Menstrual Suppression Using Oral Contraceptives by Female Hajj Pilgrims

The Hajj ceremony is the most important life event for any Muslim.1 For the majority of pilgrims, it is a long-desired journey that may happen only once in a lifetime. Annually, millions of Muslims from various countries gather in the holy cities of Mecca and Medina in the Kingdom of Saudi Arabia to perform their religious rituals.2-4 According to religious instructions, purity or cleanness is a condition for entering Masjed Al’Haram (the respected mosque) or other mosques. Women are not permitted to enter mosques or say their prayers while menstruating.2 To take the greatest advantage of their pilgrimage, many women of reproductive age try to prevent menstruation during the pilgrimage3 by taking oral hormonal medicines. The first case of taking medicine to postpone menstruation dates back to 1977.3 Today, this method is used to decrease the number of menstruation cycles. Similar utilization of hormonal medicines is common among Jewish females.4 Definitely, delaying menstruation by taking hormonal medicines intermittently and for short periods to remove http://ijtmgh.com Int J Travel Med Glob Health. 2016 Dec;4(4):111-114 doi 10.21859/ijtmgh-040405 TMGH IInternational Journal of Travel Medicine and Global Health J


Introduction
The Hajj ceremony is the most important life event for any Muslim. 1 For the majority of pilgrims, it is a long-desired journey that may happen only once in a lifetime.][4] According to religious instructions, purity or cleanness is a condition for entering Masjed Al'Haram (the respected mosque) or other mosques.Women are not permitted to enter mosques or say their prayers while menstruating. 2o take the greatest advantage of their pilgrimage, many women of reproductive age try to prevent menstruation during the pilgrimage 3 by taking oral hormonal medicines.The first case of taking medicine to postpone menstruation dates back to 1977. 3 Today, this method is used to decrease the number of menstruation cycles.Similar utilization of hormonal medicines is common among Jewish females. 4efinitely, delaying menstruation by taking hormonal medicines intermittently and for short periods to remove impediments to religion, is regarded as a special case and has its own side effects and problems. 5Usually, women who are willing to use this method of prevention have not taken these medicines before and are more likely to experience more side effects.The emotional effects of contraceptive pills can be worse than their physical effects. 6The inefficiency of these medicines in delaying menstruation appears mainly in the form of spotting during consumption and can endanger the main philosophy of consumption, to remove impediments to religion, and cause stress and other problems for the consumers.Some studies have investigated the consumption of these medicines, and spotting while on the medicine has been reported as a main complaint of pilgrims. 2,7Some women who use contraceptive pills during their pilgrimage experience side effects.The most important and most commonly occurring side effect of the contraceptive pill is spotting, which can lead to anxiety and depression.
Based on informal reports of menstrual disorders among pilgrims in Mecca, the current study aimed to determine the prevalence of menstrual disorders and related factors in Mufradah pilgrims in 2012.

Methods
This descriptive study considered 400 female Iranian pilgrims aged 15-50 years who did not have an intrauterine device (IUD).The participants were selected through random cluster sampling from Umrah caravans.The size of the population was determined to be 350 people based on similar studies, but for the sake of higher reliability 400 participants were studied.The exclusion criteria included women who were reluctant or unwilling to participate in the study.The instrument used in this study was a two-part questionnaire developed by the researchers and based on pilgrims' complaints and questionnaires from prior studies.The first section contained questions regarding personal characteristics, and the second section involved questions about methods of menstruation prevention, symptoms of menstrual disorders, spotting, and treatment precautions.The questionnaire included 3 openended questions about the side effects of the medicine, the emotional effects of the resultant disorder, and the impact the resultant disorder had on the performance of Umrah rituals.
The questionnaire consisted of 23 questions, 5 regarding demographic data, 15 regarding menstruation and medicine consumption for menstrual suppression, and 3 open-answer questions which addressed side effects and problems.
Content validity of the questionnaire was checked through the opinions of 3 gynecologists and 3 faculty members of the Rafsanjan University of Medical Sciences.The reliability of the questionnaire was 0.84.The questionnaire was distributed among the participants at their hotels 3 days before their return to Iran.Random cluster sampling was used to randomly select hotels and the Iranian caravans staying in them.Women from each caravan volunteered to distribute and collect the questionnaires.The collected data was inserted into SPSS version 18 software and analyzed using parametric and nonparametric tests such as the chi-square test.

Results
Four hundred female Umrah pilgrims participated in the study.The average age of the participants was 34.4 ± 1.33; 19.2 % of them were single, and 80.8 % were married.The results indicated that 53.2% were housewives, 44.7% had a bachelor's degree or higher, and 2% of them were illiterate.
Results indicated that 98.7% of participants reported taking birth control pills to suppress menstruation, and 74.7% of them reported successfully preventing it.The average number of pills used per day was 1.13 ± 0.45.The average start time for taking medicine before menstruation was 10.37 ± 9.7; 51.5% of participants received consulted regarding the pills, and 19.9% of them had no consultation at all before the pilgrimage.Consultation was received by 42.4% of participants one week, 14.7% two weeks, 6.8% three weeks, and 36.7% more than 21 days prior to departing for Hajj.The average time before departure for counseling was 22.23 ± 23.95 days (Table 1).
Despite taking medicine to postpone menstruation, 26% of the participants reported spotting.Spotting was more frequent in participants aged 25-45 years than participants under the age of 25 years or over 45 years.Statistically, the differences were significant at P = 0.03 (Table 2).The average start time for spotting was on the eleventh day of the menstrual cycle (11 ± 11.88).Also, 11.6% of the individuals taking medicine to postpone menstruation reported menstruation.To obviate spotting, 74.6% had referred to a doctor; of those individuals, 61.6% reported their spotting was obviated and 27.9% reported increasing the dose of the medicine to obviate this problem.
Among the participants, 41% of those who consumed medicine experienced at least one medicinal side effect, mostly sickness and vomiting.
There was no significant difference between menstruation delay and individuals' educational background; however, the rate of medicine consumption was higher among persons holding a college degree (Table 3).There was no significant difference at P ˃ 0.05 between menstruation delay and factors such as marital status and the dispatch city in Iran.There was a significant difference between the consumption of medicine and the age category; fewer participants over the age of 45 years took medicine than the others.
Qualitative analysis of the open-ended questions showed that spotting and menstruation were reported as stressful for participants in performing Umrah rituals.Some participants reported menstruation as causing feelings of their visit to the Ka'beh being rejected by God and expressed experiencing great stress and anxiety.

Discussion
Results of the current study indicated that 74.7% of the female pilgrims successfully prevented menstruation during their to the Ka'beh (God's house in Mecca), and most of them reported using contraceptive pills to prevent it.Currently, the long-term use of contraceptive pills to decrease the occurrence of menstruation has been of great interest to researchers and women of reproductive age.Large numbers of women from all over the world prefer to take contraceptive pills to prevent menstruation for many days. 5,8espite taking pills, 26% of the pilgrims participating in the current study experienced spotting and 11.6% menstruated.The average start time for spotting was on the eleventh day of the menstrual cycle.Spotting is a common side effect of contraceptive pills, even in the common 21-day method of using them. 9Most cases of spotting in this study can be attributed to the short interval between starting medication and spotting.Since contraceptive pills have a low amount of estrogen in them, a low dose of conjugated estrogen is easily used to alleviate the problem of spotting.Furthermore, with the low dose of conjugated estrogen, the user is not disposed to the side effects of the higher hormone dosage.
In a study by Sulak et al on 318 patients, they found that the pills decrease the symptoms of PMS in 13%, hypermenorrhea 19% and headache 35%. 10 Other studies which applied extended and continuous regimens for preventing menstruation reported a high and variable prevalence of spotting and bleeding; however, these unwanted side effects were eliminated after a few cycles.A high prevalence of side effects was reported in women who used contraceptive pills for the first time.
Ghorashi et al reported the occurrence rates of spotting and menstrual bleeding in Hajj pilgrims in 2000 as 13.6% and 2.1%, respectively. 11The low occurrence of these side effects in the study of Ghorashi et al compared with the results of the present study can be attributed to the high dose of the pills taken by participants.In the study of Ghorashi et al, about 20% of the individuals took HD pills from the beginning, and the others took two LD pills simultaneously.
In the present study, more than half of the individuals aged over 45 years had used hormonal medicines to postpone menstruation.An increase in the age of the user increased the side effects of the contraceptive pills. 8Moreover, most of the middle-aged women in this study suffered from diseases like diabetes or hypertension, both of which can endanger the consumption of contraceptive pills.Therefore, special training and care for postponing menstruation, such as the use of non-estrogenic pills, should be allocated to this group.
Statistically, there was no significant difference between the start time for taking pills and the occurrence of spotting.Therefore, those women who had a delayed start in taking pills during their menstrual cycle did not report the occurrence of spotting any more than those who started taking the pill on the fifth day of their menstrual cycle.Furthermore, Ghorashi et al found no significant difference between these two variables.It can be concluded that the delay in starting medicine consumption did not create additional problems for the users.This will be helpful for those who tend to decrease the consumption of the pill for different reasons.Therefore, decreasing the number of pills can help decrease their side effects. 7bout 20% of the participants in this study who had used menstruation postponement methods had received no counseling on the use of medicine before starting consumption.From those who reported receiving counseling, more than 60% reported receiving counseling a short time (three weeks or less) before the pilgrimage.It should be noted that unadvised use of contraceptive pills among those who are at a high risk can be dangerous or even deadly.Furthermore, the unadvised use of contraceptive pills can lead to inappropriate consumption, the possibility of increased side effects, and a lack of necessary instruction on how to cope with side effects such as spotting.Therefore, it is suggested that counseling be taken into account in justification classes.
It is recommended that justification classes be held duly and more than one month before the pilgrimage to allow women to make better decisions about how to postpone menstruation.
The most common side effect of taking contraceptive pills noted in this study was vomiting, which is a prevalent side effect of contraceptive pills. 12Because of the short period of consumption and the specificity of the occasion, it is essential to advise pilgrims on possible side effects of contraceptive pills and the necessity of having them during the pilgrimage. 13ince the Hajj pilgrimage is an important and sometimes exclusive event in the life of most pilgrims, the experience of menstrual disorders during pilgrimage can be stressful, disappointing, and problematic for them. 14To reduce such problems, holding counseling sessions on menstruation postponement as a part of the justification classes before departure for Hajj and compiling an equal and coordinated nationwide protocol seem necessary. 15

Conclusion
The side effects of taking contraceptive pills for menstrual suppression and their failures are considerable and cause pilgrims to feel much stress and inconvenience.It is suggested that this traditional approach be replaced with progestin-only pills, such as megestrol.

Table 1 .
Sample Frequency in Terms of Job, Educational Background, Prevention Method, Counseling and the Time of it

Table 2 .
Spotting Frequency by Age Group

Table 3 .
Comparison of Delay in Menstruation and Educational Background