RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJESCT FOR DISSERTATION

1. / NAME OF THE CANDIDATE
& ADDRESS / : MS. PREETI
1ST YEAR M Sc NURSING
GOVERNMENT COLLEGE OF
NURSING. HASSAN-573201
2. / NAME OF THE INSTITUTION / : GOVERNMENT COLLEGE OF
NURSING, HASSAN.
3. / COURSE OF THE STUDY
& SUBJECT / :1ST YEAR M Sc NURSING
OBSTETRICS AND
GYNAECOLOGICAL NURSING.
4. / DATE OF ADMISSION / : 27-07-2013
5. / TITLE OF THE TOPIC / : THE EFFECTIVENESS OF
STRUCTURED TEACHING
PROGRAMME ON
KNOWLEDGE REGARDING
POSTPONEMENT OF
MENSTRUATION AMONG
DEGREE STUDENTS OF
SELECTED COLLEGE AT
HASSAN.

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“You educate a man; you educate a man. You educate a woman; you educate a generation.”
BRIGHAM YOUNG

Menstruation is an important part of women’s life cycle. Women are taught from their early days in sex education that menstruation is a natural part of womanhood which is to be accepted and embraced as the monthly reminder of fertility, but some women try to postpone it for some reason1. Menstruation is the cyclic discharge of blood, mucous and cellular debris from the uterine lining. This cyclical (28-30 days) monthly process is by and large regular and predictable right from menarche until menopause2.

Many times it happens when women feel bloated and banging head in the painful days of periods. The impact of monthly menstruation may range from a minor inconvenience for some women to a major health concern for those who suffer from menstrual disorders that are aggravated during the menstrual cycle. Problems related to menstruation sometimes prevent women to attend important parties or functions1.

A woman may have many reasons for wanting to control the day of her period. She may not want her monthly cycle to interfere with her wedding or vacation or another important event. Female athletes may also want to avoid having their monthly cycle during a performance or competition. Some of the communities, Hindus and Islam has their culture beliefs and values regarding menstruation. At the period of menstruation the girls are not allowed to do pooja (prayers) and are not allowed to go to temple and religious function. So because of these reasons, most of the girls postpone their menstruation for the short time3.

Contraceptives or birth control pills are a good way to better control the day of period. These pills have high levels of those hormones estrogen and progesterone. When we stop taking the pills after a full week’s cycle we may have what is called withdrawal bleeding within 2 to 3 days. Some risk factors are aggravated by the use of contraceptives pills4.

There are some home remedies to postpone or prepone the period. These can be safer than birth control pills, although, need to realize that they don’t always work to exactly control monthly cycle. Eating foods that raise the level of estrogen is one way to prepone the cycle and warming the body near the uterus can also cause an early period5.

6.1 NEED FOR THE STUDY

Reasons for suppressing menstrual flow range from avoiding bleeding during a particular event (e.g., a wedding, graduation, or sports competition) to finding relief from dysmenorrhoea or reducing or eliminating menstruation in the treatment of endometriosis, migraine, and other medical conditions exacerbated by hormonal changes around the time of menses.Alternatively, some women may practice menstrual manipulation for no other reason than to simply avoid menstruation7.

Many religions have menstruation-related traditions; these may be bans on certain actions during menstruation, or rituals to be performed at the end of each menses. Women can experience a range of problems with their periods, including lack of a menstrual period, pain, heavy bleeding, and skipped periods. Menstruation is a normal, healthy process. In most cases, menstrual cycle should not affect day-to-day activities5. However, a few symptoms are signs of menstrual irregularity. Some of the abnormal menstruation includes, bleeding in between cycles, heavy bleeding, bleeding for more than 7 days, experience severe pain before or during periods6.

Using synthetic hormones, it is possible for a person to completely eliminate menstrual periods.When using progestogen implants, menstruation may be reduced to 3 or 4 menstrual periods per year. By taking progestogen-only contraceptive pills (sometimes called the 'mini-pill') continuously without a 7-day span of using placebo pills, the menstrual period is eliminated entirely. Some people do this simply for convenience in the short-term, while others prefer to eliminate periods9.

Benefits include fewer menstrual-related syndromes, less absenteeism from work or school, and greater overall satisfaction. Medical indications for it are conditions exacerbated by hormonal changes around the time of menses7.

Since the late 1960s, many women have chosen to control the frequency of menstruation with long-actinghormonal birth control, often simply called 'the pill'. They are most often combined hormone pills containingoestrogenand are taken in 28 day cycles, 21 hormonal pills with either a 7 day break from pills, or 7 placebo pills during which the person menstruates.Hormonal contraceptionacts by using low doses of hormones to prevent ovulation, and thus prevent conception in sexually active women. But by using placebo pills for a 7-day span during the month, a regular bleeding period is still experienced7.

Some women by using hormonal contraceptives in extended or continuous regimens, they can have their period less often, hormonal contraception in this way to eliminate their periods for months or years at a time, a practice called menstrual manipulation or menstrual suppression. Menstrual manipulation, i.e. adjusting the menstrual cycle by taking hormonal contraceptives, allows women to have their period less often or to avoid bleeding at inconvenient times. The options for menstrual manipulation are extended or continuous regimens of oral, transdermal, or vaginal hormonal contraceptives; a levonorgestrel-releasing intrauterine device; a progestin implant; and depot medroxyprogesterone injection8.

In 1977, Loudon et al reported the results of a study in which women took active pills for 84 days instead of 21 days, which reduced the frequency of menstruation to every 3 months. Since then, extending the active pills beyond 21 days to avoid menses and other hormone withdrawal symptoms has become popular in clinical practice, and many studies have investigated the extended or continuous use of oral and other forms of contraception to delay menses7.

Norethisterone 5mg tablets can be taken three times daily to delay periods. Start tablets 4 to 5 days before a period is due and continue for as long as needed. A period bleed will normally start 2 to 3 days and possibly longer, after stopping norethisterone . The balance of hormones changes during the menstrual cycle. During the time norethisterone tablets are being taken a period (shedding of the womb lining) will be delayed. Women currently taking a contraceptive pill should not use norethisterone to delay their periods. Norethisterone is not a contraceptive and will not prevent pregnancy17.

Primolutn Tablets also used for the postponement of menstruation. 1 tablet containsnorethisterone(17-hydroxy-19-nor-17alpha-pregn-4-en-20-yn-3-one) 5, 0mg. Norethisterone has an inhibitory effect on the secretion of gonadotropins in the anterior lobe of the pituitary. Norethisterone increases the basal body temperature: 10mg norethisterone daily increases it by about 0, 5°C. In addition to the transformatory action norethisterone also has a styptic effect. A local influence on the endometrium leads to the cessation dysfunctional bleeding. Adverse effects of Primolutn drug is Visual disturbances Nausea Headache, oedema Migraine Dyspnoea Hypersensitivity reactions (e.g. rash, urticaria)9.

In this situation, the midwife as an educator can help the women to develop self confidence and self esteem. Hence, the investigator felt the need to conduct this study.

6.2 REVIEW OF LITERATURE

The purpose of review of literature is to obtain comprehensive knowledge base and in depth information from previous studies.

Research and literature were organized under the following headings:-

A.  Studies related to knowledge of adolescent girls regarding postponement of menstruation.

B.  Studies related to contraceptives used for the postponement of menstruation.

A.  STUDIES RELATED TO KNOWLEDGE OF ADOLESCENT GIRLS REGARDING POSTPONEMENT OF MENSTRUATION

A self-administered email survey was conducted on Characteristics of scheduled bleedingmanipulationwith combined hormonal contraception in university students. Lack of information concerning the decision factors and sources of information influencing women who purposefully deviate from the prescribed use of their combined hormone contraceptives to exert elective control of their scheduled bleeding. The result was found that 1719 respondents to the survey, 1374 (79.9%) reported using combined hormonal contraception. Approximately 17% of these women altered their scheduled bleeding pattern by deviating from package instructions. Of these, 50% indicated they delayed or skipped their scheduled bleeding for convenience or personal choice. Within this group, 47% of women indicated they learned to modify their scheduled bleeding from health care professionals, while 30% indicated such knowledge was obtained from family or friends. The study concluded that, majority of University females who choose to modify their scheduled bleeding cycle with combined hormonal Contraceptives do so for convenience rather than to avoidmenstrualsymptoms, and many learn from nonmedical sources15.

A randomized control trial study was conducted to assess the published evidence on the effectiveness, side effects, and risks of using long term oral contraceptives for menstrual suppression. Ten papers were located, two were randomized trials comparing long term oral contraceptives to standard oral contraceptives, and the remaining studies were single-group observational studies. The published literatures had not conducted studies on the effects of long term oral contraceptive use on breast tissue, breast density, endometrial safety, or adolescent maturation and reproductive development. Study concluded that scientific evidence for safety of long term oral contraceptive use is presently lacking10.

A study was conducted on Cultural and social practices regarding menstruation among adolescent girls that the study attempts to find out the existing social and cultural practices regardingmenstruation, awareness levels, and the behavioural changes that come about inadolescentgirls duringmenstruation, their perception about menarche, how do they treat it, and the various taboos, norms, and cultural practices associated with menarche. The study was conducted on 117adolescentgirls (age 11-20 years). The findings unfolds many practices: cultural and social restrictions associated withmenstruation, myth, and misconception; the adaptability of theadolescentgirls toward it; their reaction, reaction of the family; realization of the importance ofmenstruation; and the changes that have come in their life after menarche and their resistance to such changes. The study concludes that cultural and social practices regardingmenstruationdepend on girls' education, attitude, family environment, culture, and belief16.

A study to describe women's knowledge regarding menstrual suppression. Study group consisted of 1470 women. Participants responded to questionnaire. Results found that 78% of the women had never heard of menstrual suppression with oral contraceptives. 59% of women interested in not menstruating every month and one third would choose never to have a period. Study concluded that more research should be conducted on the long-term health effects, side effects, and future fertility of using oral contraceptives19.

B.  STUDIES RELATED TO CONTRACEPTIVES USED FOR THE POSTPONEMENT OF MENSTRUATION.

A study was conducted on Postponementof menstruation in women using low-dose combined oralcontraceptives. Postponementof menses is widely practised by women using oralcontraceptives. One-hundred volunteers, consisting of three groups of women, each group using a different extensively used contraceptive regimen, were tested and compared. The test period consisted mainly of a double (monophasics) or extended (triphasics) pill cycle without a tablet-free interval. Based on daily records of vaginal bleedings as well as on the results of a questionnaire, the study concluded thatpostponementof the menstruation for twenty extra days was generally effective; the occurrence of the bleedings was related to the duration ofpostponementof menses and to thecontraceptiveregimen that was used. However, the introduction of a seven-week cycle pill is not yet a promising alternative since the majority of the volunteers preferred the inconvenience of a monthly menstrual bleeding12.

A study was conducted on Long-cycle treatment with oral contraceptives. The conventional regimen of oral contraceptive (OC) use mimics the natural cycles by causing regular withdrawal bleeding, which can be avoided by omission of the hormone-free interval of 7 days. Consequently, long-cycle regimens with continuous administration of OCs for 3 or 6 months followed by a hormone-free interval of 7 days may reduce the frequency of menstruations and cycle-dependent complaints. Study concluded that, many physicians tend to prescribe extended OC cycles for postponementofmenstruationor reduction of frequency of regular bleeding. This review summarises and examines the available data on OC long-cycle regimens. The data suggest that the rate of treatment-related sideeffectswith OCs according to the long-cycle regimen is similar to that of conventional OC regimens14.

A study was conducted on Menstrual-cycle-related symptoms: a review of the rationale for continuous use of oral contraceptives. Study reveals that 80% of reproductive-aged women experience physical changes associated with menstruation, and 20% to 40% experience menstrual-cycle-related symptoms. Decades of research in women with menstrual disorders, such as dysmenorrhoea and menorrhagia, have shown that continuous use of oral contraceptives (OCs), without the hormone-free interval, is a safe and effective method to relieve these symptoms and ultimately induce amenorrhea in many women. Study concluded that a majority of women would opt for extended-cycle or continuous regimens, and numerous clinical trials have shown that continuous OC regimens induce amenorrhea in 80% to 100% of women by 10 to 12 months of use11.

A study was conducted on Postponementof menstruation with a monophasic oralcontraceptivecontaining desogestrel and ethinylestradiol to postpone menstruation in normal healthy women. In the analyzed group of 105 regular users about 75% did not experience any vaginal bleeding during the 21 days ofpostponement. A 95% confidence interval was calculated which suggests that the percentage of women able to postpone their menstruation successfully for 19 days ranges between 67.0% and 83.5%. Women with no vaginal blood loss in thepostponementperiod were more willing to try this method ofpostponementagain, compared to women who experienced vaginal blood loss in thepostponementperiod. The study concluded that the difference was statistically significant and the majority of women with vaginal blood loss were also willing to try this method. The effective and acceptable method of postponing menstruation for three weeks for most regular users of thiscontraceptive13.