When Contraceptives Change Monthly Bleeding:
How Family Planning Providers Can Help Clients

Bleeding changes are common among women using hormonal contraceptive methods and IUDs. These are among the most effective reversible family planning methods, and many women choose them for this reason. But the monthly bleeding changes they cause often lead to dissatisfaction and discontinuation. Many women who discontinue a contraceptive method do not immediately begin to use another one, or they switch to a less effective method, leaving them at risk of unintended pregnancy.

Combined hormonal methods—oral contraceptives (OCs), monthly injectables, the patch, and the vaginal ring—tend to make monthly bleeding shorter and more predictable. Progestin-only methods—long-acting injectables, implants, and progestin-only OCs (the “minipill”)—and the hormonal levonorgestrel-releasing IUD can cause changes that range from breakthrough bleeding and spotting to no monthly bleeding. Copper IUDs can cause somewhat heavier and longer bleeding. A method’s effects can differ among women, or differ over time for an individual.

Research Findings: Counseling Improves Client Satisfaction and Continuation

Women who know beforehand about possible bleeding changes are more satisfied with their contraceptive method.¹ This finding may suggest both better-informed method choices and better-prepared users. Providers who offer information and counseling about potential bleeding changes in advance may help clients choose a method that suits them and also help them know what to expect from its use.

Several studies also suggest that new clients continue using their chosen method longer when providers have offered in-depth counseling about bleeding changes and encouraged them to return for help if they have problems.² Counseling and encouragement at follow-up visits also can help continuing clients manage bothersome bleeding changes and thus help them avoid discontinuation and the risk of unintended pregnancy.³

What Family Planning Providers Can Do

To help clients choose and use methods that meet their needs, family planning providers can take the following steps:

Help new clients decide whether to choose a family planning method that may change monthly bleeding:

• Describe the common bleeding changes in ways that clients understand, including how the changes may vary over time.
• Explain that the common bleeding changes are normal with these contraceptives. They are not harmful, and they are not signs of illness.
• Help each client consider how she would feel and what she would do if bleeding changes happened to her.
• Invite her to return any time that she has concerns.

Help continuing clients manage bleeding changes caused by contraceptive use:

• In the first few months of use, explain that the changes probably will lessen with time.
• If the bleeding changes persist, or whenever a client asks, offer available treatments to relieve the bleeding.
• At any time a client finds bleeding changes unacceptable, help her choose a method that better suits her.

Additionally, providers can gain an understanding of cultural and social beliefs and behavior concerning menstruation. This knowledge can help providers be sensitive to their clients’ attitudes towards contraceptive-related bleeding changes. To answer common questions that clients have about menstruation and the menstrual cycle, providers can refer to the INFO Reports issue, “Key Facts About the Menstrual Cycle.” Full text of the report can be seen online at: http://www.infoforhealth.org/inforeports/. This report presents information in a simple way, accompanied by illustrations that providers can use with clients.

¹Backman, T., et al. Advance information improves user satisfaction with the levonorgestrel intrauterine system. Obstetrics and Gynecology 99(4): 608-613. Apr. 2002; Tan, A., et al. Improvements in knowledge of Norplant implants acceptors: An intervention study in West Sumatra and West Java, Indonesia. Final report. Bandung, Indonesia, Padjadjaran University, Study Group on Biomedical and Human Reproduction, Jun. 1995. 41 p.

²Canto de Cetina, T.E., et al. Effect of counseling to improve compliance in Mexican women receiving depot-medroxyprogesterone acetate. Contraception 63(3): 143-146. Mar. 2001; Hubacher, D., et al. Factors affecting continuation rates of DMPA. Contraception 60(6): 345-351. Dec. 1999; Lei, Z.W., et al. Effect of pretreatment counseling on discontinuation rates in Chinese women given depo-medroxyprogesterone acetate for contraception. Contraception 53(6): 357-361. Jun. 1996. 25(4): 200-202.

³Rager, K.M., et al. Successful treatment of depot medroxyprogesterone acetate-related vaginal bleeding improves continuation rates in adolescents. Scientific World Journal 6: 353-355. 2006.

For more information:

Other technical briefs can be found at: www.maqweb.org

Revised: 09/29/06
Produced in association with The Maximizing Access and Quality Initiative

Designed and produced by: The INFO Project at the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs. Published with support from the United States Agency for International Development (USAID), Global, GH/POP/PEC, under the terms of Grant No. GPH-A-00-02-00003-00.