about the Copper-T, many women said that they had heard from others that it could lead to excessive bleeding, might “travel up in the body” or damage the uterus. Heavy bleeding triggered a desire for removal —

“I had to get the Copper-T removed because of heavy bleeding. My body became weak”.

Thirty year-old Mangi did not clearly recall that a Copper-T was inserted after her third delivery. Just before leaving the government facility on being discharged, she went to the toilet and found that a device had come out. She confided in her mother-in-law who told her to keep quiet about it.

We know that front-line primary care workers in the area have not been systematically trained on how to counsel and support women in dealing with menstrual changes expected from contraceptive use. Meanwhile, India’s fifth National Family Health Survey (2019-21) points to an increasing shift on part of women, towards reversible contraceptive options. This underscores the importance of building a deeper, practical understanding of contraceptive induced menstrual changes among frontline workers, so that they may help women better navigate their fertility journeys by offering counselling, treatment or referral as required. Knowing how women respond to contraceptive induced menstrual changes would be critical to promoting continued use of reversible contraception across India.

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1. All names in this blog have been changed
2. Polis, C. B., Hussain, R., & Berry, A. (2018). There might be blood: a scoping review on women’s responses to contraceptive-induced menstrual bleeding changes. Reproductive health,15(1), 114. https://doi.org/10.1186/s12978-018-0561-0