Journal of Womens Health, Issues and Care ISSN: 2325-9795

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Research Article, J Womens Health Issues Care Vol: 7 Issue: 1

The Perceived Benefits and Barriers for Oral Contraceptive Use in Women Grouped for Physical-Activity

Fisher RN1*, McLellan CM1, Sinclair WH2 and Minahan C3

1Bond University Institute of Health and Sport, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia

2Sport and Exercise Science, College of Healthcare Sciences, James Cook University, Townsville, Australia

3Griffith Sports Physiology, Menzies Health Institute Queensland, Griffith University, Australia

*Corresponding Author : Fisher RN
Bond University Institute of Health and Sport, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
Tel: 400836073
E-mail: [email protected]

Received: November 06, 2017 Accepted: January 07, 2018 Published: January 12, 2018

Citation: Fisher RN, McLellan CM, Sinclair WH, Minahan C (2018) The Perceived Benefits and Barriers for Oral Contraceptive Use in Women Grouped for Physical-Activity Level - An Exploratory Study. J Womens Health, Issues Care 7:1. doi: 10.4172/2325-9795.1000299

Abstract

Introduction: The prevalence rate of oral contraceptives (OC) use in women varies greatly among women, potentially due to demographics including age, income and education. Little is currently known regarding the influence of physical-activity level on OC use and if the perceived benefits and barriers of OC use is affected by exercise levels.
Methods: Participants (n=125) were recruited via email and social media and grouped for weekly physical activity levels. Participants were distributed in to untrained women (UT; n=26), recreationally active (REC; n=44) and trained women (TR; n=55). Online survey software was used to inquiry about the OC practices and physicalactivity levels of Australian women. The survey included rankedresponse question regarding the perceived benefits and barriers of OC use, with the option of open ended response to provide explanation.
Results: The prevalence rates of OC use were 31%, 39%, and 47% for the UT, REC, and TR groups, respectively. Despite an apparent mean increase in prevalence with physical-activity level, there were no significant differences among the three groups (p>0.05). All women, regardless of physical-activity level reported birth control, cycle regularity and a reduction in menstrual symptoms as perceived benefits of taking OC. The perceived reasons for not taking OC were somewhat more diverse between the groups and included the introduction of exogenous hormones, weight gain, utilising alternative methods of birth control and the commitment habitually to take the medication.
Discussion /Conclusion: Results of the present study suggest physical-activity levels do not appear to play a direct role in OC use in the cross-section of female participants and does not influence the prevalence of use.

Keywords: Oral contraceptives; Physical activity; Dysmenorrhea; Sex hormones

Introduction

Oral contraceptives (OC) are one form of hormonal contraception that includes the administration of pills that vary in their preparation of synthetic sex-hormones estradiol and progestin. An accurate prevalence rate of OC use is difficult to ascertain given the variability in research findings, as an example, 25-76% of Australian women reported using OC between 2001 and 2011 [1-3]. This large variance in the prevalence rate of OC use might be due to the spectrums in participant demographics and in particular age, income, and education [2-4]. Of particular interest, the OC practices of female athletes have been reported as being less prevalent when compared to the general population [1], although the prevalence of OC use in Australian female athletes was reported to be similar when compared to the general population [2,3].

The perceived benefits and barriers for OC use in the general female population have been explored in previous survey-based studies [5-7] suggesting that cycle regularity, a reduction in dysmenorrhea, and acne relief were the most commonly perceived beneficial reasons for OC use, aside from birth control. In contrast, potential weight gain and mood changes were commonly reported as the main barriers associated specifically with OC use [8]. Few research studies however, have investigated the perceived benefits and barriers of OC use in physically active populations, despite a known association between synthetic hormone administration and decrements in peak aerobic power [9-12] and a reduced ability to recover from eccentric exercise [13,14]. These factors may constitute credible barriers for active women to avoid OC use whereas they may be regarded as less important in less active women, and warrant further investigation.

Therefore, the purpose of the current study was to explore the ‘perceived benefits and barriers’ for OC use and the role physicalactivity levels may play on OC use in physically active women. It was hypothesized that the prevalence of OC use would be high in physically-active women compared to sedentary women, to allow for cycle regulation or manipulation, despite the potential adverse effects on aerobic power. Furthermore, we envisaged that the noncontraceptive motives for OC use within less physically-active women may be tailored towards attenuating symptoms associated with dysmenorrhea, treating acne, and cycle regulation.

Methods

Participants

Participants (n=125) were recruited via email and social media with the criteria for inclusion into their respective group based upon and Exercise and Sport Science Australia (ESSA) physical-activity intensity guidelines [15] regarding recommended frequency, duration and intensity of physical-activity. For recruitment, participants were drawn from targeted populations which included active, multisport athletes and University students in the immediate area (Gold Coast, Australia) and their respective social media networks. As a result, participants were distributed in to untrained women (UT; n = 26; 32.2 ± 7.3 yr; i.e. <2 sessions/wk of low intensity exercise or <2 METs/session), recreationally active (REC; n = 44; 30.6 ± 6.8 yr; i.e. 3-4 sessions/wk of moderate intensity exercise or 3-6 METs/session) and trained women (TR; n=55; 27.0 ± 8.3 yr; i.e. 5+ sessions/week of vigorous intensity or >6 METs). Demographical information about participants is shown in Table 1.

Procedures

A survey was created using an online, web-based survey creator (SurveyMonkey Inc., USA) and distributed to the athletic and general population cohorts via email and social media for 3 months; of the individuals who engaged in the survey by answering at least one question, 84% of surveys were completed in their entirety and accepted in to the present study. The survey comprised twenty-five questions and aimed to identify why participants use, or do not use, OC. Initial physical-activity background was established for all groups via participants providing details of the type of physicalactivity they undertake (per week) in an open-ended response, as well as the frequency, and intensity of these sessions.

For women using OC, the survey inquired about the duration of use and form of OC currently being used. Participants were also asked to rank the reasons for using OC from a list of seven responses and to only rank the reasons relevant to them. If participants indicated there were other reasons not included in the list, they were asked to clarify their reason in an open-ended response. In a subsequent open-ended question, participants were also asked if they have any concerns in regards to taking OC. If participants indicated they were not currently using oral contraceptives (i.e., considered “normallymenstruating” but not necessarily regular), they were asked to rank their reasons for avoiding OC. Participants were provided with nine potential deterrents and were again instructed to only rank the reasons relevant to them. If participants indicated that there were other reasons not included on the list, they were asked to clarify their reason in an open-ended response.

Informed consent was attained from all participants prior to participating via the introductory page of the online survey and as approved by the Bond University Human Research Ethics Committee. All participants remained anonymous unless they wished to participate in follow-up research, in which case they were asked to provide their name and contact details.

Statistical analysis

Chi-Square (χ2) Test for relatedness was conducted to identify commonly perceived benefits and barriers for OC use or non-use within the three defined physical-activity groups (UT, REC, TR). Variables showing a Pearson’s chi-square (2-sided) of p<0.05 were re-tested with adjusted standardised residuals (z-scores). In the instance of a z-score of > 1.96, a p-value was calculated using the standardised residual method post-hoc technique, as described by Beasley 1995 and Garcia-Perez 2003 [16,17]. An adjusted Bonferroni was used to maintain an accurate family-wise alpha rate by dividing the alpha level (α = 0.05) by the number of comparisons made. Our determined αadj was p = < 0.0016. Results are presented as frequencies (percentages), Chi-square and p-values. Data analysis was conducted using statistical software package (IBM SPSS Statistics Version 21).

Results

The prevalence rates of OC use were 31%, 39%, and 47% for the UT, REC, and TR groups, respectively (Table 1). Despite an apparent mean increase in prevalence with physical-activity level, there were no significant differences among the three groups (p >0.05).

Subject characteristics / Group UT (n=26) REC (n=44) TR  (n=55)
Age (years) 32.2 ± 7.3 30.6 ± 6.8 27.1 ± 8.3
Employment statusa
Full time 15 28 21
Part time / Casual 3 9 21
Student 4 7 20
Mother / Homemaker 3 3 0
Not stated 1 0 3
Currently using oral contraception      
Yes 8 (31%) 17 (39%) 26 (47%)
No 18 (69%) 27 (61%) 29 (52%)
Duration of use      
< 1 year 0 2 (12%) 1 (4%)
1 – 3  years 1 (13%) 4 (23%) 7 (27%)
4 - 8 years 3 (37%) 2 (12%) 5 (19%)
8 – 15 years 3 (37%) 5 (30%) 10 (38%)
> 15 years 1 (13%) 4 (23%) 3 (12%)
Type of oral contraceptive      
Monophasic 2 (25%) 7 (41%) 9 (35%)
Biphasic 0 3 (18%) 5 (19%)
Triphasic 4 (50%) 5 (29%) 6 (23%)
Progesterone only (i.e., mini pill) 2 (25%) 2 (12%) 6 (23%)
Type of activitya      
Walking 17 (65%) 15 (34%) 6 (11%)
Jogging / running 1 (2%) 18 (41%) 24 (44%)
Cycling 2 (7%) 4 (9%) 3 (5%)
Swimming / Surf-Based Sports / Rowing 4 (15%) 14 (32%) 28 (33%)
Organised sport (tennis, soccer, hockey & netball) 2 (7%) 5 (11%) 9 (16%)
Group classes / Resistance training 3 (12%) 24 (55%) 33 (60%)
Playing with children / walking pets 1 (2%) 2 (5%) 0
Housework / Gardening 1 (2%) 0 0
None 1 (2%) 0 0

Table 1: Subject characteristics including the prevalence of oral contraceptive use in untrained (UT), recreationally active (REC) and trained (TR) women.

For all groups, preventing unwanted pregnancies (90%), cycle control (86%) and reducing menstrual symptoms (88%) were the major reasons for using OC. Additionally, a decreased risk of anaemia or bone mineral density were reported as a benefit of using OC in the UT group (50%) and a reduction in acne in the REC (52%) and TR group (54%) (Table 2).

Benefit UT   REC   TR  
  Frequency Chi-square (c2) p-value Effect Size (w) Frequency Chi-square (c2) p-value Effect Size (w) Frequency Chi-square (c2) p-value Effect Size (w)
Birth Control 7 (87%) 1.37 0.242 0.16 15 (82%) 0.21 0.646 0.06 24 (92%) 1.96 0.162 0.20
Cycle Control 8 (100%) 0.28 0.596 0.07 12 (70%) 1.88 0.171 0.19 24 (92%) 3.06 0.080 0.24
Reduce Menstrual Symptoms 5(62%) 1.25 0.260 0.16 10 (58%) 0.94 0.330 0.14 20 (77%) 3.42 0.060 0.26
Relief from PCOS 3(37%) 0.34 0.562 0.08 7 (41%) 0.03 0.973 0.02 9 (35%) 0.10 0.749 0.04
Reduce Acne 3 (37%) 1.72 0.190 0.18 9 (52%) 0.00 0.940 0.00 14 (54%) 1.30 0.250 0.16
Reduce Anaemia / BMD Loss 4 (50%) 0.03 0.870 0.02 6 (35%) 0.03 0.860 0.02 8 (31%) 0.00 0.970 0.00

Table 2: Perceived benefits of using oral contraception in untrained (UT), recreationally active (REC) and trained (TR) Australian women (n = 51).

In the UT group, the predominant reason for not using OC were using other forms of birth control (55%) and lacked the commitment to take the pill each day (61%; Table 3). Trained women reported using other forms of contraception (51%) and the presence of synthetic hormones (51%) as reasons for avoiding OC. Side effects associated with OC use (66%) and a desire to fall pregnant (66%) were the predominant reasons contributing to the avoidance of OC in the REC group (Table 3).

Barrier UT   REC   TR  
  Frequency Chi-square (c2) p-value Effect Size (w) Frequency Chi-square (c2) p-value Effect Size (w) Frequency Chi-square (c2) p-value Effect Size (w)
Using other Contraception 10 (55%) 0.48 0.490 0.08 16 (59%) 0.40 0.529 0.07 15 (51%) 1.37 0.242 0.14
Side Effects 9 (50%) 0.10 0.749 0.04 18 (66%) 2.46 0.116 0.18 13 (44%) 3.17 0.075 0.21
Medical Condition 6 (33%) 0.11 0.741 0.04 15 (55%) 2.56 0.110 0.19 11 (37%) 1.61 0.204 0.15
DVT/Blood Clot 1 (16%) 0.09 0.764 0.03 3 (20%) 0.64 0.423 0.09 2 (18%) 0.25 0.617 0.06
Hypertension 2 (33%) 1.21 0.027 0.13 1 (6%) 0.49 0.482 0.08 2 (18%) 0.04 0.841 0.02
CVD 0 0 0 0.00 1 (6%) 1.96 0.161 0.16 0 0.81 0.376 0.10
Medical Concerns 7 (38%) 0.03 0.865 0.02 16 (59%) 4.12 0.042 0.24 9 (31%) 4.41 0.036 0.24
Desire to Conceive 6 (27%) 0.40 0.529 0.07 18 (66%) 5.62 0.018 0.28 11 (37%) 3.13 0.077 0.21
Commitment to take 11 (61%) 1.12 0.290 0.12 17 (62%) 0.77 0.380 0.10 14 (48%) 2.92 0.090 0.20
Synthetic Hormones 8 (44%) 0.00 0.960 0.00 15 (55%) 0.44 0.510 0.08 15 (51%) 0.45 0.500 0.08
Reduced Exercise Performance 4 (22%) 0.58 0.450 0.09 13 (44%) 3.17 0.080 0.21 9 (31%) 1.17 0.280 0.13

Table 3: Perceived barriers towards oral contraceptive use in untrained (UT), recreationally active (REC) and trained (TR) Australian participants (n = 74).

A reduction in menstrual symptoms were consistently reported across all women taking OC (n=51) as a benefit of taking the pill (Table 4). Whilst the perceived side effects and medical conditions associated with OC were reported as the primary barriers for OC use (n = 74; Table 5).

Menstrual Symptom UT   REC   TR  
  Frequency Chi-square (c2) p-value Effect Size (w) Frequency Chi-square (c2) p-value Effect Size (w) Frequency Chi-square (c2) p-value Effect Size (w)
Heavy Period 3 (60%) 0.14 0.704 0.06 6 (60%) 1.12 0.258 0.18 3 (15%) 1.93 0.165 0.23
Painful Period 3 (60%) 0.83 0.360 0.15 7 (70%) 0.14 0.710 0.06 12 (60%) 1.21 0.270 0.19
Bloating 1 (20%) 0.77 0.379 0.15 5 (50%) 1.04 0.308 0.17 4 (20%) 0.07 0.787 0.04
Breast Tenderness 2 (40%) 0.09 0.764 0.05 2 (20%) 0.38 0.535 0.10 4 (20%) 0.12 0.726 0.06
Mood Disturbance 2 (40%) 0.05 0.830 0.04 3 (30%) 5.76 0.020 0.41 6 (30%) 0.55 0.460 0.13

Table 4: Commonly experienced menstrual symptoms as identified in untrained (UT), recreationally active (REC) and trained (TR) women leading to OC use (n = 35).

Side Effect   UT       REC       TR    
  Frequency Chi-square (c2) p-value Effect Size (w) Frequency Chi-square (c2) p-value Effect Size (w) Frequency Chi-square (c2) p-value Effect Size (w)
Weight gain 9 (100%) 2.4 0.121 0.24 12 (66%) 0.64 0.424 0.13 8 (61%) 4.12 0.042 0.32
Increased appetite 1 (11%) 0.36 0.549 0.09 3 (16%) 0.02 0.889 0.02 4 (30%) 0.12 0.726 0.05
Increased acne 2 (22%) 3.92 0.048 0.31 1 (5%) 0.00 0.944 0.00 0 0 0 0.00
Nausea 2 (22%) 1.17 0.280 0.17 2 (11%) 0.05 0.818 0.04 1 (7%) 1.21 0.271 0.17
Headache 3 (33%) 0.92 0.337 0.15 5 (27%) 1.77 0.184 0.21 1 (7%) 4.24 0.039 0.33
Mood Changes 6 (66%) 0.67 0.412 0.13 7 (38%) 0.14 0.711 0.06 9 (69%) 0.10 0.749 0.05
Reduced Libido 2 (22%) 0.64 0.424 0.13 9 (50%) 4.58 0.032 0.34 4 (30%) 2.07 0.150 0.23

Table 5: Common side effects and medical conditions of oral contraception in untrained (UT), recreationally active (REC) and trained (TR) women (n = 40) contributing to non-OC use.

Discussion

Weekly physical-activity levels do not appear to influence the prevalence of OC use in those women that participated in the present study, although perceptions did distribute differently among the groups. All women regardless of physical-activity level reported reducing menstrual symptoms, controlling menstrual cycle and birth control as the main reasons for taking OC. However, the predominant reasons for women to not use OC varied between groups with UTwomen reporting the commitment to take the pill every day as the main barrier, while REC women reported the associated negative side effects of OC and the desire to conceive as reasons for not taking the pill. Trained women reported using other methods of contraception and the presence of synthetic hormones as barriers to using OC.

In-line with the findings of the present study, a previous investigation [7] into the perceived benefits and barriers of OC use in general population women identified cycle regularity, a reduction in dysmenorrhea (menstrual disturbances) and acne relief as the most known non-contraceptive benefits of taking OC. Both REC and TR women reported a reduction in acne vulgaris as a reason contributing to OC use in the present study. Additionally, 60% of UT and REC women reported experiencing heavy periods (menorrhagia); characterized as a menstrual blood loss of >80 mL per cycle [18] and is the most frequent cause of iron-deficiency anaemia in women of reproductive age [19]. Interestingly, only 15% of TR women reported experiencing menorrhagia, suggesting a potential association between physical-activity levels and less menstrual blood loss. However, it was the UT women who considered a reduced risk of anaemia and bone mineral density (BMD) as more important benefits of OC use. It is possible that frequent menorrhagia may have contributed to the higher amount of UT women reporting a decreased risk of anaemia or reduced BMD (50%) as an important benefit of OC use, particularly if they are not engaged in adequate weight-bearing exercise regimes to maintain bone health. Collectively, these findings suggest physicalactivity levels may indirectly contribute to a woman’s decision whether or not to engage in OC use.

Painful periods were a major side effect of the menstrual cycle and contributed to OC use in 60% of TR women. It is possible the presence of dysmenorrhea (or severe menstrual pain) may interfere with physical activity and therefore more active women may wish to minimise this discomfort. Additionally, other side effects of the menstrual cycle including bloating, breast tenderness and mood disturbances were also reported to contribute to OC use in all women. Interestingly, the commitment to take OC each day was considered a common barrier in UT women (61%) and REC women (62%) compared with TR women (48%). This could reflect a greater amount of discipline in TR women due to strict physical activity and often dietary habits.

Side effects of OC were one of two predominantly reported barriers for use in REC (66%), and often reported by UT (50%) and TR (44%) participants. As found in previous investigations [8,20], weight gain and mood changes associated with OC were considered major barriers for OC use which parallel those findings from the present study where weight gain was reported as the leading side effect experienced in UT (100%) and REC (66%) women. Mood change was perceived as the most commonly experienced side effect in the TR (69%) women. These findings are in agreeance but surpass previous research which identified weight gain in 17% of medical students who were OC users and could therefore provide rationale for pill discontinuation [21]. It is possible however, that REC and TR women may experience fewer changes in weight due to their dietary and exercise regimes, whereas UT women may be less inclined to adhere to a restricted dietary intake and exercise programs. Therefore, this higher prevalence of perceived weight gain reportedly experienced by all UT women may be due to behavioural differences rather than solely an influence of OC use. This is further substantiated by a Cochrane review [22], which was unable to conclude OC use had a direct effect on weight, suggesting instead that behaviour could be a contributing factor. Collectively therefore, it is possible that TR women consider mood changes associated with OC to be a more important barrier for use than weight gain, as any changes to cognitive thinking and arousal may negatively affect exercise performance or the desire to be physically-active regularly.

The major reasons for not taking OC in TR women were the presence of synthetic hormones (51%) as well as utilising other methods of birth control (51%), with similar rates observed in UT and REC women. It is possible that women may wish to avoid ingesting unnatural substances or may have concerns about how these exogenous hormones will affect health and exercise performance. However only 31% of TR women reported a reduction in exercise performance as a barrier for OC use, which may reflect an unfamiliarity of the association between OC and reduced peak aerobic power [9-12] and ability to recover from eccentric exercise [13,14]. Medical conditions and concerns were considered a barrier of OC use in over half of REC women, but appear less concerning in UT and TR women, despite hypertension and deep vein thrombosis/blood clotting (DVT) reportedly perceived as a barrier of OC use across all three sample groups. Additionally, it is possible that the REC women in the present study reflect a wider range of women than TR or UT women, and therefore REC women may have a higher prevalence of medical conditions or concerns in relation to taking OC because of larger sample representation. Recreationally active women also reported a greater desire to fall pregnant (66%) far exceeding both the UT (27%) and TR (37%) groups. This greater desire to become pregnant in REC women may be a further reflection of a broader representation of women within the REC sample, compared with the UT and TR women. It is also possible that TR women may be preparing for upcoming competitions or events and therefore may be less inclined to start a family until after they have achieved any potential athletic goals.

Results of the present study suggest physical-activity levels do not appear to play a direct role in OC use in the cross-section of female participants and does not influence the prevalence of use. All women, regardless of physical-activity level reported birth control, cycle regularity and a reduction in menstrual symptoms as perceived benefits of taking OC while less active women also considered a reduction in anaemia a key benefit for OC use. The perceived reasons for not taking OC were somewhat more diverse between the groups and included the introduction of exogenous hormones, weight gain, utilising alternative methods of birth control and the commitment habitually to take the medication. Additionally, the reported side effects of OC use and a desire to become pregnant prevented recreationally active women from using OC. It is possible a lack of education and awareness about the influence of OC on health and performance may have contributed to the findings of the present study, and women may benefit from an improved understanding of the effect of synthetic estradiol and progestin on physiology.

Practical Applications

• Physical-activity level does not appear to play a role in OC use in Australian women.

• Birth control, cycle control and reducing symptoms associated with the menstrual cycle were perceived benefits of taking oral contraceptives in all women regardless of physicalactivity levels.

• Oral contraceptives appear to be commonly used by untrained women to reduce the risk of anaemia or reductions in bone mineral density.

• The most commonly experienced side effects associated with taking oral contraceptives were weight gain and mood changes.

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