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Monograph Series-05 James P. Grant School of Public Health
Monograph series: 5
Menstrual Problems of Women in Bangladesh
School of Public Health Dhaka, Bangladesh Menstrual Problems of Women in Bangladesh Monograph Series-05 TABLE OF CONTENTS
2. Notions surrounding the polluted state of menstrual blood 3. Terminology and Perceived Causes of Menstrual Problems 4. Adolescence and Menstrual Problems 5. Menstrual Rags & Hygiene 6. Causes of Infertility and Social Stigma 7. Uses of Contraceptives: Side Effects and Perceptions 8. Health Seeking Behaviour Annex: Menstrual Problems as Side Effects of Contraceptives Menstrual Problems of Women in Bangladesh Monograph Series-05 The author would like to thank Dr. Hilary Standing of the Institute of DevelopmentStudies, University of Sussex, UK, Dr. Mushtaque Chowdhury, Dr. Sabina Faiz Rashidand Mr. Ilias Mahmud of the James P Grant School of Public Health, BRAC University,Bangladesh for their intellectual input and invaluable advice. The author expressesappreciation for the financial support (Grant HD4) provided by the UK Department forInternational Development (DfID) for the Realising Rights Research ProgrammeConsortium. This document is an output from a project funded by DfID for the benefitof developing countries. The views expressed are not necessarily those of DfID.
Menstrual Problems of Women in Bangladesh Monograph Series-05 Bangladeshi women suffer from menstrual problems such as dysmenorrhoea,menorrhagia, light and heavy bleeding during menstruation, and irregular period andare constantly worried if they menstrual flow is not a "normal" amount. They believethat a good menstrual flow is needed to stay healthy. If the flow decreases, they thinkthat they're must be "bad blood" trapped within their bodies, and if it stops altogether,they are concerned that they may have become infertile. Inability to conceive is viewednegatively in Bangladeshi society and women are subjected to psychological distress bysociety if they are perceived as infertile. Also, there are many social, cultural andreligious taboos surrounding menstruation such as staying away from food such asfish, eggs, meat, sour fruits, etc during menstruation. Moreover, they are often advisedto stay indoors as menstrual blood may attract evil spirits. Furthermore, these womenalso experience menstrual problems as side effects of contraceptives such as Norplant,IUD, and the pill, and sometimes discontinue its use as a result which may lead tounplanned pregnancies. Gynaecological problems such as those related tomenstruation are a major concern among Bangladeshi women, but social stigma andshame stand as a barrier against seeking proper healthcare. Often, they seek healthadvice from female relatives and unqualified health providers which in turn often leadsto incorrect treatment and chronic menstrual related illnesses. Only a few studies havebeen carried out on menstrual problems in Bangladesh and most of them are eitherpart of larger studies on side effects of contraceptives or a few small-scale exploratorystudies.
The aim of this literature review is to learn about local terminologies used to describemenstrual problems, to understand the practices and restrictions surroundingmenstruation during adolescence, to learn about concerns surrounding infertility andits causes, to look at menstrual problems which result from use of contraceptives, andto examine patterns of health seeking behaviour of Bangladeshi women to treat theirmenstrual illnesses.
This literature review was carried out by obtaining information from published reports,books and articles collected from local NGOs. Some information was also gathered frominterviews with staff from local NGOs and gynaecologists from Bangladesh RailwayHospital.
The review found that notions surrounding menstrual blood include perceptions that itis polluted and women should not serve food during this condition or touch anyonewith an eye or skin infection as it may worsen their illness. Religious teaching alsostates that women are polluted during menstruation and cannot offer prayers in thisstate. Women tend to use local terminology to refer to menstrual problems such askaler chut for dysmenorrhoea, humka batas for menorrhagia, and khum jhore if they gettheir periods twice or more a month. Perceived causes of menstrual related illnessesinclude evil spirits, lack of enough food, birth control pills, etc.
Menstrual Problems of Women in Bangladesh During adolescence, girls are taught about the various restrictions during menstruationsuch as not going outside and staying away from certain foods such as fish, eggs, meat,sour fruits. When they encounter menstrual problems, family members either takethem to traditional and religious healers such as pir, fakir and huzurs or their motherssend someone to buy medicine from the pharmacy.
Bangladeshi women from lower socio economic backgrounds mostly use menstrual ragsto absorb menstrual blood. These rags are often not washed well with soap. Also theyare dried in dark places as it is considered embarrassing if others see these rags and itis believed that ghosts, fakirs, crows and flies can cause menstrual problems if theycome in contact with these rags. These improper cleaning practices cause women to getillnesses such as RTIs from these rags.
When menstrual flow is low or absent, women often perceive themselves to be infertile.
Fertility is highly valued in Bangladeshi society and infertile women face many forms ofsocial rejection and marginalization from their communities. In several studies, it wasfound that women blame evil spirits for their infertility. As Bangladeshi women equate aregular amount of menstrual flow with good health, contraceptive methods which alterthis flow are causes for concern among these women. A study showed that use ofNorplant implants cause dysmenorrhoea, intermenstrual bleeding or amenorrhoeawhich the women dislike, yet they continue to use this method because of itseffectiveness as a contraceptive. DMPA injectables were shown to cause spotting oramenorrhoea among its users, but also had benefits of improving dysmenorrhoea withtime. Oral contraceptives were shown to cause mainly intermenstrual bleeding butlowered menstrual pain, amount of menstrual flow and duration of menstruation. Theintra uterine device (IUD) was said to cause excessive menstrual bleeding (22-24%),irregular menstruation (11-12%), and lower abdominal pain (11-13%) among 801women in a study. About a quarter of the women reported pain during the lastmenstrual period and virtually all said they had no intermenstrual bleeding. Among the198 who had discontinued use, 34.3 % had reported excessive bleeding, 17.2% reportedcomplete expulsion, and 16.1% stated lower abdominal pain/white discharge as thecauses for discontinuation. Other studies showed women to be concerned whetherNorplant causes amenorrhoea because they feel impure blood is trapped within theirbodies or when Norplant or IUD causes continuous bleeding because they cannot gonear their husbands, pray or prepare food, as they are perceived to be in a pollutedstate. Despite the side effects some women may choose to continue use of Norplant as itprotects them for 5 years from getting pregnant. Women in some studies also agonizedwhen the pill or injectables brought about amenorrhoea because they believed themethods had dried out the uterus and had made them infertile.
Women tend to ask other women for advice for their gynecological problems, especiallywomen from their natal homes but rarely those who are their in laws according to astudy. They also asked a traditional healer (kabiraj) from problems such asmenorrhagia as they feel that these illnesses are caused by evil spirits which onlytraditional healers can cure. Herbal pills that cause severe bleeding are prescribedwhen menstrual blood is thought to be trapped within the womb by herbalists. Anothermethod employed to remove this trapped blood is D&C (Dilation and Curettage) which"washes" out the perceived build up of fat.
Monograph Series-05 Gynaecological problems such as menstrual problems, RTIs, cervical cancers, ectopicpregnancy, infertility, and prolapse continue to haunt women in South Asia but remainneglected because of the shame and stigma that surround sexual and reproductivehealth. Reproductive morbidity in general, is an outcome of not just biological factorsbut of women's poverty, powerlessness and lack of control over resources as well. Evenif they seek treatment, a majority of women seek health care from quacks or unqualifiedproviders. In addition to health consequences, women experience social consequencesin terms of emotional distress related to gynecological morbidity (Singh, 2006). As mostof these illnesses progresses to chronic state and remain with the women for the rest oftheir lives, the importance of early detection and management becomes evident (Singh,2006). Furthermore, gender and status prevents women from discussing theirreproductive health needs openly due to social shame and stigma, as many studiesindicate. Although speaking to women health providers is somewhat easier, poorwomen still face discrimination due to their difference in status (Bangladesh HealthWatch, 2006; WHO, 1998).
Menstrual problems are perceived by Bangladeshi women as the second most commonhealth problems they experience (Ziauddin, 1993). Yet the data regarding menstrualproblems in this country are scarce, and the few that are present are part of a largerstudy, such as the side effects of contraceptives (Faruqui, Begum & Begum, 1997;Faruqui, Khan & Begum, 1998; Akhter, Chowdhury, & Rahman 1996; Akhter,Chowdhury, Rahman & Hussain, 1996) and a few small-scale exploratory studies suchas those by Blanchet (1984) and Mahbub and Ahmed (1997). Menstrual blood is viewedin South Asia, including in Bangladesh, as polluted. Women are always concernedabout their menstrual flow. When rural women are not pregnant, they are concernedthat their menstrual blood is released to ensure good health. If there is decreasedmonthly blood flow, it is perceived that the "bad blood" remains within the body andthus pollutes it (Rashid, 2001). Also, if there is low bleeding, the women believe that themenstrual blood will not be cleared at all and the colour of blood will be black likepoison. They also think that if a woman suffers from this illness, she will not conceive(Mahbub & Ahmed, 1997). A good menstrual flow is linked to fertility, and in SouthAsian culture marriage and the ability to have children is highly valued. Children aredescribed as torchbearers of the family lineage. Childlessness is considered a failure inthe family and often leads to psychological and social consequences for both womenand men. Women, are more often than men, however, subjected to more negativeexperiences as a result of their inability to conceive (Papreen et al, 2000). On the otherhand, women worry that excessive bleeding during menstruation may lead to death(Mahbub & Ahmed, 1997).
Moreover, there are many beliefs and restrictions surrounding menstruation. Womenbelieve that during menstruation, their body is polluted and this attracts evil spirits.
When having their periods, women are advised by elder sisters, sisters-in-law or femalefriends not to eat food containing protein like fish as well as to avoid sour fruits, Menstrual Problems of Women in Bangladesh turmeric, and salt. They are often told not to go outside of the house during this state.
Some of the menstrual disorders experienced by Bangladeshi women includedysmenorrhoea, light bleeding during menstruation, and heavy bleeding duringmenstruation, menorrhagia, and irregular period (Mahbub & Ahmed, 1997).
The objectives of this literature review are: 1. To learn about the local terminologies employed to describe menstrual problems by Bangladeshi women.
2. To understand the practices and restrictions surrounding menstruation learned during adolescence.
3. To learn about the stigma surrounding infertility and its causes.
4. To look at some of the types of menstrual problems encountered as the side effects of contraceptives.
5. To examine patterns of the health seeking behaviour of Bangladeshi women to alleviate their menstrual problems.
Menstrual blood is viewed as being polluted by many South Asian cultures, includingBangladesh, and there are, among others, religious reasons behind this notion. Also,menstrual blood is considered to bring bad luck to men, and, without its monthlyexpulsion, it is thought to remain within the body as "stagnant" and hence impure(Blanchet, 1984). Below, some of these notions surrounding menstruation are furtherelaborated: Women and her polluted stateIn a study carried out in Jamalpur district by Blanchet (1984) found that, a girlexperiencing her first menstruation is briefed by a married woman of the neighborhoodor household, preferably not her mother in front of whom she feels shy. She is told thatshe is in a polluted state and warned not to endanger anyone with her condition. She istold not to prepare or serve food, not to go barefoot, as she would pollute the earth, andnot to touch anyone with an eye or skin infection, as she would then make them worse.
Some women in this study found their polluted state physically disgusting, while othersviewed it as natural and accepted the rules regarding pollution as a rational means ofinducing auspiciousness or accumulating spiritual merit. A woman's ritual status isdetermined by the fact that she is a woman. She cannot escape pollution since it is partof her "nature". All women menstruate and are expected to bear children- one functionautomatically leads to the other.
Religious reasons behind menstruating women viewed as polluted In the village that this study by Blanchet (1984) was carried out, there are munshiswho interpret Islamic orthodoxy at the village level. Although their education andteaching is not always that of the Quaran, the villagers look them upon as religiousauthorities. According to these munshis, haez (menstruation) and nefaz (puerperalblood) are the greatest of all pollution. It is repulsive to Allah who will not accept theprayers or the fast of the woman in that state. In fact, a woman would be committing asin if she were to offer anything to God in that condition. This blood is considered mostpolluted because it was given to Eve as a punishment when she took the forbidden fruitfrom the tree. As she had caused the tree to bleed, thus Allah caused her to bleed everymonth.
Menstrual blood brings bad luck to menMenstrual blood is considered to bring about danger to men, according to the villagemunshis. First the man may have his lifespan shortened. Secondly, the fields will notgive abundant crops, he won't be able to save money, his son may fail his exams, or hemay have an accident: in other words, it will bring him bad luck. And thirdly, he maybecome ill from such contamination. Sores on the sexual organs are often blamed onthis pollution. Sometimes it is even thought to cause decaying of a man's brain.
According to the munshi, if a man dies under this condition, his punishment may beextremely severe (Blanchet, 1984).
Menstrual Problems of Women in Bangladesh Bhadok: A hardened ball of blood stuck in the wombThe blood in the womb is said to be stagnant (joma rokto), as opposed to circulatingblood (challu rokto) such as blood which runs from a cut finger. Thus this stagnantcondition of blood and the fact that it comes through a dirty channel makes it especiallyrepulsive and polluted. Hence if the blood is not periodically eliminated every month asmenstrual blood, it will make the woman ill. Timely, abundant menstruation is believedto be good. A condition called "bhadok" exists among these women, which is thepresence of a hardened ball of blood stuck in the womb. It causes sever abdominal painand makes the girl experiencing it temporarily sterile (Blanchet, 1984).
Terminologies used to describe menstrual problems were found to be local specific; forexample, the same causes of menstrual problems were not given as by everyone.
Moreover, the terminologies were found to be always changing and experiential. Inorder to better understand of the various types of menstrual problems that thesewomen are facing, it is crucial to learn the local terminology they employ in describingthese illnesses. This section is a brief description of some of the different types ofmenstrual irregularities that Bangladeshi women face, with the names that arecommonly used to refer to them.
An exploratory qualitative study was carried out on the perceptions of women abouttheir illnesses in a village in Matlab called Char Nilokkhi of Baradia Union (Mahbub &Ahmed, 1997). Fifty women were selected for free listing and twenty women for pilesorting and severity rating while twenty-four women (8 in each group) were selected forthree sessions of matrix ranking. Several menstrual problems were described bywomen, including dysmenorrhoea, irregular period, menorrhagia, and light and heavybleeding during menstruation The women in this study described several types of menstrual problems, employinglocal terminology to refer to each problem. The women referred to dysmenorrhoea askaler chut and described it as severe pain in the abdomen. They perceived it as a verysevere problem because they thought that if women had this, she could never conceive.
There were three reasons they stated that were responsible for this illness: Kal is a typeof devil which waits in the bushes around the homestead, beside the pond or latrinelike a shadow. If a woman is menstruating and she happens to be in one of these placesduring evening or at night, or even at mid noon the shadow may enter her body. Thepond is usually the location the devil seems to lurk around the most of all these places.
If the woman goes there in the evening, the devil knocks three times on her back. Uponasking who it is, the women's body is entered into by the devil, her body inflates andshe feels severe pain in her abdomen. Kal also is able to enter the body through thepore of the skin and make the blood black. Thus the woman is able to understand shehas this illness when she feels severe abdominal pain during menstruation and passespervaginal clotted blood. As the blood is clotted the woman is unable to conceive. Oncewithin her body the devil is able to destroy her uterus (bachcha nali). If the devil fails toenter her body, he can still give her drishti (evil eye). The causes of dysmenorrhoea areexplained by an elderly woman in the study as follows: when a girl experiences her firstmenstruation, if her feet touch the mud of a crab hole, she is bound to have abdominalpain during menstruation. Also, if the girl experiencing menarche touches a cat or cow'sbones with her feet, this may cause her to have dysmenorrhoea as well. The study alsorevealed that since the reasons that cause kaler chut mainly occur when the women areoutside the home; women are strictly prohibited from going outside duringmenstruation and are advised not to walk barefoot outside on the ground. Furthermore,they are told to stay away from foods such as fish eggs and meat: these foods make the Menstrual Problems of Women in Bangladesh blood smelly and black. Thus this elderly ladies advice is that if the women can followall these restrictions they will be able to prevent kaler chut (Mahbub & Ahmed, 1997).
The study also showed that when a woman experiences a low flow of blood duringmenstruation (masike kom rokto jai), she blames lack of enough food in her diet andweakness as the primary causes. She experiences lower abdominal pain during thiscondition. They believe that if enough blood is not given out during menstruation it isnot cleared out of the uterus and stays within the woman's body as poison. The colourof the blood becomes black and she is unable to conceive (Mahbub & Ahmed, 1997).
According to an old woman in the study, the younger women would experience heavybleeding (mashike beshi rokto jai) during her period due to the birth control pills (mayabori) and injections that she uses as contraceptives. Some of the other women alsobelieved that this phenomena is caused by a spiritual being called batas laga. Generallythe women feared this illness because the woman may die due to excessive bleedingand thus they are told to be aware of the spirit (Mahbub & Ahmed, 1997).
When a woman had a prolonged period with heavy bleeding, she was said to havehumka batas (menorrhagia). The spirit batas laga is also claimed to cause thiscondition. When the women get their period twice or more a month they refer to it askhum jhore. As stated above conditions that cause a lot of blood loss are feared becauseit may lead to death (Mahbub & Ahmed, 1997).
In general, when a woman is menstruating, her body is said to be in a polluted state –napak shorir (polluted body). In this state, she is said to attract evil spirit which maycause illnesses (Mahbub & Ahmed, 1997).
In order to better understand the perspectives of Bangladeshi women about theirmenstrual problems it is necessary to know about their experiences when they firsthave their periods, i.e., menarche. This is because we can then understand whatmindset they come from when they become adult women, what are the differentrestrictions they are taught as girls regarding menstruation, and what lessons theypass on to their daughters when they experience menstruation.
In a study conducted among urban and rural adolescents of Bangladesh, it was foundthat most girls in the study did not know about menstruation before they experiencedit. Therefore, they experienced menarche with severe trauma. Some of them screamedout when they noticed blood, and some thought they had an injury or cut in theirprivate parts. They learned about it from their elder sisters, sisters-in-law or femalefriends (Nahar et al., 1999). The following are some of the dilemmas that are faced,practices that are taught, and restrictions that are imposed, at the onset ofmenstruation. Bangladeshi women typically take these practices and restrictions withthem throughout their lives until menopause: Most girls reported they used old cloths for protection and dried them in dark places.
Many taboos exist; including going out of the house in the evening, climbing trees, putoil in hair or henna in hands. Hindu girls are kept locked in a room after menarche,given food there and only allowed to go out for toilet and bathing. Certain foods are tobe abstained from during menstruation: Eating fish is believed to give menstrual blood"fishy smell", sour fruit is thought to cause excessive bleeding, turmeric is perceived toform ugly yellow stain in the cloths used for managing menstrual flow and salt isclaimed to clot menstrual blood. Ninety percent of the girls studied had abdominal pain;twenty percent had pain in the waist while eleven percent had loss of appetite duringtheir menstrual period. Family members take them to traditional and religious healers,such as pir, fakir, or huzurs, or for treatment or their mothers send someone to buymedicine from the pharmacy (Nahar et al., 1997).
Menstrual Problems of Women in Bangladesh 5. MENSTRUAL RAGS & HYGIENE
During menstruation, it is common for the Bangladeshi woman, especially from lowersocio-economic background to use pieces of old clothing to absorb the blood. Impropercleaning of these rags may cause gynaecological illnesses such as RTIs. Thus it iscrucial to learn about the practice of the use of menstrual rags, so that the causesbehind such illnesses can be better understood.
In a study to learn about beliefs and practices of adolescent girls regardingmenstruation in six villages in Manikganj and Joypurhat (where BRAC maintainsresearch stations), the practices during menstruation of 49 girls between the ages of 12and 19 were learned about. Most of these girls used soft, light material, usually tornfrom old saris. The girls are told not to use cloth from men's lungis (skirt like wrap) butsome did because they were thicker and lasted longer. Only one girl reported usingsanitary napkin. Once they used a rag, they have to wash it and reuse it again. One girlin the study used to throw hers away in the jungle but then she realized she was toopoor to get new material every time she had her period so she began to reuse her rags(Huq & Khan, 1991).
To clean the rags, the girls wash the rags along with their clothing at the pond or by thetube well while bathing. Some girls wash them in the toilet. Most of them did not usesoap. As one girl said "We do not even have soap to use every day for ourselves, letalone these rags." Washing with soap differed among different villages: In Joypurat, thegirls did not wash the rags with soap even after their period ended – they only usedwater. Several girls in this village washed their rags with the ashes of the banana plant.
In Manikganj however, most of the girls tried to use soap to wash the rags after theirperiod ended (Huq & Khan, 1991). One girl said, "I throw the rag away when it's toodisgusting to wash" (Huq & Khan, 1991, p.66).
After washing their rags, the girls are instructed to dry them and store them where noone can view them. This is not only because someone else's seeing them would beembarrassing, but also they have to be protected from fakirs, flies, crows and ghosts(bhut). If a fakir sees them, he will steal them to make medicine and amulets; then thegirl who it was stolen from will suffer from abdominal cramps and become barren. If afly sits on the rag or a crow flies over it, they will have severe abdominal pain and couldend up becoming infertile. If the rag is left outside at night, the bhut will find it and lickit causing abdominal pain and infertility (Huq & Khan, 1991).
When the rags have reached a condition when it can no longer be used, they have to bewashed and buried. If they throw it away in the river, a fish can swallow it and the girlcan become infertile as a result. Again, bhuts and flies may cause them abdominal painand infertility if the rags are thrown outside (Huq & Khan, 1991).
According to the authors of this report, menstrual rags may be an ecological andinexpensive means of menstrual protection and appropriate for the context in which the Monograph Series-05 girls live. However the way they wash and dry these are not exactly most hygienicpractices. Usually they do not use soap to wash them – this does not ensure thoroughcleaning of the rags. Also they dry them in dark corners to hide them from the view ofothers – this prevents the rags from drying completely and may result in the growth ofmildew and other fungal or bacterial colony on them, thus causing the women to havevaginal or urinary tract infections. Some girls who have few rags and use ones that havenot dried thoroughly may also have infections of this kind (Huq & Khan, 1991).
Menstrual Problems of Women in Bangladesh 6. CAUSES OF INFERTILITY AND SOCIAL STIGMA
Young women are constantly worried about menstrual flow, and always discusswhether "blood flow is red or black, clotted or dark and clumpy", "regular" or non-existent (Rashid, 2005). Furthermore, they believed that "if the menstrual flow is low,the blood remains trapped within the body and a woman who experiences this is unableto conceive" (Mahbub & Ahmed, 1997, p.17). Fertility, particularly women's, is highlyvalued in Bangladeshi society. Not having children results in a sense of role failure withsocial and emotional consequences for both men and women (Papreen et al., 2000). Theinfertility rate was found to be 6.9% according to a 1976 survey (Papreen et al., 2000).
Many women also are subject to physical and psychological abuse in their homes due toinfertility. The case of Phulbanu illustrates the point: Phulbanu perceives herself to be infertile. Initially, she had komore batha (severe lowerback pain) and did not menstruate for two years. She says people tease her and call herbaja (barren) now and do not want to see her, particularly, and in the morning, as theybelieve that if they see her face, tader jatara noshto hobe (they will experience misfortunethat day.) She tried consulting several different types of health providers for her illness,but to no avail: The tabiz (amulet) from a faith healer failed and he diagnosed her withkal dristi (evil spirit). She went to a kobiraj (herbalist) who then diagnosed her with algadosh (evil spirits carried by the wind) and gave her herbal medication which also broughtno fruitful results. Finally in a public hospital (IPGMR) in Dhaka, she was diagnosed withtuberculosis but received no treatment for infertility. Moreover, her relationship with herhusband had deteriorated: She had no pleasure during sex and was worried that herhusband may divorce her & find other women to have children with (Papreen et al.,2000). Infertile women face many forms of social rejection and marginalization from theircommunities (Papreen et al., 2000). The study that Phulbanu (mentioned earlier) was arespondent of, had a total of 20 women who all claimed that women who had childrentold them not to touch their baby or their will be misfortune. In this study and others(Rashid, 2005; Papreen et al, 2000), evil spirits that affect menstruation are thought tocause infertility. It is understood that spirits are attracted to the polluting smell of dirtymenstrual cloths, which if not disposed off properly can result in the invasion of youngwomen's bodies (Rashid, 2005). Two women explained how they know that they havebeen possessed by an evil spirit: "If there is pain in the belly and if black blood passesduring menstruation, then you understand that there is an evil spirit" "An evil spirit is aferocious, evil power, which can eat up the baby in the womb. If it falls upon a woman,she has menstrual problems. Later, if a child comes into the womb, then it eats thechild in the womb." (Papreen et al., 2000, p. 35). In the study among urban slumwomen in Dhaka, of the 35 who said they were suffering from infertility, 24 of themblamed it on kal drishti (Rashid, 2005). Whereas in another urban slum study, out ofthe 20 respondents, 2 cited menstrual problems as a cause of infertility. Other causesinclude God's will (Papreen et al., 2000).
Monograph Series-05 Absence of a public health policy on infertility results in men not being blamed andwomen continue to be viewed as the problem. Women are seen as responsible forinfertility. Also, there are no public health programmes that focus on infertility inBangladesh and few private clinics provide infertility services. The few that do are veryexpensive.
The promotion of female contraceptive methods is emphasized by the health and familyplanning programme of Bangladesh, and the programme is designed primarily forwomen (Rashid, 2001). Pills, condoms, IUDs, sterilization techniques, injectables, andNorplant are the choices of contraceptives provided by public policy for Bangladeshimen and women. A good amount of regular menstrual flow is considered by manyBangladeshi women to ensure good health (Rashid, 2001). Consequently, when sideeffects of contraceptives alter this flow, it brings about several problems for thesewomen. Some of these menstrual problems are outlined below: Norplant is a long-acting, low dose, progestin-only contraceptive for women (Rashid,2001)1. In a 2-year non-comparative study of Norplant in Dhaka Medical CollegeHospital, Bangladesh 690 women were observed after Norplant insertion. Follow upvisits were scheduled at 1 month (m), 6m, 12m, 24m, 36m, 48 m, and 60 m afterinsertion. As in the studies mentioned above, menstrual problems were cited as one ofthe three most frequent reasons for discontinuation of method (the other two reasonswere personal reasons & medical reasons). In 45 (1.1%) of these early removal wasrequested due to menstrual problems, the majority of which were to prolonged heavybleeding. A worsening in the degree of intermenstrual bleeding was reported by 15% ofthe women who returned for 1st year follow up visit. About 28% of the women at the endof one year reported that the degree of dysmenorrhoea had worsened since admission.
About 19% reported an improvement in the degree of dysmenorrhoea while 7% reportedtheir level of discomfort as unchanged. 27% of the acceptors reported at least oneamenorrhaeic episodes (deprived as no menses in the three months prior to a follow upvisit) during the 1st year of the study (See Table 1 in Annex for details). Although 90% ofthe women in this study planned to use another set of Norplant implants, menstrualirregularities was cited as the least like side effect by 70% of these women. Low riskpregnancy was reported as the most liked aspect of the implants (50%; n = 690) whilelong lasting and ease of use were other aspects liked by the women (30% & 20%respectively) (Faruqui et al., 1997). This study showed that although womenexperienced menstrual problems such as dysmenorrhoea, intermenstrual bleeding, andamenorrhoea while using Norplant implants, they were willing to continue its usagebecause of other advantages it brought to them (namely, low risk of pregnancy).
Norplant is an advantageous form of contraceptive in a resource poor country likeBangladesh where pharmacies and clinics are not accessible due to high travel costsand restricted mobility for women due to cultural regulations. Also it is provided free ofcost by the government who receives it as donations from international organizations(medical officer, Railway Hospital, personal communication, January 2006). Thus1 It is a birth spacing method in which six capsules are implanted in the inner side of the upper arm of a woman through a minor surgical procedure that causes infertility for up to 5 years. Itis an effective and acceptable reversible contraceptive method which is suitable for women who Monograph Series-05 rather than discontinue Norplant as a contraceptive method due to its high rate ofmenstrual problems as side effects, more research needs to be carried out to developthis family planning method to decrease such side effects.
DMPA was made available in Bangladesh by National family planning program in theearly eighties (Faruqui et al., 1998).2 In a clinical study conducted at the Dhaka MedicalCollege Hospital to study the safety and efficacy of DMPA among 3580 cases of DMPAusers, during a period of four years, the most frequent side effect or reason fordiscontinuation was found to be menstrual disturbances. The most common cause ofdiscontinuation was spotting (20-30%) similar to another study. Amenorrhoea wasfound in about 75% of woman during 1st and 2nd follow up visit, which is significantlyhigher than other studies. There was significant (7%) improvement of dysmenorrhoeawhich lowers with time (See Tables 2 (a), (b), (c), (d), (e), in Annex for details) (Faruqui etal., 1998).
The oral contraceptive (OC) is the most commonly used contraceptive in Bangladesh(Akhter et al., 1996b).3 A prospective comparative study was conducted to compare lowdose and regular dose pill acceptors, their characteristics, use related eventscontinuation rates and their reasons for discontinuation. Thus about 600 low doseacceptors were selected at Sripur and Kaliakair thanas of Gazipur District and another600 standard dose acceptors were recruited at Pangsha and Rajbari Sadar than ofRajbari district. It was found that intermenstrual bleeding (whose appearance seemedto be more like breakthrough bleeding than scanty menstruation) was the only problemin the low dose OC. Other than that duration of menstruation pain, amount ofmenstrual flow and pain during menstruation were all lowered. Prior to use of the pill,93% of the women reported an average duration of their menstrual cycle as 26-36 days.
The period was reported as 6 days in duration for 89% of the women. (n= 1200) Alsopain during menstruation was reported by 47.6% of the entire study group. Onexamining features of the last period, it was found intermenstrual bleeding was absentamong 98.1 % of the group and present only among 1.9% of the group - the majoritysaid it occurred as scanty bleeding. About a quarter of the low dose pill users reportedmenstrual problems during their use of the OC. Among these ¼ of low dose users, 35%reported excessive bleeding (vs. 25% for standard dose OC). Both low and regular dosegroups reported painful menstruation. During the last 2 weeks after interview, between240 standard dose and 236 low dose acceptors, 90% had no intermenstrual bleeding,and 10% had some intermenstrual bleeding. This varied in amount ranging fromspotting to moderate bleeding to less amt of bleeding (Akhter et al., 1996b).
cannot easily access pharmacies or clinics and who want an effective, long acting method(Faruqui et al 1997).
2 This is a form of injectable contraceptive that contains 150 mg of Medroxy Progesterone Acetate in 1 ml of aqueous solution. Initially another injectable NET-EN was launched around the sametime period as DMPA, but NET-EN is now no longer available in Bangladesh. Before DMPA isinjected, a thorough gynecological exam is needed and pregnancy should be excluded and it isonly recommended among females having a regular cycle. The first injection should be givenwithin the first five days of the cycle. The following injections are administered at intervals of 12weeks. Injections are given deep within the gluteus. Fertility is usually restored within 4 to 7months after discontinuance of the study.
3 Low dose OC is defined as the pill containing less than 50 micrograms of estrogen. With lower doses, it is more important to take pills correctly and regularly as per instruction. Skipping pilland other inconsistencies may not only lead to pregnancy, it also increases breakthroughbleeding which itself may cause women to stop taking pills.
Menstrual Problems of Women in Bangladesh A comparative double blind randomized clinical trial was conducted among Bangladeshiwomen attending 96 centers where intrauterine device4 (IUD) services are being providedto compare the nature and extent of bleeding with the use of IUDs TCU 200, TCU 380Aand ML 375. The number on the IUD refers to the corresponding amount of copper thatit is comprised of, i.e., the TCU 200 has 200 of copper. In this study, upon theiradmission, women were asked about their knowledge about the side effects of IUDs ingeneral. Majority of the clients (44 to 47 %) appeared to be ignorant of the side effectsand 5 to 7% said there are no side effects. The mentioned side effects included excessivemenstrual bleeding (22 – 24%), irregular menstruation (11- 12%) and lower abdominalpain (11- 13%). Nearly 96% of clients reported normal quantity of menstrual bleeding(N= 801) (No significant differences were found among the three groups of acceptors inthe distribution of length of menstrual cycle, duration of menstrual period & quantity ofbleeding during menstruation) About 25.6% reported pain during last menstrual periodwhile 99% had no intermenstrual bleeding. Out of the total of 801 acceptors of the threeaforementioned IUD devices, 198 had discontinued use. Among the 198, a total of 82.8% had their IUD removed voluntarily, 5.6% had partial expulsion and 11.6 % hadspontaneous expulsion. The main reasons for removal of IUD among users of all threedevices are excessive bleeding (34.3%), partial /complete expulsion (17.2 percent) andlower abdominal pain/white discharge (16.1%). The TCU 200 model of the IUD wasbetter accepted than the 380A in this study. The copper content and copper dissolutionmay be directly related to their bleeding complications. i.e., IUD with less coppercontent appears to cause less menstrual complications (Akhter et al., 1996). An authorof this study whom I spoke to explained that as the TCU 200 has only 200 ofcopper and it dissolutes less copper into the uterus than the TCU 380 which has ahigher copper content ( Hence less dissolution of copper seems to correlatewith less bleeding problems. The author also explained that sometimes foreign IUDs arenot small enough for Bangladeshi women who are smaller in frame than their westerncounterparts.
Perceived side effects of contraceptives
An extensive study to evaluate Norplant acceptability as reported by Akhter et al (1996)
on 1,327 acceptors found that quite a large number of women suffered from
amenorrhea and bleeding problems (Rashid, 2001). In the context of Bangladeshi
society, menstrual blood is seen as polluted blood. When not pregnant, rural women are
concerned that their blood is released monthly to ensure "good health" (Blanchet, 1984;
Huq & Khan, 1991; Mahbub & Ahmed, 1997). Thus if for any reason a woman
experiences low blood flow during menstruation or if her menstrual bleeding ceases
altogether, she perceives the impure blood as remaining within her body and thus
polluting it. In a Norplant study a woman stated, "I want to open Norplant. My body
doesn't feel good because my menstruation has stopped. My head and eyes hurt"
(Rashid 2001). Side effects may also be too much menstrual bleeding which cause
major disruptions in a woman's everyday life. The following is an account of a woman of
the dilemmas she faced upon continuous bleeding after accepting a Norplant implant:
"My menstruation wouldn't stop. Many people know that when women get menstruation,
if they don't wash themselves or their clothes, they cannot go near their husbands and

4 The Intra Uterine Device (IUD) is a contraceptive device inserted through the cervix into the uterus to prevent pregnancy by interference with sperm transport, ovum development,fertilization and implantation. Continuous copper release into the uterine cavity from the deviceenhances contraceptive effect of the device.
Monograph Series-05 they cannot eat with them. They cannot go near them in bed, as a man's life isshortened… what can we do? There is no one to cook. We have to cook and give themfood. If I have my menstruation all the time, then everything is disturbed for me! I couldnot say my prayers or read the Quran properly, I was washing my clothes all the time,and all the time there (were) drops of blood coming and it became a big problem for me."(Rashid 2001, p.95) Also, even though a number of husbands approved of Norplant, afew of them were not happy with the health problems and extra money spent on theirwives health, i.e., in managing these side effects. However, a few women are acceptingof this family planning method, and feel that the benefits far outweigh the negativeeffects. Reassured by a family planning worker, a woman states: "Apa (sister) told menot to worry, I will be okay. Yes, I have menstruation problems and I have lower abdomenpain but I will keep Norplant on. It is good for me because for 5 years I will not have anyworries" (Rashid 2001, p.94). Non-stop bleeding as a side effect of IUD can be further elaborated from a qualitativestudy where women perceived the bleeding as problematic in that it left them in a stateof perpetual impurity and rendered them unable to pray. Also they were unable to gonear their husbands or eat with them. It is commonly believed among Bangladeshiwomen that the body needs to have sufficient amount of blood to remain balanced andhealthy and only certain foods can produce good rokto (blood) in the body. "Ourhusbands are poor, how will they feed us such food," a woman stated with despair(Rashid, 2001b, p.65).
On the other hand, contraceptive use is also perceived to bring about side effects of
amenorrhea and often believed to lead to infertility. In a study among young women in
urban slums in Dhaka, it is understood that contraceptive use can "dry out the uterus",
and in some cases obstruct fertility. These understandings are often reinforced because
of the disruption in menstruation brought on by contraceptive use. Young women
constantly worried about menstrual flow, and always discussed whether "blood flow
was red or black, clotted or dark and clumpy", "regular" or non-existent. Young women
who stopped using the pill and others who used injectables spoke of experiencing
amenorrhea; fears it would lead to "bad blood building up inside their stomachs."
Married adolescent women in this slum were interested in using family planning
methods to control their fertility but remained worried that long-term FP use will lead to
menstrual irregularities and more dangerously "dry out the uterus" and make them
infertile (Rashid, 2005).
Menstrual Problems of Women in Bangladesh 8. HEALTH SEEKING BEHAVIOUR
For their illnesses, including gynecological ones, women tend to ask other women foradvice. Usually these women are from their natal home. They rarely asked women fromtheir in-laws side of the family for health related advice, and mothers-in-law were notreported at all for health consultation in this study. For menstrual problems such asmenorrhagia (khum jhore) women find it appropriate to ask a kabiraj (traditional healer)for treatment because they feel that, as this illness is caused by humka batas, only akabiraj can cure them of this spirit. The kabiraj usually gives them an amulet thatcontains a kind of herbal medicine and the patient is told to eat sweet pumpkin, someselected fish like puti, gojar and taki, kheshari dal, tamarind, etc (Mahbub & Ahmed,1997).
To treat the condition of bhadok, a hardened ball of blood trapped in a woman's body, akobiraj (Herbalist) gives the woman seven pills made of herbal medicine, bathes herthen changes her soiled sari and takes it home. The oral medication taken is verysimilar to that used for abortion: it caused severe bleeding and another medication isoften used to stop the excessive bleeding (Blanchet, 1984).
A popular belief given for infertility is the "build up of fat" which can happen fornumerous reasons such as stopping of one's menstruation as well as other reasons(family planning use, eating certain kinds of hot or oily foods, etc). A popular way tocure this problem is to "wash out and remove this fat" by the process of D&C. A healthworker explained how she took her sister in for a "wash" after the doctor had advisedher to do so, because her abdomen had become heavy from the build up of menses.
These "washes" are very expensive and the few women who use this service often haveto take loans to afford them. A hujur (spiritual leader) who treats for infertility said thathe most often gets female patients because women menstruate and are therefore, morevulnerable to jinn and bhut (evil eyes and ghosts) who like fresh bloody matter that isalive (Mahbub & Ahmed, 1997).
Monograph Series-05 Menstrual problems are a source of worry for most Bangladeshi women becausechanges in flow not only cause physical discomfort and ill health, but also bring aboutdisruptions in their traditional and religious beliefs. On one hand, when there is lowmenstrual flow or its absence, perceptions of infertility or accumulation of trappedimpure blood within the body subject women to social stigma and the uneasiness ofholding in polluted blood. On the other hand, excessive bleeding disrupts the dailyrituals of prayers, preparing or serving food, and coming close to their husbands.
Despite the problems women face due to menstrual illnesses, social stigma preventsthem from discussing gynaecological problems such as these with barely anyone butother women or traditional health providers. Beliefs that evil spirits are the causesbehind these illnesses lead them to seek health care from kobiraj (herbalists) who maygive herbal pills which cause severe bleeding. Menstrual problems as side effects ofcontraceptives may be tolerated in exchange for having an effective means of birthcontrol. Expensive procedures such as D&C may be used to remove perceived fat in theuterus, which is often paid for from loans.
Currently, few studies have been carried out on menstrual problems of women inBangladesh. As these problems cause ill health, subject women to social stigma anddisrupt them from carrying out daily activities, in depth research needs to be carriedout to measure the magnitude and prevalence of menstrual problems, ways to clarifythe misconceptions surrounding menstruation need to be explored, and, information onside effects of contraceptives and the range of options available need to be given out towomen before they adopt a contraceptive method.
Menstrual Problems of Women in Bangladesh Akhter, H., Chowdhury M., & Rahman M. (1996). A Study to Compare the Side Effects, Continuation and Acceptability of TCU 200, 380A and ML 375. Bangladesh Institute ofResearch for Promotion of Essential & Reproductive Health and Technologies (BIRPERHT).
Akhter H., Chowdhury M., Rahman M., Hussain M. (1996). A Study to Compare Compliance, Continuation & Failure Rates and Reported Side Effects of Low Dose & Standard Dose Oral Pillin Rural Bangladesh. Bangladesh Institute of Research for Promotion of Essential &Reproductive Health and Technologies (BIRPERHT) Bangladesh Health Watch (2006). The State of Health in Bangladesh 2006: Challenges of Achieving Equity in Health. Abridged report.
Blanchet T. (1984) Meanings and Rituals of Birth in Rural Bangladesh.
Faruqui M., Begum A., & Begum F. (1997). Two Years Evaluation of Safety, Efficacy and Acceptability of Norplant Implants in Dhaka Medical College Hospital. Dhaka: Dhaka MedicalCollege Hospital (DMCH).
Faruqui M., Khan J., & Begum A. (1998). Safety and Efficacy of DMPA at Model Family Planning Clinic of DMCH. Dhaka: Dhaka Medical College Hospital (DMCH).
Huq N., & Khan M., (1991). Menstruation: Beliefs and Practices of Adolescent Girls.
Dhaka: Research and Evaluation Division, Bangladesh Rural Advancement Committee (BRAC), Mahbub A., & Ahmed S. (1997). Perspectives of Women about their own Illness. Dhaka: ICDDR, B, Working Paper Number 16.
Mathews A., Menstruation Issues in Bangladesh, InternetNahar Q., Tunon C., Houras I., Gazi R., Reza M., Huq N., & Khuda B. (1999). Reproductive Health Needs of Adolescents in Bangladesh: A study report. Dhaka: ICDDR, B. Working Paperno. 161.
Papreen N., Sharma A., Sabin K., Begum L., Ahsan S., & Baqui A. (2000). Living with Infertility: Experiences among urban slum populations in Bangladesh. Reproductive Health Matters, 8(15), 33-43.
Rashid, SF. (2001a). Indigenous Notions of the workings of the Body: Conflicts and Dilemmas with Norplant Use in Rural Bangladesh. Qualitative Health Research, 11 (1), 85-102.
Rashid SF. (2001b). Indigenous Understanding of the Workings of the Body and Contraceptive Use amongst Rural Women in Bangladesh. South Asian Anthropologist, 1(1), 57-70.
Rashid SF. (2005). Kal Dristi, Stolen Babies & Blocked Uteruses: Poverty & Infertility Anxieties Among Married Adolescent Women Living in Slums in Dhaka, Bangladesh. James P. GrantSchool of Public Health, BRAC University, Singh, S. (2006). Reproductive Morbidity among the Rural Women in Maharastra. M.P.S. Seminar Paper retrieved June 18, 2007, from World Health Organization (1998). Gender and health: Technical paper Reference WHO/FRH/ Ziauddin S., & Hyder. (1993). Women's Health & Illness: Perception of men & women in Rural Area of Bangladesh. Bangladesh.
Monograph Series-05 Menstrual problems as side effects of contraceptives
A. Side effects of Norplant
TABLE 1: Percentage of Women (Norplant Users) with change in menstrual
characteristics between characteristics between admission and yearly follow up
Menstrual characteristics
First year (n = 350) Second year (n= 300) B. Side effects of DMPA
Table 2 (a)

On admission
First follow up at 3
Second follow up at
month (n= 2788)
6 month (n= 2478)
Table 2 (b)
On admission
First follow up at 3
Second follow up at
month (n= 2788)
6 month (n= 2478)
Menstrual Problems of Women in Bangladesh Table 2 (c)
Number of
On admission
First follow up at 3
Second follow up at
month (n= 2788)
6 month (n= 2478)
Table 2 (d)
On admission
First follow up at 3
Second follow up at
month (n= 2788)
6 month (n= 2478)
Table 2 (e)
On admission
First follow up at 3
Second follow up at
month (n= 2788)
6 month (n= 2478)



How to deal with toxicity of targeted therapies Liesbeth Lemmens, BSc, MSc, Coordinator clinical trials digestive oncology, University Hospitals, Leuven, Belgium ‘mouse' part of the chimeric drug. Nurses must be aware that this During the last decade, targeted therapies such as epidermal growth reaction can occur immediately after the start of the

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