Fertility Awareness Affects Method Use

Education on menstruation and fertility can serve as a starting point for discussions with both women and men about pregnancy, contraception and reproductive health, experts say.

Providers who teach clients about fertility awareness should explain how family planning methods affect ovulation and menstruation. Natural family planning methods, male contraceptive methods and barrier methods do not affect women's menstruation cycles, nor do they interfere with ovulation. Hormonal methods and the intrauterine device (IUD) can affect menstruation, and hormonal methods work primarily by interfering with ovulation.

Hormonal methods

Combined oral contraceptives (COCs), which contain estrogen and progestin, suppress ovulation. COCs can decrease the number of days of menstrual bleeding, decrease menstrual cramps, and reduce the unpleasant physical and emotional symptoms of premenstrual syndrome. COCs also can reduce the volume of menstrual blood loss. They can cause breakthrough or intermenstrual bleeding, as well as amenorrhea (missed periods).

Progestin-only contraceptives include the progestin-only oral contraceptive or mini-pill, Norplant subdermal implants, and some injectables, such as depot-medroxyprogesterone acetate (DMPA or Depo-Provera). They suppress ovulation in about half of the menstrual cycles. In all women, they thicken cervical mucous, making it difficult for sperm to enter the uterus.

Progestin-only contraceptives may reduce menstrual cramps, and they also may cause bleeding disturbances, such as amenorrhea or intermenstrual bleeding. Amenorrhea occurs infrequently in women using Norplant but is more likely the longer a woman uses DMPA. Since bleeding disturbances are often cited by women as a reason for discontinuation of progestin-only contraceptives, counseling can help women anticipate how methods will affect their menstrual cycles and whether these changes will be acceptable to them.

Emergency contraception

Fertility awareness can help couples understand better that pregnancy can be prevented even after unprotected intercourse. Although not as effective as contraceptives used prior to intercourse, emergency contraception can be used by women who have been sexually assaulted, who forgot to use a contraceptive method, who used it incorrectly, or who experienced a condom failure. Emergency contraception is considered safe for all women, and is about 75 percent effective at preventing pregnancy.

Around the time of ovulation, a woman's cervical mucus changes, protecting sperm from the normally acidic environment of the vagina and providing nutrients that enable sperm to survive. Consequently, conception may not occur until several days after intercourse. Women who use emergency contraception prevent pregnancy before it begins. Certain types of oral contraceptives can interfere with ovulation or fertilization. Pills also may alter the uterine lining (endometrium).

An advisory committee of the U.S. Food and Drug Administration, a regulatory agency, recently endorsed the use of some brands of oral contraceptives for emergency use. Certain COCs can be taken within 72 hours of unprotected intercourse and repeated 12 hours later to be effective. Specific brands of progestin-only pills can also be effective, the panel said, if taken within 48 hours after intercourse and repeated 12 hours later.

IUDs and sterilization

IUDs, such as the Copper T, prevent fertilization by impeding the movement of the sperm and their viability.

While IUDs do not affect ovarian function, users may experience increased menstrual bleeding and pain. These side effects typically subside over time, although providers can give iron supplements to improve hemoglobin levels if bleeding is heavy or the woman is anemic. Providers also can offer nonsteroidal, anti-inflammatory drugs, such as ibuprofen, to reduce pain and bleeding. IUDs containing synthetic progestin, which are available in a few industrialized countries but not in developing nations, can reduce menstrual bleeding and cramping.

Tubal ligation or the use of clips to achieve female sterilization do not affect ovulation. Pregnancy is prevented by cutting or clipping the fallopian tubes to keep the egg and sperm from uniting. Some women who have undergone surgical sterilization report changes in bleeding patterns or increased dysmenorrhea (painful periods).

Reproductive health

While the average menstrual cycle lasts about 28 days, lengths of cycles vary. Even within the same woman's lifetime, cycle length, duration of bleeding and volume of bleeding may vary.

Providers should help clients understand what types of genital symptoms are normal for them and which are not. For example, many women in less developed countries view purulent vaginal discharge as natural.1 However, abnormal vaginal discharge may be a sign of a sexually transmitted disease for a woman. In a man, pain or abnormal discharge from the urethra may be a sign of STD infection.

Left untreated, some STDs can lead to pelvic inflammatory disease in women, a cause of infertility. Excess vaginal bleeding or bleeding and pain can be symptoms of ectopic pregnancy or illness, such as myoma or cancer.

Women taught to be aware of deviations in cervical secretions, such as noticeable discharge or pain during intercourse, are alerted to seek medical attention, says Dr. Victoria Jennings of the Institute for Reproductive Health at Georgetown University in Washington.

"For a woman to be able to note this earlier, rather than later, and describe her symptoms to a health-care provider, is important" for her reproductive health, says Dr. Jennings.

-- Barbara Barnett

References

1. Zurayk H, Khattab H, Younis N, et al. Comparing women's reports with medical diagnoses of reproductive morbidity conditions in rural Egypt. Stud Fam Plann 1995:26(1):14-21.