Written by Mr M. Imran Zia BSc MBBS MRCS FRCEM PgDip (Med Ed)
Consultant in Emergency Medicine
Whipps Cross Hospital, Barts Health, London
Rather than giving a didactic lengthy narrative these articles will instead focus on the common medical themes leading up to, and then during the days of Hajj themselves. Hajj spans from the 8th to the 12/13th Days of the Islamic month of Dhul Hijjah.
This is the third of a series of articles being written in the spirit of helping prospective Hajj Pilgrims avoiding commonly seen medical mishaps based upon the authors 11 years experience accompanying pilgrims to Saudi Arabia for the Hajj.
Menstrual Issues: Getting it right for the Hajj
The physical journey of the Hajj involves much walking and exertion. It is both physically and mentally draining. In such situations, menstrual irregularities are common, in that bleeding may occur sooner or later than expected. As a requirement to fulfil religious obligations, for certain periods of the pilgrimage rites, a woman is required to be in the physical state, free of her menstrual bleeding. This invariably leads to a heightened levels of stress and common errors in judgment often result in females sharing hormonal tablets with each other or practicing multipharmcy in the hope that taking multiple tablets will help. These problems can often be overcome with foreword planning and taking some sensible precautionary measures.
The following is thus being written in the spirit of food for thought to help alleviate some of this stress. However it should not be taken as a substitute for a personal one to one medical consultation, which is what is required.
The control of menses usually requires the taking of hormonal medication, which fall into two main categories. The contraceptive hormonal pill and the non-contraceptive hormonal pill. The type to be used is best determined by the patients family doctor as factors such as age, smoking, thrombus risk, cancer history and contraception need, plus others need to be considered. If you elect to see your GP to address this issue, please emphasise that the aim of any prescribed medication is to stop menstrual bleeding completely. (Top Tip)
I will discuss the three most commonly used options.
This is the once a day contraceptive pill which in most cases involves taking one tablet at the same time for 21 consecutive day, followed by a seven day break during which menstrual bleeding may occur. To prevent menstrual bleeding, the packs need to be taken back to back with no breaks. Care needs to be taken to ensure that the tablets are taken at the same time each day. This contraceptive, when taken regularly at the prescribed time, works well. My advice is to set your alarm to ensure regularity in timings is maintained. (Top Tip)
This is the progestogen only pill and it is used for women over the age of 35, smoking, those who are obese or have a history of bloods clots. This is often referred to as the ‘mini pill’, of which there are a number of different brands. These tablets are also effective contraceptives but often many tablets in this group will not completely stop menstrual bleeding. For regular users of the mini pill roughly 40% will have no bleeding, 40 % will have something like a monthly period and 20% will have bleeding to some extent within their monthly cycle. So as you can see, this option does carry a failure rate, which is undesirable in the days of Hajj.
This is the most common and involves the use of a progesterone only tablet (similar to option 2 in that is contains the same type of hormone), but it is not a contraceptive. This tablet contains an active drug, which has a short half-life, which means in essence its effects will wear off quickly. For this reason, to be most effective it should to be taken 3 times a day, ideally spread 8 hours apart. Taking it at breakfast, lunch and with the evening meal will not be sufficient as the pilgrim’s meal times will be erratic during the days of the Hajj. Unfortunately many practitioners fail to appreciate the importance of emphasising this. For it to have the best chance of success it should be started a few days before the anticipated due on date, be taken strictly eight hours apart, and be continued until the need to be free of menstrual bleeding is no longer necessary. Once it is stopped menstrual bleeding is likely to occur soon after. For this reason I would suggest these tablets be taken at 6am (after morning prayers), at 2pm and then again at 10pm. Is it best to set an alarm as a reminder. (Top tip)
Now with the above said, there is still a failure rate with all three methods, thus in such cases medical help should be sought. Options the medical practitioner could consider may include, doubling the dose or adding in further tablets that could help stem menstrual bleeding. The medical practitioner themselves should take time to thoroughly understand what has happened, ask about the mixing of medications and then take a carefully considered response. The practitioner should also be happy to refer to someone else, if women’s menstrual issues are not something they deal with regularly. For the patient, in the event of medication failure, seek help sooner rather than later and do not seek out unqualified guidance because you feel the topic is one of an embarrassing nature.
Finally with the above said, this matter and all its associated stress can often be dealt with by using careful foreword planning and through the early involvement of your medical practitioner.
In summary, understand your choice of medication, ensure your doctor understands your issue wholly, set an alarm to ensure regularity in timings and seek medical help if things are not working as expected.
About the Author
Mr Imran Zia is a Consultant in Emergency Medicine at the Whipps Cross Hospital, Barts Health, London.
He has travelled accompanying pilgrims as a medical advisor and tour group doctor to the Hajj for the last 11 years. Over this time he has gained a valuable insight into the common medical themes that affect pilgrims and how they can be addressed in a practical manner, at times where local medical help may not easily available. These short articles are being written with a ‘prevention is better than cure’ mind set. The numbers of years experience based upon exposure, dealing with illness in a congested foreign healthcare structure has placed him in the unique position to be able to share