Plain English summary
Some contraceptive methods cause changes in women’s menstrual bleeding patterns. For example, a woman’s period may become lighter or heavier, longer or shorter, less regular, or may disappear altogether. Concerns about side effects and health issues – including those related to changes to menstrual bleeding patterns – may limit use of contraceptive methods. However, the research on how women respond to contraceptive-induced menstrual bleeding changes (CIMBCs) has not been summarized in a systematic scoping review. We collected and summarized the body of evidence on women’s responses to CIMBCs in a standardized manner. We identified 100 studies from around the world relevant to this issue. We summarized what studies found regarding how women respond when contraceptive methods stop their periods or cause other non-standard bleeding patterns, and the extent to which CIMBCs make women unhappy with their method of contraception, or stop their method of contraception, or not use any method of contraception. We also summarized what the evidence suggests regarding how women think about CIMBCs in terms of their own health, as well as other themes that emerged from our review of studies. While women across countries and populations respond differently to different CIMBCs, due to individual and social influences, it is clear that CIMBCs impact many areas of women’s lives. It is important that researchers, medical providers, and contraceptive product developers recognize this as an important issue, and we offer recommendations on how to do so.
Background
About 99 million unintended pregnancies occur annually, the majority of which could be prevented through use of modern contraception [
1,
2]. Concerns about side effects and health issues are common reasons for non-use or discontinuation of contraception among women who do not desire pregnancy [
3‐
5]. Among married women with an unmet need for contraception in 52 developing countries, 7–53% reported not using a method due to these concerns [
3]. Some smaller (often qualitative) studies report on women’s experiences with or fears about side effects or health concerns in relation to various contraceptive methods, but few large or nationally-representative studies specifically investigate these issues in detail [
6]. Some large-scale surveys (e.g., PMA2020 and Demographic and Health Surveys (DHS)) ask about reasons for contraceptive non-use and discontinuation, and include health concerns, fear of side effects, and interference with bodily processes as broad response categories, but neither survey asks which specific side effects or health concerns led to non-use or discontinuation [
7,
8]. Furthermore, other broad response categories, such as self or partner opposition to contraceptive use, inconvenience of use, or other reasons, may be intertwined with health or side effect-related concerns. Therefore, it is difficult to estimate the prevalence or impact of these concerns, or to disentangle which issues are of greatest concern to women or couples, particularly on a national scale.
Furthermore, while certain contraceptive side effects are clinically documented, various contraceptive-induced bodily processes may be interpreted variably by different individuals. Perceptions of contraceptive-related side effects may be rooted in personal experience, knowledge of others’ experiences, or misinformation [
9,
10]. While discordance between documented and perceived side effects is acknowledged in the literature [
11,
12], both experienced and perceived side effects can be highly influential in contraceptive decision-making processes [
10,
13]. Furthermore, cultural norms and values may shape tolerance (or lack thereof) and fears around various side effects.
Hormonal contraceptive methods and IUDs may induce changes in menstrual bleeding patterns [
14‐
16], which can impact willingness to try or continue using these methods, or method satisfaction [
6,
17‐
23]. Contraceptive-induced menstrual bleeding changes (CIMBCs) may include bleeding patterns which are predictable but diverge from a “typical” menstrual pattern (such as amenorrhea, commonly induced by methods such as progestin-only injectables, or heavy, prolonged bleeding often experienced by copper IUD users [
24,
25]), or may cause unpredictable bleeding patterns. While menstrual bleeding can be measured in straightforward clinical categories, there may be large ranges defined around normal menstruation [
26,
27] and these clinical definitions may not be in line with women’s perceptions of normal bleeding. Furthermore, women may experience CIMBCs they consider abnormal or unacceptable, but may still clinically fall within the range of normal.
In addition to inconvenience (for unpredictable bleeding patterns in particular), and the menstrual hygiene management costs of many bleeding patterns, some individuals may perceive changes to bleeding patterns as being tied to overall notions about their health [
23,
28,
29] or to physical or mental health issues [
6,
9,
10,
12,
13,
20,
23,
29]. For example, some women fear that injectable-induced amenorrhea leads to permanent infertility, which is not supported in the literature [
30]. Counseling may not always be comprehensive enough to adequately prepare women to fully understand, anticipate, or manage CIMBCs [
31]. Though difficult to precisely quantify (owing in part to lack of sufficiently specific nationally representative data, as described above), some evidence suggests that CIMBCs are a central aspect of what women mean when they report “side effects” or “health concerns” [
32‐
35], and may be an important reason for non-use or discontinuation. However, the importance of CIMBCs may be underappreciated in the reproductive health field as a key contributor to issues such as unmet need for modern contraception.
In sum, side effects constitute a major reason for contraceptive non-use and discontinuation, and CIMBCs are linked, in both real and perceived ways, with a range of concerns. Differences exist between what bleeding patterns a woman
prefers (including the potential for no bleeding changes) and what she is willing to
tolerate in exchange for the benefits of the contraceptive options available to her [
36]. Understanding women’s responses (including attitudes and behaviors) to experienced or anticipated CIMBCs has significant implications for current contraceptive use patterns and for the development of future products, including contraceptives and contraceptive-containing multipurpose prevention technologies (MPTs), which are products in development that aim to deliver varied combinations of contraception and prevention from HIV and other STIs. However, to our knowledge, no recent systematic scoping reviews have examined the extent and range of research on this topic. Thus, we conducted a scoping review to gather and synthesize data on women’s responses to CIMBCs and to provide recommendations for providers, researchers, and product developers.
Conclusions
Substantial variability exists in terms of how women respond to CIMBCs – including what they prefer and what they are willing to tolerate – and these responses are shaped by individual and social influences. For example, women’s stated preferences for amenorrhea ranged from 0 to 65% across included surveys. Contraceptive-induced amenorrhea may be viewed more positively in certain geographical regions (e.g., the Americas, some European and South American countries; though little comparative data is available in Africa) and by certain subpopulations (e.g., women younger than 24 or older than 34). In several multi-country surveys, prior use of hormonal contraception was associated with greater openness to non-monthly bleeding patterns. While several included studies suggest that CIMBCs do substantially impact contraceptive non-use, dissatisfaction, and discontinuation, most studies assessing this domain specifically evaluated discontinuation. Specific menstrual bleeding pattern preferences vary widely across contexts and sub-populations, but it is clear that CIMBCs can impact multiple aspects of women’s daily lives, including health-related perceptions, experiences, and fears, as well as participation in domestic, work, school, sports, social, religious, sexual, or other activities [
146,
147]. Furthermore, several studies suggest that menstrual regularity (whether as part of normal menstruation or less frequent bleeding patterns) may be perceived positively [
70,
74], and unexpected bleeding may be perceived negatively [
43,
46,
48‐
54,
72,
75,
77,
78,
81,
82,
86,
88‐
92,
94,
97,
98,
100,
102,
105,
106,
108‐
111,
114,
116‐
119,
122,
123,
127‐
129,
132]. Monthly bleeding may relate to the reassurance of not being pregnant [
51,
52,
55,
57,
58,
60,
140] and perceptions of continued fecundity [
46,
47,
58,
60,
67,
87,
106,
134,
137,
139]. As such, women’s responses to CIMBCs (and the factors correlated with those responses) should be broadly recognized as a key issue in contraceptive research, counseling, and product development. A substantial proportion of relevant studies come from Europe, Northern America, and other higher-income settings, so studying these issues in other regions (e.g., Africa, Asia, and Oceania) is particularly needed, as results from these contexts may not generalize to lower-income settings.
This scoping review fills a key gap in the literature by mapping recent data on women’s responses and preferences to CIMBCs, and follows methodological guidance for conduct of scoping reviews [
37]. Limitations of this review include searching a single database (PubMed) and the challenge of crafting a search strategy that is both specific and sensitive to such a broad topic of inquiry. We iteratively tested multiple search strategies, hand-searched reference lists of key studies, and consulted with an expert group to identify additional relevant articles. Crafting clear study inclusion criteria was also challenging, given the wide variety of pertinent study designs. To maximize comprehensiveness and feasibility while minimizing inclusion of irrelevant or minimally informative studies, we required that studies reference women’s responses to CIMBCs in the title and/or abstract; this may have influenced which studies were included. For example, among studies assessing contraceptive discontinuation, if CIMBCs were not a top reason (and thus not mentioned in the abstract), inclusion was less likely, which could mean that other reasons for discontinuation are underrepresented among our included studies. However, among included studies, we did attempt, where possible, to determine whether CIMBCs or other factors were the primary reasons for discontinuation (or other outcomes). While scoping reviews are intended to broadly map a domain in the literature, future systematic reviews assessing multiple reasons for contraceptive discontinuation could assess whether this approach to study inclusion impacted our findings. Finally, like all scoping reviews, we did not assess underlying study quality [
38].
Several recommendations for contraceptive researchers, providers, and product developers emerge from this review. For example, in large, nationally representative surveys, inclusion of response options more specific than “side-effects” or “health concerns” pertaining to CIBMCs would enable more precise quantification of the association of CIMBCs with unmet need for family planning and contraceptive discontinuation. Longitudinal studies collecting information on bleeding patterns should adhere to guidelines used to classify bleeding patterns, to enhance comparability across studies [
26,
148]. Collecting and controlling for key variables believed to influence responses to CIMBCs (i.e., age, prior contraceptive use, etc.) could also enhance comparability. In addition to disparities in geographic distribution of studies, several overall research gaps remain, including understanding how women’s knowledge of various physiological processes (i.e., menstruation, contraceptive mechanisms of action, etc.) impacts responses to bleeding patterns; the impact of contraceptive-induced amenorrhea or irregular bleeding on timing of pregnancy recognition and reproductive options; and linkages between CIMBCs and menstrual hygiene management. Researchers should adopt a neutral stance when asking women about menstrual preferences (e.g., avoid assuming that amenorrhea is viewed positively or negatively), and should be familiar with the range of instruments which have been used to investigate women’s responses to various menstrual-related issues (e.g., Menstrual Attitudes Questionnaire, Menstrual Distress Questionnaire, Attitudes towards Menstrual Suppression Instrument, Inconvenience Due to Women’s Monthly Bleeding instrument, etc.); consideration of using common, standardized measurements across studies may also be valuable.
Contraceptive providers should take women’s concerns about CIMBCs seriously and address them in a non-judgmental manner, as these changes may not be viewed merely as a minor side effect and, in some cases, may have profound impacts on multiple aspects of women’s lives. Given varied views on whether monthly bleeding is necessary for optimal health [
135], providers should also be aware that some individuals may be skeptical about medical advice regarding what is “safe” or “normal”. Future work could help to clarify paradoxical findings [
115] or investigate limited impacts of some counseling approaches [
149]. Development of a method-specific tool to assist providers in counseling and treatment options around CIMBCs may be useful, particularly for contraceptive methods that result in variable bleeding patterns in different women [
150]. Similarly, prospectively eliciting individual’s bleeding preferences could assist in helping them select a method most likely to suit their needs, and identification of factors that could help predict which side effects (including specific bleeding changes) a woman might expect to experience when initiating a contraceptive method may assist providers to better tailor contraceptive counseling [
151]. Addressing some women’s concerns that menstrual irregularity is associated with reduced contraceptive effectiveness may be important [
46]. Finally, providers and contraceptive users should be aware of treatment options for management of unwanted CIMBCs [
152‐
155] (e.g., non-steroidal anti-inflammatory drugs, combined oral contraceptive pills, etc.), though more research is also needed to refine treatment options and improve bleeding patterns and user satisfaction/acceptability. Some evidence does suggest that treating undesirable CIMBCs may improve contraceptive continuation [
156,
157].
Development of new contraceptive or MPT products hold promise from a public health perspective [
158], but actual impact may be inhibited if acceptability (and consequently, adherence) is not adequately addressed [
146,
159]. Studies on responses to CIMBCs within regions which would be targeted for rollout of new products may be useful during development stages, in order to enhance product acceptability. Furthermore, provision of clear information around expected CIMBCs for new products can help providers assist women to anticipate and manage these changes, and help avoid negative perceptions from becoming associated with new products. Ideally, product development will continue to expand method options to meet diverse women’s ideal contraceptive profiles (including preferred bleeding patterns), so contraceptors are not required to tolerate undesirable product characteristics in order to use effective pregnancy prevention strategies.
Overall, the importance of how women perceive and respond to CIMBCs may be currently underappreciated in the reproductive health field, despite likely – and potentially substantial – impacts on key issues such as contraceptive discontinuation and unmet need for modern contraception. Contraceptive researchers, providers, and product developers – in addition to policy-makers, service delivery suppliers, and funders – can use the body of knowledge summarized in this scoping review to better ensure that women and girls have a reliable supply of contraceptive (and MPT) options that align with their preferences and effectively prevent unintended pregnancies and other adverse outcomes.
Acknowledgements
We are grateful to the individuals who agreed to participate in our expert consultation and who provided valuable input and feedback, including (in alphabetical order by last name): Dr. Diana Blithe, Dr. Jeanne Marrazzo, Dr. Carolina Sales Vieira, Dr. Cynthia Woodsong, and Dr. Bethany Young-Holt. We also thank Dr. Ann Biddlecom and Dr. Gilda Sedgh, Ms. Jesse Boyer, and Ms. Colette Rose for their feedback on earlier drafts of the manuscript.