|Year : 2019 | Volume
| Issue : 1 | Page : 12-16
Awareness and experiences of female pilgrims about menstrual suppression during Hajj 1437 Hijrah: A cross-sectional study
Nikita Islam1, Aqueela Ayaz1, Mian Usman Farooq2
1 Department of Gynae Oncology, King Abdullah Medical City, Makkah, Saudi Arabia
2 Department of Strategic Planning and Institutional Advancement, King Abdullah Medical City, Makkah, Saudi Arabia
|Date of Web Publication||16-May-2019|
Dr. Mian Usman Farooq
King Abdullah Medical City, Makkah
Source of Support: None, Conflict of Interest: None
Objectives: Our objective was to determine the awareness, use of medications to suppress menstruation along with their side effects, and satisfaction level among the pilgrims. Methods: An observational cross-sectional survey was conducted during the pilgrimage (Hajj) period 1437 Hijrah in Makkah, Saudi Arabia. Women pilgrims (n = 594) between menarche and menopause were interviewed. The proportion of females who was aware of menstrual suppression by medication, who used the medication during Hajj period, and who experienced complaints while using drugs to postpone the periods, and after stopping the drugs were sorted. Results: The participants were mean aged 35.3 years (standard deviation = 8.4), with 413 (69.5%) being multiparous, 556 (93.6%) were aware of menstruation postponement by medications, and 313 (56%) got this information from their family doctors. However, 381 (64%) used medications, and 356 (93.3%) successfully achieved menstrual suppression. Out of 381, majority used Norethisterone, i.e., 301 (79%) and 80 (21%) complained of side effects, of which the most common was irregular spotting 31.3% (25/80) followed by abdominal pain. Satisfaction of medications users was 324 (85%). Out of 381 women, 87 (22.8%) reported side effects after discontinuing the hormones; the commonly experienced side effect was heavy prolonged bleeding 47 (54%). Conclusions: The awareness about hormones usage to postpone menstruation was high. Norethisterone was commonly used medication. Overall satisfaction with medications' usage was high. Most women did not know what to do in case of unscheduled bleeding.
Keywords: Menstrual suppression, norethisterone, oral contraceptive pills
|How to cite this article:|
Islam N, Ayaz A, Farooq MU. Awareness and experiences of female pilgrims about menstrual suppression during Hajj 1437 Hijrah: A cross-sectional study. Saudi J Health Sci 2019;8:12-6
|How to cite this URL:|
Islam N, Ayaz A, Farooq MU. Awareness and experiences of female pilgrims about menstrual suppression during Hajj 1437 Hijrah: A cross-sectional study. Saudi J Health Sci [serial online] 2019 [cited 2019 Jul 17];8:12-6. Available from: http://www.saudijhealthsci.org/text.asp?2019/8/1/12/256786
| Introduction|| |
Menstrual suppression has been practiced by women since the 1960s, mainly for medical conditions associated with the heavy menstrual flow.,
A recent Canadian clinical practice guideline describes menstrual suppression in special circumstances. The aim is to decrease blood loss in women with heavy menstrual bleeding, especially in young girls with developmental disabilities and women undergoing cancer treatment with iatrogenic thrombocytopenia.
Hormonal preparations have been used by women worldwide to postpone menstruation to accommodate important events such as honeymoons or vacations.,, The Canadian consensus guideline describes other indications for menstrual suppression including social choice, which is the focus of our discussion.
The pilgrimage of Hajj is unparalleled as regards to a number of women using medication to postpone menstruation and provides us with a unique opportunity to study the subject of menstrual suppression in women of a diverse ethnic and educational background. Over two million people from worldwide gather in one place. Pilgrims come from different countries and women makeup 45% of all pilgrims, with many being in the childbearing age group. The pilgrimage is during a fixed time of the year, and pilgrims have a very tight itinerary and must return to their countries of origin on a specified date.
One of the rituals of Hajj, Tawaf-ul-Ziyarah, involving circumambulating around the Kaaba, can only be performed by a woman in a state of purification. If a woman cannot complete this rite, her Hajj is not complete. If a female pilgrim starts menstruating toward the end of her pilgrimage, then she needs to remain in Makkah (or return to Makkah) when, or until her period is over and she can perform the Tawaf. This might mean splitting from their Hajj group or delaying the return flight, which can cause a lot of inconveniences.
The second reason is that for most people, Hajj is a once in a lifetime event. During menstruation, a woman should not enter Masjid Al-Haram, and therefore cannot perform many of the extra rituals associated with Hajj. Women do not want to miss out on any of these extra spiritual benefits and so take medicines to suppress menstruation.
There are hygiene issues relating to safe and effective disposal of sanitary towels in a very crowded place. Many women chose to suppress menstruation to avoid this inconvenience during their stay in Makkah.
In this study, we aimed to determine the awareness, use of medications to suppress menstruation along with their side effects, and satisfaction level among the Hajj pilgrims.
| Methods|| |
An observational cross-sectional survey was performed using semi-structured questionnaire during pilgrimage (Hajj) from 15th of Dhul-Qadah to 30th of Dhul-Hijjah; 1437 corresponding to (August 18, 2016–October 1, 2016) in Makkah, Saudi Arabia.
All the females of reproductive age group (11–55 years) who came to perform Hajj were considered as the study population. On the other hand, postmenopausal and pregnant women, as well as women who refused to take part in a survey or had language barrier were excluded.
A semi-structured questionnaire of 33 questions with some open-ended, closed-ended, and partially closed-ended questions was prepared in English along with Urdu and Arabic translation. The questionnaire had 29 questions regarding demography, awareness, and the use of medications to delay menstruation along with side effects of medication during and after usage, and overall satisfaction level. No identification data such as passport number, national identity card number, picture, or any Hajj mission registration number were collected, except study participants' names, phone numbers, and/or E-mails. These identification data have been kept confidential and accessible to only study collaborators, for the purpose of follow-up to fulfill the study objectives. The content validity was measured by calculating the content validity index (CVI) for individual items (I-CVI). Each item was answered by four subject experts about the relevancy with the research objectives on a 4-point Likert scale, i.e., 1-not relevant, 2-somewhat relevant, 3-relevant, and 4-very relevant. Each item's I-CVI was calculated by taking the proportion of experts who scaled the item as 3 or 4 and then average item content validity (I-CVI/average) and scale CVI universal average was measured, i.e., 0.94 and 0.72, respectively.
Questionnaire face validity was ensured against readability, layout and style, and clarity of the wordings after pilot testing by data collaborators on ten Hajj pilgrimage females followed by readjustment of questionnaire items.
Nonprobability convenience sampling method has been adopted because of its cost-effectiveness, as well as limited time period available due to a busy schedule of study collaborators as well as women performing religious rituals. Moreover, the population of Makkah nearly doubles during the Hajj days. This hinders the easy movement from one place to another. Data were collected from women in person by approaching Hajj commission leaders'/group representatives, based on their accessibility, and also by repeatedly visiting the Al-Haram mosque. A verbal informed consent was taken from women who took part in the study after they had been made aware of study rationale and objectives. Data about the complaints after discontinuing the medication were collected through given phone numbers and/or E-mails by study collaborators.
The outcome of the study was assessed by measuring the proportion of females who were aware that periods could be postponed by medication, and who used the medication during the above period. The percentage of females who experienced complaints while using drugs to postpone the periods, and after stopping the drugs, was measured.
A minimum sample (n) of about 385 females was estimated by the formula, i.e., n ≥ Z2 (P [1-p]/e2) by keeping the confidence interval of 95% (Z = 1.96), margin of error of 5% (e = 0.05), and percentage of individuals using hormones to delay the periods was assumed as 50% (P = 0.5). About 30% of 385 were added to reach a minimum total sample size of 498 to accommodate any contingencies such as nonresponse or observer bias or recall bias or lack of follow-up. A total of 625 women were interviewed by the study collaborators, but 594 individuals were included in a study as the rest had deficiencies and lacked important data.
Statistical analysis plan
Data were analyzed using SPSS version 16 (SPSS Inc., Chicago, IL, USA). Numeric data were presented as mean ± standard deviation (SD), or as median and range according to the type of distribution of each variable. For categorical variables, numbers along with percentages were used.
Ethical approval has been sought from the Institutional Review Board, King Abdullah Medical City, Makkah, Saudi Arabia.
Authors have not declared any conflict of interest. No source of funding was available and declared.
| Results|| |
The average age of the participants (n = 594) was 35.3 years (SD = 8.4), with 413 (69.5%) being multiparous. The majority of the participants were Pakistani 255 (42.9%). Of the total, 202 (34%) had attended university, 458 (77.1%) were currently married, 41 (6.9%) had irregular cycles, of which infrequent menstruation was common, some being aware that they had the polycystic ovarian disease [Table 1].
|Table 1: Demographic data along with detail of awareness about delaying periods|
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Of the total, 33 (5.6%) were using contraceptive measures, with 14/33 (42.4%) using combined oral contraceptive (COC) pills. The majority of the women 556 (93.6%) were aware of menstruation postponement by medications, 445 (80%) were aware of the medications' name, and 313 (56%) got this information from their family doctors. Only 16 (2.9%) got this information from the just awareness programs conducted by their local authorities. Of the total, 237 (39.9%) had used the medication in the past, while 381 (64%) women used medication to postpone menstruation during the study. The mean period of the use of hormonal medication was 20.7 days (SD = 6.9), and a majority of the women 365/381 (95.8%) were taking their medication on time. The most common reason for not taking medication on time was busy schedule 10/16 (62.5%) [Table 1] and [Table 2].
Norethisterone (Primolut N) was the most frequently used medication 301/381 (79%) and 356 (93.3%) successfully achieved menstrual suppression; however, 80/381 (21%) complained of side effects, of which the most common was irregular spotting 25/80 (31.3%), followed by abdominal pain and a feeling of weight gain. Of the total women used medications, 87 (22.8%) reported side effects after discontinuing the hormones, the most commonly experienced side effect was heavy prolonged bleeding 47 (54%). Out of 381 women, only 28 (7.3%) wanted to discontinue the medication because of side effects, and 298 (78.2%) did not know what to do in case of breakthrough bleeding (BTB). Nearly 85% (324/381) women were satisfied and would use it again [Table 3].
|Table 3: Types of medications used to delay periods and their complications|
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| Discussion|| |
Our study had higher number (n = 594) of participants from 15 nationalities as compared to Nigerian (n = 116) and Iranian (n = 400) studies, which included only their respective nationality., Our study depicted higher level of awareness (93.6%) about menstruation postponement by medications than that of Nigerian study (70.7%). Moreover, Andrist et al. reported that 78% women in a random survey had never heard about menstrual suppression by oral contraceptives. The higher awareness level of the use of medication to postpone menstruation in female pilgrims was due to the need of purity required for entering the Masjid Al-Haram (the holy mosque) to perform one of the rituals of Hajj, Tawaf-al-Ziyarah.
We found lower uptake of medication (64%) than awareness (93.6%). This difference was mostly related to the perception of delaying menstruation as something “unnatural” and as Hajj is a religious journey, many women were unsure about its religious permissibility and tended to be safe by avoiding using it. Another reason was that their expected days of menstruation were not in specific days of Hajj, that is, 8th–13th Dhul-Hijjah and also there was a fear of BTB, either from personal experience, or the experience of friends and family.
The most common medication used was COCs (47.7%) in Nigerian pilgrim, birth control pills (98.7%) in Iranian pilgrim, while norethisterone (79%) was in the current study. The achievement of menstrual suppression was highest, i.e., 93.3% in the current study compared to Iranian study (74.4%). This may be due to norethisterone (a synthetic progesterone), the commonly used medication in our observation. Dandehbor et al. also suggested using progestin-only pills for effective suppression of menstruation. Among the users of medications, 21% complained medicinal side effects. This rate was lower than that of reported by Dandehbor et al., (41%). However, the most common side effect of medication in all studies was irregular spotting and BTB. Ghorashi et al.; in 2000, Mohammed-Durosinlorun et al.; in 2007, and Dandehbor et al.; in 2012, reported spotting in Hajj pilgrims 13.6%, 10%–30%, and 26%, respectively.,,
In the current study, only 6.7% reported spotting. The high occurrence of these side effects in the other studies compared to present study can be attributed to a variable estrogenic component in contraceptive pills as opposed to our study where 84.3% of individuals used only progesterone.,, Most of the women were unaware of what to do if they had BTB. In the current study, 22.8% reported side effects after discontinuing the hormones; the most commonly experienced side effect was heavy prolonged bleeding. However, we did not find any other study addressing this issue.
| Conclusions|| |
The awareness that hormones can be used to postpone menstruation was high. However, the information was patchy, usually obtained through their family doctors, and not so much from awareness programs. Most women did not know what to do in case of unscheduled bleeding. Norethisterone was commonly used medication. Overall satisfaction rate with medication's usage was high.
- We would like to see the Ministry overseeing Hajj matters, make recommendations, and information leaflets available to individual Hajj groups. Just like education about religious rituals is very important, standardized information about health-related matters including medications for postponement of menstruation should be made available. A sample leaflet should be translated into different languages to ensure uniform distribution of information
- All countries have an awareness program before Hajj. It would be helpful if there could be standardized information available to all pilgrims. This should include the religious permissibility of using medication to postpone menstruation, after making sure the pilgrims have had a health check to make sure there is no contraindication to using hormones. Information about the use of common medications such as COCs and norethisterone should be provided to the pilgrims, emphasizing when to start, ensure regular use, and what to do in case BTB occurs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Meirow D, Rabinovici J, Katz D, Or R, Shufaro Y, Ben-Yehuda D, et al.
Prevention of severe menorrhagia in oncology patients with treatment-induced thrombocytopenia by luteinizing hormone-releasing hormone agonist and depo-medroxyprogesterone acetate. Cancer 2006;107:1634-41.
Savasi I, Spitzer RF, Allen LM, Ornstein MP. Menstrual suppression for adolescents with developmental disabilities. J Pediatr Adolesc Gynecol 2009;22:143-9.
Kirkham YA, Ornstein MP, Aggarwal A, McQuillan S; Canpago Committee. Menstrual suppression in special circumstances. J Obstet Gynaecol Can 2014;36:915-24.
Glasier AF, Smith KB, van der Spuy ZM, Ho PC, Cheng L, Dada K, et al.
Amenorrhea associated with contraception-an international study on acceptability. Contraception 2003;67:1-8.
Andrist LC, Arias RD, Nucatola D, Kaunitz AM, Musselman BL, Reiter S, et al.
Women's and providers' attitudes toward menstrual suppression with extended use of oral contraceptives. Contraception 2004;70:359-63.
Guilbert E, Boroditsky R, Black A, Kives S, Leboeuf M, Mirosh M, et al
. Society of Ob- Stetricians and Gynaecologists of Canada. Canadian consensus guideline on continuous and extended hormonal contraception. SOGC Clinical Practice Guidelines, No. 195, July 2007. J Obstet Gynaecol Can 2007; 29 Suppl 7:S1-32.
Central Authority of Statistics, Kingdom of Saudi Arabia. Central Authority of Statistics; The Number of Pilgrims for the Years from 1416H (1995G) to 1436H (2015G); September, 2015. Available from: http://www.cdsi.gov.sa/en/1787
. [Last updated on 2016 Jul 20; Last accessed on 2016 Jul 20].
Mohammed-Durosinlorun A, Raji HO, Hussain NA, Badmus SA, Ijaiya MA. Menstrual suppression among female Nigerian pilgrims during Hajj. J Fam Plann Reprod Health Care 2012;38:270-1.
Dandehbor W, Kazemi M, Shahrbabaki MH, Ghorashi Z, Sadrmohammad R, Bzorg B, et al
. Menstrual suppression using oral contraceptives by female Hajj pilgrims. Int J Travel Med Glob Health 2016;4:111-4.
Ghorashi Z, Taleghani F, Shafiee M. Failure and side effects of contraceptive pills used for postponement of menstrual bleeding in Hajj Pilgrims of Kerman (2000). JSSU 2005;12:65-70.
[Table 1], [Table 2], [Table 3]