Women's attitudes toward menstruation and toward contraceptives that can cause amenorrhea differ significantly across settings and ethnic groups.¹ According to a survey of a thousand female family planning clinic clients, more than half of respondents in Scotland and China and of nonblack respondents in Africa do not like having periods; at least three-quarters of black Africans, however, report that they like having them. One-third to three-fourths of women in each area would consider trying a contraceptive method that can induce amenorrhea; however, the vast majority of health care providers from those clinics believed that menstruating while using contraceptives is important to their clients. Even so, most providers said that they would recommend a contraceptive method that can stop bleeding.

For some women, menstruation can be a monthly source of pain and discomfort. To examine women's attitudes on menstruation and willingness to use contraceptives that can induce amenorrhea (such as the progesterone-only injectable or implant), researchers surveyed female clients of and health care providers from one or more family planning clinics in each of five cities: Edinburgh, Scotland; Cape Town, South Africa; Sagumu, Nigeria; Hong Kong, China; and Shanghai, China. Between December 2000 and June 2001, researchers recruited 200 women from family planning clinics in each of the five urban centers; in Cape Town, women were selected so that the sample had equal proportions of black, colored and white women. After receiving informed verbal consent from women, trained interviewers administered a questionnaire that took participants 5-10 minutes to complete. To survey health care providers, researchers sent or hand-delivered questionnaires to clinics; at least 50 responses were received from providers in each city.

Clients were asked about their demographic characteristics, gynecological history, contraceptive use and attitudes on menstruation; providers were asked about their attitudes toward and perceptions about their clients' attitudes on menstruation and contraceptive use.

As expected, the demographic characteristics of the respondents varied substantially by location. Women in Edinburgh, Cape Town and Shanghai were significantly younger than those in Hong Kong and Sagumu; greater proportions of respondents in Shanghai, Hong Kong and Sagumu (81-99%) than in Cape Town or Edinburgh (33-49%) were married or cohabitating. Almost all of the women in Edinburgh were white (97%), whereas in Shanghai and Hong Kong, the vast majority were Chinese (92-99%). All of the participants in Sagumu were black; one-third of the women in Cape Town were white, one-third black and one-third colored, reflecting the sampling strategy. The majority (78-84%) in the two African cities reported being Christian, but most women (64-96%) in the other three urban centers reported having no religion. Respondents from Edinburgh were the most likely to have no children (76%), and those from Sagumu were the most likely to have four or more (59%).

The vast majority of women reported having menstrual cycles of 26-35 days, with their periods lasting 4-7 days. At least half of the respondents from each city considered their menstrual flow to be "normal." Two percent of women in Hong Kong, 10% in Edinburgh and 29% in Cape Town reported being amenorrheic, as a result of using the injectable. The pill was the most widely used contraceptive method in Edinburgh (47% of women); the women in the two African cities were most likely to rely on the injectable or the implant (30-53%), and those in the two Chinese cities were most likely to use the condom (38-39%).

In response to questions about menstruation, between half and three-fourths of all women in Edinburgh, Hong Kong and Shanghai and of white and colored women in Cape Town reported that they did not like having their period--most commonly because they found it "inconvenient" (65-85%); 33% of women in Edinburgh and 13% of those in Hong Kong reported that they disliked their periods because of menstrual problems. In contrast, at least three-fourths of all women in Sagumu and of black women in Cape Town liked menstruating--most commonly because it got rid of "bad blood." Nonblack women in Cape Town and women in Edinburgh were significantly more likely than those in other cities to want to dispense with menstruation (29-37% vs. 6-15%); women in Sagumu were more likely than others to prefer to menstruate monthly (71% vs. 30-49%).

With the exception of women in Cape Town, a minority of participants (0-23%) reported having used a contraceptive method that caused amenorrhea. Among women in Cape Town, experience with a contraceptive method that caused amenorrhea differed by race: Sixty percent of black women had used a method that stopped their period, compared with 32% of white and 37% of colored women. More than half of women in Edinburgh (65%), Cape Town (52-64%) and Sagumu (73%) reported that they would be willing to use a contraceptive method that can cause amenorrhea; 37% of women in Hong Kong and 48% of women in Shanghai would consider using such a method. Willingness to use a contraceptive method that can stop menstruation was not related to age, parity, education, religion or perception of one's menstrual flow (i.e., normal, heavy or light) except in Shanghai, where younger women and those who wanted children were significantly more willing than others to try a method that could stop their period.

The demographic characteristics of health care providers varied significantly by location. The majority in each urban center were female and married, and providers' racial and ethnic backgrounds were similar to those of their clients. However, providers in Scotland and Africa tended to be older than those in China, and the majority of providers in Scotland and Africa reported being Christian, whereas the majority in China reported not belonging to any religion.

More than half of health care providers in Scotland (82%) and Cape Town (53-88%) did not believe that it is important for women to menstruate while practicing contraception. However, the vast majority of providers in each city (91-98%) believed that it is quite or very important to their clients. Even so, more than half (52-100%) of providers in all cities except for Shanghai said they would recommend a method of contraception that can cause amenorrhea.

The authors comment that the proportions of women in this study who were willing to consider using contraceptive methods that can cause amenorrhea were greater than those in previous studies, even among women who liked having their period. The researchers attribute this, at least in part, to their respondents being younger and less likely to be married than those in previous studies and having been recruited from family planning clinics. They speculate that "the results may also reflect an increased willingness of women to accept therapeutic interventions if the benefits are seen to be real."--J.Rosenberg

REFERENCE

1. Glasier AF et al., Amenorrhea associated with contraception--an international study on acceptability, Contraception, 2003, 67(1):1-8.