Menstrual health and hygiene amongst adolescent girls and women of reproductive age: a study of practices and predictors, Odisha, India

BACKGROUND

Menstruation is a major physiological change in a woman's life, but lack of knowledge, poor practices, socio-cultural barriers, poor access to products and their improper disposal have significant consequences on health, dignity and well-being of women and adolescent girls.

OBJECTIVES

This study aimed to assess the knowledge and practices related to menstrual health and hygiene amongst females of 10-49 years of age; explore the experiences and challenges of women during menstruation; and identify the key predictors of healthy menstrual health and hygiene.

METHODS

Using a cross-sectional study design, we adopted a mixed methods approach for data collection. For quantitative household survey, a total of 921 respondents were selected from three districts of Odisha. Qualitative findings through focus group discussions and in-depth interviews supplemented the survey findings and helped to identify the barriers affecting good menstrual practices. Epi data version 2.5 and R 4.2.2 was used for data entry and data analysis, respectively. Descriptive statistics was used to calculate proportion, mean and standard deviation; Chi square test was used to measure the association between categorical variables. Bivariate and multivariate logistics analyses were done to identify predictors of healthy menstrual health and hygiene. For qualitative data analysis, thematic analysis approach was adopted using software Atlas.ti 8.

RESULTS

For 74.3% respondents, mothers were the primary source of information; about 61% respondents were using sanitary pad. The mean age at menarche was 12.9 years and almost 46% of respondents did not receive any information about menstruation before menarche. Lower age and education up to higher secondary level or above had statistically significant associations with the knowledge about menstruation. Age, caste, respondent's education, mother's education, sanitation facility, availability of water, accessibility and affordability for sanitary pads were found to be strongly associated with good menstrual hygiene practices.

CONCLUSION

Traditional beliefs regarding menstruation still persists at the community level. Educating mothers, increasing awareness about safe menstrual hygiene, providing adequate water and sanitation facilities and ensuring proper disposal of menstruation products need priority attention.

COVID-19 and abnormal uterine bleeding: potential associations and mechanisms

The impact of COVID-19 on menstruation has received a high level of public and media interest. Despite this, uncertainty exists about the advice that women and people who menstruate should receive in relation to the expected impact of SARS-CoV-2 infection, long COVID or COVID-19 vaccination on menstruation. Furthermore, the mechanisms leading to these reported menstrual changes are poorly understood. This review evaluates the published literature on COVID-19 and its impact on menstrual bleeding, discussing the strengths and limitations of these studies. We present evidence consistent with SARS-CoV-2 infection and long COVID having an association with changes in menstrual bleeding parameters and that the impact of COVID vaccination on menstruation appears less significant. An overview of menstrual physiology and known causes of abnormal uterine bleeding (AUB) is provided before discussing potential mechanisms which may underpin the menstrual disturbance reported with COVID-19, highlighting areas for future scientific study. Finally, consideration is given to the effect that menstruation may have on COVID-19, including the impact of the ovarian sex hormones on acute COVID-19 severity and susceptibility and reported variation in long COVID symptoms across the menstrual cycle. Understanding the current evidence and addressing gaps in our knowledge in this area are essential to inform public health policy, direct the treatment of menstrual disturbance and facilitate development of new therapies, which may reduce the severity of COVID-19 and improve quality of life for those experiencing long COVID.

What do we know about why women bleed and what do we not know?

Women or people with a uterus are vulnerable to both normal and abnormal bleeding. During the reproductive years, the uterus is prepared physiologically to accept an embryo and support its growth and development during pregnancy, or in the absence of implantation of an embryo, recycle through the process of menstruation and accept an embryo a month or so later. If fertilization takes place and an embryo or embryos implant in the uterus, the fetal trophoblast, or outer cell layer of the embryo, invades and dilates the maternal spiral arteries and forms the placenta. No matter when in gestation a pregnancy ends, at the conclusion of pregnancy, the placenta should separate from the wall of the uterus and be expelled. Abnormal bleeding occurs during pregnancy or after delivery when the normal uteroplacental interface has not been established or is interrupted; during miscarriage; during ectopic pregnancy; during premature separation of the placenta; or during postpartum hemorrhage. Heavy menstrual bleeding, a subset of abnormal menstrual bleeding, can be quantitatively defined as >80 mL of blood loss per cycle. Unlike postpartum hemorrhage, heavy menstrual bleeding is significantly associated with an underlying bleeding disorder. While there is other reproductive tract bleeding in women, notably bleeding at the time of ovulation or with a life-threatening ruptured ectopic pregnancy, the unique bleeding that women experience is predominantly uterine in origin. Many of the unique aspects of uterine hemostasis, however, remain unknown.

A mixed-methods study measuring the effectiveness of a menstrual health intervention on menstrual health knowledge, perceptions and practices among young women in Zimbabwe

OBJECTIVES

While integral to women's physical and mental well-being, achieving good menstrual health (MH) remains a challenge for many women. This study investigated the effectiveness of a comprehensive MH intervention on menstrual knowledge, perceptions and practices among women aged 16-24 years in Harare, Zimbabwe.

DESIGN

A mixed-methods prospective cohort study with pre-post evaluation of an MH intervention.

SETTING

Two intervention clusters in Harare, Zimbabwe.

PARTICIPANTS

Overall, 303 female participants were recruited, of whom 189 (62.4%) were seen at midline (median follow-up 7.0; IQR 5.8-7.7 months) and 184 (60.7%) were seen at endline (median follow-up 12.4; IQR 11.9-13.8 months). Cohort follow-up was greatly affected by COVID-19 pandemic and associated restrictions.

INTERVENTION

The MH intervention provided MH education and support, analgesics, and a choice of menstrual products in a community-based setting to improve MH outcomes among young women in Zimbabwe.

PRIMARY AND SECONDARY OUTCOMES

Effectiveness of a comprehensive MH intervention on improving MH knowledge, perceptions, and practices among young women over time. Quantitative questionnaire data were collected at baseline, midline, and endline. At endline, thematic analysis of four focus group discussions was used to further explore participants' menstrual product use and experiences of the intervention.

RESULTS

At midline, more participants had correct/positive responses for MH knowledge (adjusted OR (aOR)=12.14; 95% CI: 6.8 to 21.8), perceptions (aOR=2.85; 95% CI: 1.6 to 5.1) and practices for reusable pads (aOR=4.68; 95% CI: 2.3 to 9.6) than at baseline. Results were similar comparing endline with baseline for all MH outcomes. Qualitative findings showed that sociocultural norms, stigma and taboos around menstruation, and environmental factors such as limited access to water, sanitation and hygiene facilities affected the effect of the intervention on MH outcomes.

CONCLUSIONS

The intervention improved MH knowledge, perceptions and practices among young women in Zimbabwe, and the comprehensive nature of the intervention was key to this. MH interventions should address interpersonal, environmental and societal factors.

TRIAL REGISTRATION NUMBER

NCT03719521.

Menstrual health and factors associated with school absence among secondary school girls in Luang Prabang Province, Lao People's Democratic Republic: A cross-sectional study

In Lao People’s Democratic Republic (Lao PDR), information on school sanitation and menstrual health among secondary school girls is limited. This study aimed to explore knowledge and practices surrounding menstrual health and to identify factors associated with school absence due to menstruation among secondary school girls in Lao PDR. The study involved 1,366 girls from grade 9 to grade 12 in six secondary schools in Luang Prabang Province. Data on socio-demographics and menstrual health of the girls and data on school toilets was collected. Logistic regression analysis was performed to identify the factors associated with school absence due to menstruation. The mean age was 15.8 years old. The average age of menarche was 12.9 years old. Of 1,366 girls, 64.6% were shocked or ashamed when they reached menarche and 31.8% had been absent from school due to menstruation in the six months before this study was conducted. Factors associated with school absence due to menstruation were age ≥ 16 years old (AOR = 1.79, 95% CI 1.37–2.34), higher income (AOR = 2.38, 95% CI 1.16–4.87), menstrual anxiety (AOR = 1.55, 95% CI 1.09–2.20), using painkillers (AOR = 4.79, 95% CI 2.96–7.76) and other methods (AOR = 2.82, 95% CI 1.86–4.28) for dysmenorrhea, and disposing used pads in places other than the school’s waste bins (AOR = 1.34, 95% CI 1.03–1.75). Living with relatives (AOR = 0.64, 95% CI 0.43–0.95) and schools outside the city (AOR = 0.59, 95% CI 0.38–0.90) were significantly less associated with school absence. Although the association between school toilets and school absence was not examined, the results of this study suggest that school toilets should be gender-separated and equipped with waste bins in the toilet. Furthermore, menstrual education should start at elementary schools and teacher training on menstrual health should be promoted.

Gendered health, economic, social and safety impact of COVID-19 on adolescents and young adults in Nairobi, Kenya

BACKGROUND

Infectious disease outbreaks like COVID-19 and their mitigation measures can exacerbate underlying gender disparities, particularly among adolescents and young adults in densely populated urban settings.

METHODS

An existing cohort of youth ages 16-26 in Nairobi, Kenya completed a phone-based survey in August-October 2020 (n = 1217), supplemented by virtual focus group discussions and interviews with youth and stakeholders, to examine economic, health, social, and safety experiences during COVID-19, and gender disparities therein.

RESULTS

COVID-19 risk perception was high with a gender differential favoring young women (95.5% vs. 84.2%; p<0.001); youth described mixed concern and challenges to prevention. During COVID-19, gender symmetry was observed in constrained access to contraception among contraceptive users (40.4% men; 34.6% women) and depressive symptoms (21.8% men; 24.3% women). Gender disparities rendered young women disproportionately unable to meet basic economic needs (adjusted odds ratio [aOR] = 1.21; p<0.05) and in need of healthcare during the pandemic (aOR = 1.59; p<0.001). At a bivariate level, women had lower full decisional control to leave the house (40.0% vs. 53.2%) and less consistent access to safe, private internet (26.1% vs. 40.2%), while men disproportionately experienced police interactions (60.1%, 55.2% of which included extortion). Gender-specific concerns for women included menstrual hygiene access challenges (52.0%), increased reliance on transactional partnerships, and gender-based violence, with 17.3% reporting past-year partner violence and 3.0% non-partner sexual violence. Qualitative results contextualize the mental health impact of economic disruption and isolation, and, among young women, privacy constraints.

IMPLICATIONS

Youth and young adults face gendered impacts of COVID-19, reflecting both underlying disparities and the pandemic's economic and social shock. Economic, health and technology-based supports must ensure equitable access for young women. Gender-responsive recovery efforts are necessary and must address the unique needs of youth.

Analysis on clinical association of uterine scar diverticulum with subsequent infertility in patients underwent cesarean section

To evaluate the relationship between uterine cesarean scar diverticulum (CSD) and subsequent infertility in patients who underwent cesarean section, and determine the effects of pelvic fluid-releasing inflammations on infertility.A retrospective analysis was designed among patients with CSD who were admitted to our hospital from January 1, 2018 to December 31, 2019. A total of 60 patients with CSD and uterine fibroids or benign ovarian tumors who underwent cesarean section were included, and divided into the CSD group and control group. Baseline characteristics of all patients were collected, and the pelvic adhesion scores and the percents of tubal patency were evaluated. Furthermore, the postoperative clinical outcomes were followed up. The levels of inflammatory factors in pelvic fluid were tested using Elisa kits.Preoperative data indicated that the size of the uterine scar diverticulum was (1.68 ± 0.52) cm, the pelvic adhesion scores were higher in CSD group than control group (4.67 ± 0.90 vs 0.47 ± 0.90, P < .05), and 21 of 30 patients with unobstructed fallopian tubes. The levels of tumor necrosis factor-α, interleukin-1β, and interleukin-6 in patients with CSD were obviously higher than control group (P < .05). After the follow-up, the data displayed that no CSD was found in all patients, the time of menstrual period in patients with CSD was shortened to 7.80 ± 1.27 days, and the myometrial thickness at uterine scar was significantly increased (P < .05). Additionally, the pregnancy rate was increased, and 12 of 30 patients were repregnant. Correlation analysis showed that the levels of inflammatory factors (tumor necrosis factor-α, interleukin-1β, interleukin-6), the size of uterine scar diverticulum, and the myometrial thickness at uterine scar were significantly correlated with subsequent infertility (r = 0.307, 0.083, 0.147, 0.405, 0.291, P < .05).Uterine scar diverticulum repair could improve menstrual prolongation, increased the thickness of myometrium and repregnant rate. Subsequent infertility was positively correlated with uterine scar diverticulum and the levels of inflammatory factors.

A systematic review of the menstrual experiences of university students and the impacts on their education: A global perspective

Background

Higher education attainment is linked to improved health and employment outcomes but the impact of university students’ experiences of menstruation on their education is less clear. The objective of this review was to synthesise qualitative and quantitative research on university students’ menstrual experiences and educational impacts.

Methods

Eligible studies were identified through systematic searching across eight peer-reviewed databases, websites for menstrual health organisations, grey literature databases, and reference lists of included studies. Eligible studies must have reported on at least one of the antecedents or components of menstrual experience outlined in the integrated model of menstrual experience in relation to university students or reported on the impact of their menstrual experiences on their education. Study characteristics and findings were extracted, analysed and presented as a narrative synthesis. The quality of evidence was assessed with the Mixed Methods Appraisal Tool. This study is registered on PROSPERO, number CRD42020178470.

Results

Eighty-three studies were eligible for inclusion. Most studies (n = 74; 89%) were quantitative and the highest proportion of studies were conducted in lower-middle-income countries (n = 31; 37%). Self-reported dysmenorrhea, other physical and emotional menstrual-related symptoms, and menstrual stigma contributed to negative menstrual experiences among female students. Very few studies considered the menstrual experiences of non-binary and transgender menstruating students, and culturally diverse students. Dysmenorrhea contributed to university absenteeism, impaired participation and concentration, and declining academic performance. Inadequate sanitation facilities for menstrual management and challenges containing menstruation also negatively impacted education.

Conclusions

Female university students’ experiences of menstruation can negatively impact their education, highlighting the need for program and policy responses at university to improve students’ wellbeing and educational engagement. Further research on the menstrual experiences of gender diverse, migrant and international students is needed as there is insufficient evidence to date.

Latent Tri-lineage Potential of Human Menstrual Blood-Derived Mesenchymal Stromal Cells Revealed by Specific In Vitro Culture Conditions

Human menstrual blood-derived mesenchymal stromal cells (MenSCs) have become not only an important source of stromal cells for cell therapy but also a cellular source for neurologic disorders in vitro modeling. By using culture protocols originally developed in our laboratory, we show that MenSCs can be converted into floating neurospheres (NSs) using the Fast-N-Spheres medium for 24-72 h and can be transdifferentiated into functional dopaminergic-like (DALNs, ~ 26% TH + /DAT + flow cytometry) and cholinergic-like neurons (ChLNs, ~ 46% ChAT + /VAChT flow cytometry) which responded to dopamine- and acetylcholine-triggered neuronal Ca²⁺ inward stimuli when cultured with the NeuroForsk and the Cholinergic-N-Run medium, respectively in a timely fashion (i.e., 4-7 days). Here, we also report a direct transdifferentiation method to induce MenSCs into functional astrocyte-like cells (ALCs) by incubation of MenSCs in commercial Gibco® Astrocyte medium in 7 days. The MSC-derived ALCs (~ 59% GFAP + /S100β +) were found to respond to glutamate-induced Ca²⁺ inward stimuli. Altogether, these results show that MenSCs are a reliable source to obtain functional neurogenic cells to further investigate the neurobiology of neurologic disorders.

Associations Between Dysmenorrhea Symptom-Based Phenotypes and Vaginal Microbiome: A Pilot Study

BACKGROUND

Dysmenorrhea is highly prevalent; it places women at risk for other chronic pain conditions. There is a high degree of individual variability in menstrual pain severity, the number of painful sites, and co-occurring gastrointestinal symptoms. Distinct dysmenorrhea symptom-based phenotypes were previously identified, but the biological underpinnings of these phenotypes are less known. One underexplored contributor is the vaginal microbiome. The vaginal microbiota differs significantly among reproductive-age women and may modulate as well as amplify reproductive tract inflammation, which may contribute to dysmenorrhea symptoms.

OBJECTIVES

The objective of this study was to examine associations between dysmenorrhea symptom-based phenotypes and vaginal microbiome compositions on- and off-menses.

METHODS

We conducted a prospective, longitudinal, pilot study of 20 women (aged 15-24 years) grouped into three dysmenorrhea symptom-based phenotypes: "mild localized pain," "severe localized pain," and "severe multiple pain and gastrointestinal symptoms." Over one menstrual cycle, participants provided vaginal swabs when they were on- and off-menses. We assayed the vaginal microbiome using 16S rRNA gene sequencing. Permutational multivariate analysis of variance tests were used to compare microbiome compositions across phenotypes, with heat maps generated to visualize the relative abundance of bacterial taxa.

RESULTS

The vaginal microbiome compositions (n = 40) were different across the three phenotypes. After separating the on-menses (n = 20) and off-menses (n = 20) specimens, the statistically significant difference was seen on-menses, but not off-menses. Compared to the "mild localized pain" phenotype, participants in the "multiple severe symptoms" phenotype had a lower lactobacilli level and a higher abundance of Prevotella, Atopobium, and Gardnerella when on-menses. We also observed trends of differences across phenotypes in vaginal microbiome change from off- to on-menses.

DISCUSSION

The study provides proof-of-concept data to support larger studies on associations between dysmenorrhea symptom-based phenotypes and vaginal microbiome that might lead to new intervention targets and/or biomarkers for dysmenorrhea. This line of research has the potential to inform precision dysmenorrhea treatment that can improve women's quality of life.

Obesity is associated with heavy menstruation that may be due to delayed endometrial repair

Heavy menstrual bleeding is common and debilitating but the causes remain ill defined. Rates of obesity in women are increasing and its impact on menstrual blood loss (MBL) is unknown. Therefore, we quantified BMI and MBL in women not taking hormones and with regular menstrual cycles and revealed a positive correlation. In a mouse model of simulated menstruation, diet-induced obesity also resulted in delayed endometrial repair, a surrogate marker for MBL. BrdU staining of mouse uterine tissue revealed decreased proliferation during menstruation in the luminal epithelium of mice on a high-fat diet. Menstruation is known to initiate local endometrial inflammation and endometrial hypoxia; hence, the impact of body weight on these processes was investigated. A panel of hypoxia-regulated genes (VEGF, ADM, LDHA, SLC2A1) showed consistently higher mean values in the endometrium of women with obesity and in uteri of mice with increased weight vs normal controls, although statistical significance was not reached. The inflammatory mediators, Tnf and Il6 were significantly increased in the uterus of mice on a high-fat diet, consistent with a pro-inflammatory local endometrial environment in these mice. In conclusion, obesity was associated with increased MBL in women. Mice given a high-fat diet had delayed endometrial repair at menstruation and provided a model in which to study the influence of obesity on menstrual physiology. Our results indicate that obesity results in a more pro-inflammatory local endometrial environment at menstruation, which may delay endometrial repair and increase menstrual blood loss.

Examining the predictors of use of sanitary napkins among adolescent girls: A multi-level approach

Background

This paper aimed to explore various factors associated with the use of sanitary napkins among adolescent girls in Uttar Pradesh and Bihar.

Methods

The study uses information from the Understanding the Lives of Adolescents and Young Adults (UDAYA) project survey conducted in Uttar Pradesh and Bihar in 2016. The study sample consisted of 14,625 adolescent girls aged 10–19 years. The study sample was selected using a multi-stage systematic sampling design. Multilevel logistic regression (MLR) was used to identify the individual and community level factors associated with the use of sanitary napkins.

Results

The results revealed a wide variation in sanitary napkins’ use across the socio-economic and demographic factors. The use of sanitary napkins was significantly higher among girls with 8–9 (53.2%) and 10 and more (75.4%) years of schooling compared to those who had no formal education (26.4%). The use of sanitary napkins was higher among adolescent girls who were not engaged in paid work (54.7%) than those who did any paid job (40.8%). Adolescent girls reporting frequent exposure to mass media (OR = 2.10), belonging to the richest wealth quintile (OR = 3.76), and whose mothers had 10 or more years of education (OR = 2.29) had a higher propensity to use sanitary napkins than their counterparts. We did not find a significant role of community-level education of mothers on the menstrual hygiene practices of adolescents.

Conclusion

Ensuring that adolescent girls have access to hygienic means to manage their menses is critical from a public health perspective and in enabling them to realize their full potential. Programs to enhance menstrual hygiene are warranted. These programs should involve mothers, who are an important source of knowledge about menstrual hygiene. Facilitating girls’ access to education may also produce tangible menstrual hygiene benefits.

Exogenous sex hormones, menstrual and reproductive history, and risk of non-melanoma skin cancer among women: a systematic literature review and meta-analysis

Non-melanoma skin cancers (NMSC) are more frequent among men, but women (especially those aged < 40 years) have experienced steeper growth in their incidence rates in recent years. Hormonal factors were hypothesized to be playing a role in modulating NMSC risk, but the studies published to date provided conflicting results. We systematically reviewed and meta-analysed the studies focusing on the association between hormone-related characteristics (use of exogenous sex hormones, and aspects of menstrual and reproductive history) and the risk of NMSC among women. We included observational and experimental studies published in PubMed and EMBASE until February 2020. We calculated summary relative risk (SRR) and 95% confidence intervals (CI) by applying random effects models with maximum likelihood estimation, and used the I2 statistics to quantify the degree of heterogeneity of risk estimates across studies. Eleven independent studies encompassing a total of over 30,000 NMSC cases were included in quantitative analyses. No evidence of an increased NMSC risk emerged among ever vs. never users of oral contraceptives (SRR 1.13, 95% CI 0.88-1.45) or hormones for menopause (SRR 1.09, 95% CI 0.87-1.37). Likewise, age at menarche or at menopause and parity were not associated with NMSC risk. Heterogeneity across studies was low, and pooled results were comparable between NMSC subtypes. We found no evidence that hormonal factors play a role in the pathogenesis of NMSC among women.

Sex differences and considerations for female specific nutritional strategies: a narrative review

Although there is a plethora of information available regarding the impact of nutrition on exercise performance, many recommendations are based on male needs due to the dominance of male participation in the nutrition and exercise science literature. Female participation in sport and exercise is prevalent, making it vital for guidelines to address the sex-specific nutritional needs. Female hormonal levels, such as estrogen and progesterone, fluctuate throughout the mensural cycle and lifecycle requiring more attention for effective nutritional considerations. Sex-specific nutritional recommendations and guidelines for the active female and female athlete have been lacking to date and warrant further consideration. This review provides a practical overview of key physiological and nutritional considerations for the active female. Available literature regarding sex-specific nutrition and dietary supplement guidelines for women has been synthesized, offering evidenced-based practical information that can be incorporated into the daily lives of women to improve performance, body composition, and overall health.

Use of menstruation and fertility app trackers: a scoping review of the evidence

INTRODUCTION

There has been a phenomenal worldwide increase in the development and use of mobile health applications (mHealth apps) that monitor menstruation and fertility. Critics argue that many of the apps are inaccurate and lack evidence from either clinical trials or user experience. The aim of this scoping review is to provide an overview of the research literature on mHealth apps that track menstruation and fertility.

METHODS

This project followed the PRISMA Extension for Scoping Reviews. The ACM, CINAHL, Google Scholar, PubMed and Scopus databases were searched for material published between 1 January 2010 and 30 April 2019. Data summary and synthesis were used to chart and analyse the data.

RESULTS

In total 654 records were reviewed. Subsequently, 135 duplicate records and 501 records that did not meet the inclusion criteria were removed. Eighteen records from 13 countries form the basis of this review. The papers reviewed cover a variety of disciplinary and methodological frameworks. Three main themes were identified: fertility and reproductive health tracking, pregnancy planning, and pregnancy prevention.

CONCLUSIONS

Motivations for fertility app use are varied, overlap and change over time, although women want apps that are accurate and evidence-based regardless of whether they are tracking their fertility, planning a pregnancy or using the app as a form of contraception. There is a lack of critical debate and engagement in the development, evaluation, usage and regulation of fertility and menstruation apps. The paucity of evidence-based research and absence of fertility, health professionals and users in studies is raised.

Analysis of survey on menstrual disorder among teenagers using Gaussian copula model with graphical lasso prior

A high prevalence of menstrual disturbance has been reported among teenage girls, and research shows that there are delays in diagnosis of endometriosis among young girls. Using data from the Menstrual Disorder of Teenagers Survey (administered in 2005 and 2016), we propose a Gaussian copula model with graphical lasso prior to identify cohort differences in menstrual characteristics and to predict endometriosis. The model includes random effects to account for clustering by school, and we use the extended rank likelihood copula model to handle variables of mixed-type. The graphical lasso prior shrinks the elements in the precision matrix of a Gaussian distribution to encourage a sparse graphical structure, where the level of shrinkage is adaptable based on the strength of the conditional associations among questions in the survey. Applying our proposed model to the menstrual disorder data set, we found that menstrual disturbance was more pronouncedly reported over a decade, and we found some empirical differences between those girls with higher risk of developing endometriosis and the general population.

Association Between Menstrual Patterns and Adverse Pregnancy Outcomes in Patients With Polycystic Ovary Syndrome

OBJECTIVE

To investigate the results of in vitro fertilization among polycystic ovary syndrome (PCOS) patients using the long-acting long protocol regarding the relationship between menstrual patterns and adverse pregnancy outcomes.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated reproductive medical center.

BACKGROUND

The menstrual patterns of patients with PCOS is considered related to metabolism; however, no study has analyzed the outcome of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) in patients with PCOS who have different menstrual patterns. This study aimed to observe the outcomes of IVF/ICSI in patients with PCOS with different menstrual patterns who used the long-acting long protocol.

METHODS

This was a retrospective analysis in the first cycle of IVF/ICSI at the Reproductive Medicine Center of the First Affiliated Hospital of Zhengzhou University from January 2017 to December 2019. In total, 1834 patients with PCOS were classified into the regular menstruation group (n=214), the oligomenorrhea group (n=1402), and the amenorrhea group (n=218).

RESULTS

PCOS patients who used the long-acting long protocol of IVF/ICSI had similar clinical pregnancy rates and live birth rates despite having different menstrual patterns. The overall incidence of adverse pregnancy outcomes, including abortion, spontaneous preterm birth (sPTB), gestational diabetes(GDM), hypertensive disorder inpregnancy (HDP), and premature rupture of membranes(PROM, was significantly higher in the amenorrhea group than in the regular menstrual and oligomenorrhea groups (25.88% vs. 30.41% vs. 43.69%; P = 0.013). Additionally, the rates of GDM (2.35% vs. 6.10% vs. 13.79%; P=0.015) and macrosomia (5.26% vs. 10.94% vs. 18.39%; P=0.026) in the amenorrhea group were significantly higher than those in the other two groups. Correction for confounding factors showed that menstrual patterns are related to the occurrence of adverse pregnancy outcomes. Amenorrhea is an independent risk factor for adverse pregnancy outcome (OR [odds ratio]: 2.039, 95% CI [confidence interval]: 1.087-3.822), GDM (OR: 5.023, 95% CI: 1.083-23.289), and macrosomia (OR: 4.918, 95% CI: 1.516-15.954).

CONCLUSIONS

IVF/ICSI can achieve similar pregnancy and live birth rates in PCOS patients with different menstrual patterns. However, the overall incidence of adverse pregnancy outcomes in PCOS patients with amenorrhea is higher than that in patients with regular menstruation or oligomenorrhea.

Ultradian rhythms in heart rate variability and distal body temperature anticipate onset of the luteinizing hormone surge

The menstrual cycle is characterized by predictable patterns of physiological change across timescales. Although patterns of reproductive hormones across the menstrual cycle, particularly ultradian rhythms, are well described, monitoring these measures repeatedly to predict the preovulatory luteinizing hormone (LH) surge is not practical. In the present study, we explored whether non-invasive measures coupled to the reproductive system: high frequency distal body temperature (DBT), sleeping heart rate (HR), sleeping heart rate variability (HRV), and sleep timing, could be used to anticipate the preovulatory LH surge in women. To test this possibility, we used signal processing to examine these measures in 45 premenopausal and 10 perimenopausal cycles alongside dates of supra-surge threshold LH and menstruation. Additionally, urinary estradiol and progesterone metabolites were measured daily surrounding the LH surge in 20 cycles. Wavelet analysis revealed a consistent pattern of DBT and HRV ultradian rhythm (2-5 h) power that uniquely enabled anticipation of the LH surge at least 2 days prior to its onset in 100% of individuals. Together, the present findings reveal fluctuations in distal body temperature and heart rate variability that consistently anticipate the LH surge, suggesting that automated ultradian rhythm monitoring may provide a novel and convenient method for non-invasive fertility assessment.

How can we improve knowledge and perceptions of menstruation? A mixed-methods research study

BACKGROUND

Traditionally, menstrual education has consisted of lectures directed toward women. The objective of this study was to design an innovative menstrual education (ME) program that reflects the needs of both young women and men, and verify its effectiveness.

METHODS

A mixed-method design was used to determine the program needs and assess young adults' knowledge and perceptions of menstruation and menstrual products. Focus group interviews were conducted with 14 young adults, and 150 young adults participated in an online survey. After developing the ME program, 10 young adults participated in a study to verify its effectiveness.

RESULTS

Interview results showed young adults wanted more information about menstrual products. The online survey revealed significant differences in knowledge based on participants' general characteristics and experience; exposure to menstruation and menstrual products positively impacted knowledge and perception. In addition, the results indicated young adults wanted ME content access via mobile and in-person modalities, designed for both genders, drawing on menstrual experts' knowledge. Based on these results, a multi-experimental menstrual education (MEME) program was designed and included: hands-on exposure to 60 menstrual products, product demonstrations with a female perineal model, a YouTube video created by the researchers, a true-or-false quiz, and question-and-answer sessions with menstrual experts.

CONCLUSIONS

This study clarified the requirements of an innovative menstrual education program. It led to high satisfaction among participants, and improved knowledge and perceptions of menstruation and menstrual products. The online survey showed a correlation between the extent of received ME, and respondents' perception of menstrual products. This implied that a MEME program could change perceptions when conducted systematically; by extension it could ameliorate menstruation challenges attributed to poverty. Future research could further verify the effectiveness of the MEME program, using a larger sample, and examine its suitability for incorporation into official ME curricula at universities and companies.

TRIAL REGISTRATION

This trial was registered in a Clinical Research Information Service in Korea linked with the World Health Organization's International Clinical Trial Registry Platform (WHO's ICTRP) (no. KCT0004715 ), Registered 07 Feb 2020.

Insulin Sensitizers for Improving the Endocrine and Metabolic Profile in Overweight Women With PCOS

OBJECTIVE

To evaluate the efficacy of insulin sensitizers on menstrual frequency, sex hormone, and metabolic parameters in overweight women with polycystic ovary syndrome (PCOS).

METHODS

We searched multiple databases from inception to September 2019 for randomized controlled trials. Network meta-analysis was conducted using multivariate random effects method.

RESULTS

Fourteen trials reporting on 619 women were included. Compared with metformin, metformin + thiazolidinediones (TZDs) was more superior in menstrual recovery (weighted mean difference [WMD] 3.68; 95% credibility interval [CrI], 1.65 to 8.20), metformin +  glucagon-like peptide-1 (GLP-1) receptor agonists was more effective in decreasing androstenedione (WMD -2.53; 95% CrI, -3.96 to -1.09), both metformin + GLP-1 receptor agonists (WMD 9.22; 95% CrI, 5.46 to 12.98) and metformin + TZDs (WMD 4.30; 95% CrI, 0.78 to 7.82) were more effective in increasing sex hormone-binding globulin (SHBG), while TZDs were less effective in decreasing body mass index (BMI) (WMD 1.69; 95% CrI, 0.72 to 2.66). Compared with GLP-1 receptor agonists, metformin + GLP-1 receptor agonists was associated with higher SHBG (WMD 7.80; 95% CrI, 4.75 to 10.85), lower free testosterone (WMD -1.77; 95% CrI, -3.25 to -0.29), lower androstenedione (WMD -2.70; 95% CrI, -3.91 to -1.50) and lower fasting blood glucose (WMD -0.41; 95% CrI, -0.73 to -0.08).

CONCLUSION

For overweight women with PCOS, both metformin combined with GLP-1 receptor agonists and metformin combined with TZDs appear superior to monotherapy in improving hyperandrogenemia. Metformin combined with TZDs could be particularly effective in promoting the recovery of menstruation. Metformin combined with GLP-1 receptor agonists has the additional advantage of improving fasting glucose when compared with GLP-1 receptor agonists alone. TZDs are inferior to metformin in decreasing BMI.

Recurrence of Symptoms Associated with Menstruation in a Patient with a History of Periodic Fevers

BACKGROUND

Periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) syndrome is a cyclic autoinflammatory disease generally diagnosed in childhood. There have been studies suggesting a relationship between menstruation and other autoinflammatory syndromes such as familial Mediterranean fever (FMF), but not PFAPA specifically.

CASE

This case describes a patient with a diagnosis of PFAPA who experienced complete resolution with tonsillectomy only to have recurrence of symptoms with onset of menstruation. She experienced symptom control with initiation of oral contraceptives.

SUMMARY AND CONCLUSION

Prior to this case report, there had been no evidence in the literature suggesting a relationship between PFAPA and menstruation despite the observed association in other autoinflammatory syndromes. Onset of menses may be a trigger in PFAPA.

Extended-cycle versus conventional treatment with a combined oral contraceptive containing ethinylestradiol (30 μg) and levonorgestrel (150 μg) in a randomized controlled trial

The objective was to assess efficacy and safety of a combined oral contraceptive containing ethinylestradiol (EE) and levonorgestrel (LNG) in an extended-cycle vs. a conventional-cycle regimen. This first European randomized, active controlled, open, prospective, parallel-group trial was conducted in 48 German gynecological centers. 1,314 healthy, sexually active women aged 18-35 years were randomized. With an unadjusted PI of 0.483 (upper 95% CI: 1.237), the extended-cycle regimen fulfilled the contraceptive efficacy of EE/LNG, the requirements of the European Medicines Agency. The mean total number of bleeding days per year was significantly lower in the extended-cycle vs. the conventional-cycle regimen. Analyses of bleeding patterns showed a reduced total number of bleeding/spotting days per year in the extended-cycle vs. the conventional-cycle regimen. Cycle-associated complaints and AE were comparable in both groups. Both regimens were very well accepted. The extended-cycle regimen of EE/LNG was effective and well tolerated resulting in a lower number of bleeding days and a favorable bleeding pattern compared to the conventional-cycle regimen.

Background Parenchymal Enhancement on Contrast-Enhanced Spectral Mammography: Influence of Age, Breast Density, Menstruation Status, and Menstrual Cycle Timing

To evaluate the relationship of the extent and quantitative intensity of background parenchymal enhancement (BPE) on contrast-enhanced spectral mammography (CESM) with age, breast density, menstruation status, and menstrual cycle timing. This retrospective study included women who underwent CESM from July 2017 to March 2019 and who had menstruation status records. BPE category assessment was performed subjectively. BPE intensity was quantitatively measured using regions-of-interest. 208 subjects were included (150 were regular menstrual cycle and 58 were postmenopausal). The breast density was classified as category B in 11 subjects, category C in 231 subjects, and category D in 23 subjects. Subjects based on menstrual cycle timing, 24 at days 1-7, 55 at days 8-14, 48 at days 15-21, and 23 at days 22-28. Both quantitative and categorical analyses show a weak negative correlation between BPE and age in all subjects, but there was no significant correlation in premenopausal patients. Both the BPE pixel intensity value and BPE category was significantly lower in postmenopausal patients than in premenopausal patients, and there was no significant difference in breast density according to BPE. The minimum and maximum pixel values of BPE on days 8-14 of the menstrual cycle was significantly lower than those on days 15-21. There was no correlation between BPE level and menstrual cycle timing. Breast density with category D was more likely to have a lower BPE level than category C. We show here that BPE level is affected by menstruation status and menstrual cycle timing. We suggest that CESM should not be performed on days 15-21 of the menstrual cycle, but on days 8-14.

Menstrual Cup Use Intention and the Moderating Effects of Sexual Orientation and Gender Characteristic Among Female University Students in Taiwan: A Theory-Driven Exploration

Menstruation plays an important role in women's lives as it accompanies about half of their living years. However, little is known about women's intention to use menstrual cups, a relatively new menstrual product in Taiwan. Therefore, this study aimed to systematically explore the factors associated with menstrual cup use (MCU) intention among female university students in Taiwan, using the Theory of Planned Behavior (TPB). Data from 1245 female university students in Taiwan were collected using an anonymous online survey based on the TPB from December 2016 through January 2017. Multivariate logistic regression found the following TPB factors associated with high MCU intention: positive attitudes about positive (adjusted odds ratio [AOR] = 4.35, 95% confidence interval [CI] 2.87-6.60) and negative (AOR = 2.32, 95% CI 1.54-3.49) outcomes of MCU, supportive subjective norms (AOR = 1.88, 95% CI 1.33-2.65), and high perceived control over MCU under constraining conditions (AOR = 3.40, 95% CI 2.24-5.16). Sexual orientation and gender characteristic were also found to have moderating effects. For example, bisexual college girls with masculine characteristic who perceived high control over MCU under constraining conditions had elevated MCU intention (AOR = 2.45, 95% CI 1.04-5.76). Therefore, to improve women's menstrual health, future health education could focus more on introducing the different features of various menstrual products, including menstrual cups, and help users make informed decisions about which menstrual products could best suit their needs.

Prevalence and knowledge of heavy menstrual bleeding among gynecology outpatients by scanning a WeChat QR Code

The aim of this study was to assess menstrual blood loss (MBL) and knowledge of heavy menstrual bleeding (HMB) among the gynecology outpatients at Peking University People’s Hospital, by scanning a WeChat (a social media application software developed by Tencent) QR Code using a mobile phone or tablet. This survey was conducted among outpatients who were treated at the Gynecology Department of Peking University People’s Hospital between September 2016 and November 2016. All participants filled up the questionnaires and scales through WeChat: general information questionnaire, Pictorial Blood Loss Assessment Chart (PBAC), Menorrhagia Multi-Attribute Quality-of-Life Scale (MMAS), and HMB knowledge questionnaire. Menstrual blood volume was assessed by the PBAC and self-assessment. Among the 1152 patients who filled out the survey, 77.4% (892/1152) had normal menstrual cycle (assessed by the patients), 15.6% (180/1152) patients described themselves as HMB, whereas the results from PBAC showed that 58.0% (668/1152) had HMB (PBAC ≥100). Among patients with PBAC ≥100, only 26.8% (179/668) patients reported HMB through self-assessment. Regarding its impact on daily life, the MMAS scores of HMB patients (PBAC ≥100) were significantly lower compared to those with normal blood loss (P<0.001). Regarding the awareness to HMB, 63.2% (728/1152) of the patients were not familiar with HMB. HMB is a common abnormal uterine bleeding and is frequently found among Chinese gynecology outpatients. HMB has major impacts on a woman’s quality of life, affecting both physical and emotional health domains. Since women generally have low levels of awareness and understanding of HMB, they could assess their blood loss using the PBAC, which they can forward to their health care provider using a mobile phone or tablet and the WeChat platform. This tool may be effortlessly used by the health care providers and patients to easily share HMB-related data.

Mimicking Sampson's Retrograde Menstrual Theory in Rats: A New Rat Model for Ongoing Endometriosis-Associated Pain

Endometriosis is a prevalent gynecologic disease, defined by dysfunctional endometrium-like lesions outside of the uterine cavity. These lesions are presumably established via retrograde menstruation, i.e., endometrial tissue that flows backwards during menses into the abdomen and deposits on the organs. As ongoing pain is one of the main pain symptoms of patients, an animal model that illuminates this problem is highly anticipated. In the present study, we developed and validated a rat model for ongoing endometriosis-associated pain. First, menstrual endometrial tissue was successfully generated in donor rats, as validated by gross examination, histology and qPCR. Next, endometriosis was induced in recipient animals by intraperitoneal injection of menstrual tissue. This resulted in neuro-angiogenesis as well as established endometriosis lesions, which were similar to their human counterparts, since epithelial and stromal cells were observed. Furthermore, significant differences were noted between control and endometriosis animals concerning bodyweight and posture changes, indicating the presence of ongoing pain in animals with endometriosis. In summary, a rat model for endometriosis was established that reliably mimics the human pathophysiology of endometriosis and in which signs of ongoing pain were detected, thus providing a new research tool for therapy development.

Knowledge of menstruation and fertility among adults in rural Western Kenya: Gaps and opportunities for support

An understanding of menstruation and its relationship to fertility can help women know the gestational age of any pregnancies, and thus identify preterm births. It can also help women avoid unintended pregnancies. However, little is known about women, and especially men's, menstruation and fertility knowledge, outside of research on adolescent girls and stigma, and in low and middle income countries (LMIC). Additionally, little is known about practices surrounding the tracking of menstruation and fertility, and how, if at all, women would like to be supported in this. This research is the first phase in adapting a support tool for women in a LMIC, using an implementation science approach to understand relevant cultural needs. We explored women and men's understanding of the relationship between menstruation and fertility, and their interest in support tools, through in-depth qualitative interviews in rural western Kenya. We interviewed 45 adult men, adult women and adolescent women all who had children in 2018. We found high levels of misinformation about menstruation and fertility, with most respondents not knowing the correct times when a woman could become pregnant. Common sources of knowledge included friends/family and school. Few women got information from health providers, even when they were at a facility already for care. There were mixed feelings from women about wanting support from male partners regarding tracking menstruation. While women were interested in a tool that could help them track their menstruation and pregnancies, they had privacy concerns about a mobile health app approach and preferred simpler calendar based tools. This study provides evidence for the high need for correct menstruation information among both men and women, and not only for adolescents. It also suggests that despite the international health community's enthusiasm for mobile health solutions, that approach might not be most appropriate for this topic and setting.

Menstrual health intervention and school attendance in Uganda (MENISCUS-2): a pilot intervention study

OBJECTIVES

Achieving good menstrual health and hygiene (MHH) is a public health challenge and there is little evidence to inform interventions. The aim of this study was to pilot test an intervention to improve MHH and school attendance in Uganda, in preparation for a future cluster-randomised trial.

DESIGN

Longitudinal study with pre-post evaluation of a pilot intervention.

SETTING

Two secondary schools in Entebbe, Uganda.

PARTICIPANTS

Of the 473 eligible students in secondary 2 (S2) at baseline, 450 (95.1%; 232 girls and 218 boys) consented/assented. 369 students (188 girls; 81.0%; and 181 boys; 83.0%) participated in the endline survey.

INTERVENTION

The intervention comprised training teachers to improve delivery of government guidelines for puberty education, training in use of a menstrual kit and pain management, a drama skit, provision of analgesics and improvements to school water and sanitation hygiene facilities.

PRIMARY AND SECONDARY OUTCOME MEASURES

Feasibility and acceptability of delivering the intervention. Baseline and endline quantitative surveys were conducted, with qualitative interviews conducted at endline. School attendance was assessed using self-completed daily diaries among a nested cohort of 100 female students.

RESULTS

There were high levels of uptake of the individual and behavioural intervention components (puberty education, drama skit, menstrual hygiene management (MHM) kit and pain management). The proportion of girls reporting anxiety about next period decreased from 58.6% to 34.4%, and reported use of effective pain management increased from 76.4% to 91.4%. Most girls (81.4%) reported improved school toilet facilities, which improved their comfort managing menstruation. The diary data and qualitative data indicated a potential intervention impact on improving menstrual-related school absenteeism.

CONCLUSIONS

The pilot study showed that the multicomponent MHM intervention was acceptable and feasible to deliver, and potentially effective in improving menstruation knowledge and management. A cluster-randomised trial is needed to evaluate rigorously the intervention effects on MHM and school attendance.

TRIAL REGISTRATION NUMBER

NCT04064736; Pre-results.

Monthly variation of hot flashes, night sweats, and trouble sleeping: effect of season and proximity to the final menstrual period (FMP) in the SWAN Menstrual Calendar substudy

OBJECTIVE

Although reproductive function is influenced by season, few studies have evaluated seasonal effects on menopausal symptoms. We assessed the impact of season and proximity to the final menstrual period (FMP) on frequency of symptom reporting.

METHODS

In all, 955 participants in the Study of Women's Health Across the Nation recorded whether or not they had experienced menopausal symptoms on a monthly menstrual calendar over a 10-year period. We modeled the log-odds of presence of a given symptom each month using a logistic mixed-effects model, assuming a third-order polynomial before the FMP and a different third-order polynomial after the FMP. We assumed sine and cosine functions for month of the year.

RESULTS

Five to 10 years before the FMP, ∼20% of women reported hot flashes and night sweats, whereas ∼40% reported trouble sleeping. Prevalence rose ∼4 years before the FMP with a sharp jump in hot flash (∼60%) and night sweats (∼40%) prevalence coincident with the FMP. Peaks in hot flashes and trouble sleeping were observed in July with troughs in January. The peak and trough in night sweats occurred about 1 month earlier. Odds of hot flashes, night sweats, and trouble sleeping were 66%, 50%, and 24% greater, respectively, at the seasonal peak versus the seasonal minimum.

CONCLUSION

Menopausal symptoms exhibit seasonal variation associated with the summer and winter equinoxes. Seasonal increases in night sweats precede increases in hot flashes. Prospectively recorded monthly symptom data demonstrate that hot flashes and night sweats increase notably coincident with the FMP. : Video Summary:http://links.lww.com/MENO/A476.

Ecological momentary assessment of HIV versus reproductive health symptoms in women of differing reproductive stages living with HIV

OBJECTIVE

To what extent menopause is related to symptom burden in women living with HIV (WLWH) is unclear, as a specific reproductive health analysis has seldom been undertaken, in part due to an inadequate assessment of reproductive status. The purpose of this study was to document and compare symptom frequency and attribution over 46 days and examine differences by reproductive status with a sample of 75 WLWH.

METHODS

We conducted an ecological momentary assessment using text messaging to follow 75 women confirmed for menopause stage with hormone profiles for 46 days. Participants were asked to respond to the following open-ended questions via a text message 3× weekly: (1) Did you have your period today? (Yes/No) (2) What were your top three menstrual/menopausal symptoms today? (3) What were your top three HIV-related symptoms today?

RESULTS

A total of 73 women (mean± SD age = 51 ± 8 y, range= 24-67 y) completed the study (10 pre-, 20 peri-, and 43 postmenopause). The majority of volunteers were black non-Hispanic (74%), nonsmokers (61%), with some high school (68%) and reporting <$20,000 annual income. After controlling for cofactors, HIV symptom profiles differed by menopause stage: postmenopause predicted more fatigue, muscle aches and pains, nausea/vomiting, and diarrhea (vs peri- or premenopause). HIV-related depression was predicted by the peristage. For reproductive symptoms, women endorsed fatigue (58%), hot flashes (52%), depression (49%), and muscle aches and pains (44%) as most common, but of these, only muscle aches and pains demonstrated group differences in period prevalence (post = 35%; peri = 45%; pre = 80%, P= 0.03) Surprisingly, hot flash frequency was similar, but fever/chills/sweats varied across menopause stage (period prevalence: post=42%; peri=15%; pre=0%, P=0.01). Reporting "a period today" predicted the profile of reproductive symptoms, but was not related to HIV symptoms.

CONCLUSIONS

Although fatigue, muscle aches/pains and depression are perceived as common attributes of both HIV infection and reproductive status in WLWH, they distinguish condition-specific symptom profiles that are dependent on menopause stage.

An Open-Label, Single-Arm, Efficacy Study of Tranexamic Acid in Adolescents with Heavy Menstrual Bleeding

STUDY OBJECTIVE

Heavy menstrual bleeding (HMB) occurs in up to 40% of adolescent girls, significantly affecting their daily activities. Identifying alternative treatment strategies for HMB is particularly important for adolescents who prefer not to take hormonal contraception. Our objective was to determine whether use of tranexamic acid (TA) would increase health-related quality of life and decrease menstrual blood loss (MBL) in adolescents with HMB. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: In an open-label, multi-institutional, single-arm, efficacy study, patients 18 years of age or younger with HMB were treated with oral TA 1300 mg 3 times daily during the first 5 days of menses and monitored over the course of 4 menstrual cycles (1 baseline; 3 treatment cycles). Assessment of MBL was performed using the Menorrhagia Impact Questionnaire (MIQ) and the Pictorial Blood Assessment Chart. The MIQ includes Likert scale items, validated to assess the influence of HMB on quality of life. In previous studies, a 1-point decrease or more in score correlated with clinically significant improvement.

RESULTS

Thirty-two patients enrolled in the study, and 25 had sufficient follow-up data to be deemed evaluable. The mean age of the participants was 14.7 years (range, 11-18 years). There was an overall improvement in all items of the MIQ, with a greater than 1-point improvement in the MIQ perceived blood loss scale. When using TA, mean Pictorial Blood Assessment Chart score improved by 100 points. There were no medication-related serious adverse events.

CONCLUSION

Use of TA in female adolescents with HMB is well tolerated and leads to clinically meaningful reduction in MBL.

The Role of the General Practitioner in Evaluation and Treatment of Girls with Menstrual-Related Complaints

A common scenario a pediatrician or general practitioner may encounter in the care of adolescent girls is menstrual concerns. A frequent complaint may be of irregular periods that may be coming twice a month or possibly only every other month. Sometimes the teenage patient may complain of heavy bleeding or prolonged periods lasting longer than 7 days. The typical patient with this complaint could be a 14-year-old girl with periods that started at age 13 years who has had no periods for 3 months after onset of menarche. However, once the second period comes, the patient complains of periods happening often, lasting for 5 days, and with the need to change feminine products about 3 times per day. She is otherwise healthy with no medical issues and no surgeries. The family may question if this is considered normal or if something is potentially wrong with the adolescent's pubertal development. [Pediatr Ann. 2019;48(5):e187-e189.].

Predicting Menstrual Recovery in Adolescents With Anorexia Nervosa Using Body Fat Percent Estimated by Bioimpedance Analysis

OBJECTIVE

To identify the threshold of total body fat percentage (TBF%) required for the resumption of menses (ROM) in hospitalized female adolescents with anorexia nervosa (AN) using bioimpedance analysis (BIA).

METHODS

All female adolescents hospitalized with AN in our medical center were evaluated in a longitudinal prospective study during the years of 2012-2017. Anthropometric data, body fat measured by BIA, and hormonal determinants were collected periodically, in addition to routine medical and gynecological assessments.

RESULTS

Sixty-two participants presented with secondary amenorrhea, of which 20 remained with amenorrhea and 42 had ROM during hospitalization. At discharge, participants with ROM regained significantly more weight, and had higher mean body mass index (BMI), BMI standard deviation scores, and TBF% than those who remained with amenorrhea. Receiver operating characteristic analysis identified that a TBF% of 21.2% had the highest discriminative ability for ROM (sensitivity = 88%, specificity = 85%, positive predictive value = 93%). Compared with the anthropometric parameters, TBF% had the highest area under curve (AUC = .895), which significantly differed from that of BMI standard deviation scores (AUC = .643, p = .007) and body weight (AUC = .678, p = .03).

CONCLUSIONS

BIA is a safe and relatively simple method to assess the TBF% required for the return of balanced menstrual cycles in female adolescents with AN. The TBF% with the highest discriminative ability for menstrual resumption as assessed by BIA is 21.2%.

[Heavy menstrual bleeding in teenage girls and women with inherited bleeding disorders]

Menometrorrhagia is a frequent bleeding symptom in young women, and may be related to an inherited bleeding disorder. If there is no gynecological etiology, hemostasis tests are required. The early medical management of these teenage girls is important, especially when a bleeding disorder is known. The bleeding risk of the first periods may then be anticipated. Afterwards, the objective of the treatment is to keep the bleeding symptoms under control: anti-fibrinolytic treatment, specific replacement therapy for bleeding disorder and hormonal treatment. This management requires a multidisciplinary medical team, mainly hematologist and gynecologist, all along the genital lifespan, from the first periods to the desire for pregnancy.

Could semiquantitative analysis of real-time ultrasound elastography distinguish more liver parenchyma alterations of nonalcoholic fatty liver disease in patients with polycystic ovary syndrome?

OBJECTIVE

Nonalcoholic fatty liver disease is the commonest diffuse liver disease, of which women with polycystic ovary syndrome are at an increased risk. The aim of the present study was to assess the diagnostic value of the semiquantitative strain parameters of real-time ultrasound elastography for nonalcoholic fatty liver disease in patients with polycystic ovary syndrome.

SUBJECTS AND METHODS

Thirty-five polycystic ovary syndrome patients with nonalcoholic fatty liver disease, 70 polycystic ovary syndrome patients without nonalcoholic fatty liver disease, and 70 healthy female controls of reproductive age were included. All participants underwent ultrasonic examination and semiquantitative analysis of real-time ultrasound elastography of the liver.

RESULTS

Main semi quantitative strain parameters, such as average strain value, differed significantly among groups polycystic ovary syndrome with nonalcoholic fatty liver disease, polycystic ovary syndrome without nonalcoholic fatty liver disease, and control (87.02 ± 10.16 vs. 96.31 ± 11.44 vs. 104.49 ± 7.28, p < 0.001). Clinical and laboratory parameters differed significantly between the two subgroups with low or high average strain value. For diagnostic value of average strain value for elevated aminotransferase, the area under the curve was 0.808 (range 0.721-0.895). In multiple linear regression analysis, polycystic ovary syndrome, waist circumference, and metabolic syndrome were stand-alone independent factors associated with average strain value among subjects without nonalcoholic fatty liver disease.

CONCLUSION

Semiquantitative real-time ultrasound elastography analysis could distinguish liver parenchyma alterations in patients with polycystic ovary syndrome more sensitively. The diagnostic value of the proposed method for nonalcoholic fatty liver disease need further research.

Systematic review of menstrual hygiene management requirements, its barriers and strategies for disabled people

BACKGROUND

One quarter of the global population is of menstruating age, yet menstruation is shrouded in discrimination and taboos. Disability also carries stigma, so disabled people may face layers of discrimination when they are menstruating. The objective of the review is to assess the menstrual hygiene requirements of disabled people, the barriers they face, and the available interventions to help them manage their menstruation hygienically and with dignity.

METHODS

Eligible studies, gathered across all countries, were identified by conducting searches across four databases (MEDLINE, PubMed, EMBASE, Global Health) in May 2017, with alerts set on each database to highlight new titles added until April 2018. Eligible studies incorporated analyses relevant to menstruating disabled people and/or how their carers provide support during their menstrual cycle.

RESULTS

The 22 studies included were published since 1976; the majority after 2010 (n = 12; 55%). One study was a quasi-experiment; all others were observational. Most studies (n = 15; 68%) were from high income countries and most (n = 17; 77%) focused on people with intellectual impairments, so the review findings focus on this group and their carers. Outcomes investigated include choice and preference of menstrual product, ability to manage menstrual hygiene and coping strategies applied. Barriers faced included a lack of standardised guidance for professional carers; a lack of menstruation training, information and support provided to people with intellectual impairments and their carers; a lack of understanding of severity of symptoms experienced by people with intellectual impairments, the high cost of menstrual products and lack of appropriate options for people with physical impairments. Few interventions were found, and strategies for menstrual hygiene management applied by carers of persons with intellectual impairments include limiting the disabled person's movements when menstruating and suppressing their menstruation.

CONCLUSIONS

Little evidence was identified on the requirements of disabled people and their carers in managing their menstruation, and only one intervention, but a range of barriers were identified. This gap in evidence is important, as the consequences of failing to meet menstrual hygiene needs of disabled people includes shame, social isolation, and even sterilisation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018095497.

Iron status at opposite ends of the menstrual function spectrum

OBJECTIVES

Although exercising women are at high risk of poor iron status, it is unknown how non-pathological, physiological menstrual function affects iron status. As such, this study investigates the association between menstrual function and iron status in exercising women with amenorrhea and exercising women with ovulatory, eumenorrheic menstrual cycles.

DESIGN

Cross-sectional analysis of iron depletion prevalence, iron status indices, exercise parameters, and diet composition.

METHODS

Women aged 18-35 years performing at least 2 h per week of aerobic exercise were recruited. Women with amenorrhea (AMEN) were defined by the absence of menses for at least 90 days or less than 6 menses in the past 12 months (n = 82). Women with ovulatory, eumenorrheic menstrual cycles (OvEU) were defined by the presence of ovulatory cycles of 26-35 days in length for the past 6 months (n = 109). Group differences in serum ferritin (Ft), soluble transferrin receptor (sTfR), total body iron (TBI), hemoglobin (Hb), hematocrit (Hct), iron depletion prevalence (Ft <15 μg/L), peak oxygen consumption (VO_2peak), exercise minutes per week, and diet logs were assessed.

RESULTS

The prevalence of iron depletion was greater in OvEU when compared to AMEN (26% vs. 15%, p = 0.04). No significant differences were observed between AMEN and OvEU in Ft (30.2 ± 2.2 vs. 24.9 ± 2.6 μg/L; p = 0.62), sTfR (5.2 ± 1.4 vs. 4.9 ± 1.5 mg/L; p = 0.95), TBI (5.3 ± 2.7 vs. 4.8 ± 3.7 mg/kg; p = 0.42), Hb (13.2 ± 0.4 vs. 13.4 ± 0.6 g/dL; p = 0.80), Hct (39.5 ± 0.8% vs. 39.8 ± 4.1%; p = 0.93), or exercise parameters. AMEN consumed more vitamin C than OvEU (269 ± 180 vs. 129 ± 141 mg/day, p < 0.001), but all other dietary factors were similar between AMEN and OvEU.

CONCLUSION

Exercising women with ovulatory, eumenorrheic cycles are at a greater risk of iron depletion than exercising, amenorrheic women. Thus, menstrual function must be considered when screening for poor iron status in exercising women.

Practice and lived experience of menstrual exiles (Chhaupadi) among adolescent girls in far-western Nepal

Background

Menstrual exile, also known as Chhaupadi, is a tradition of “untouchability” in far-western Nepal. Forbidden from touching other people and objects, women and girls are required to live away from the community, typically in a livestock shed, during menstruation. We assessed the lived experiences of Chhaupadi among Nepalese adolescent girls in the far-western Achham district of Nepal, observed the safety and sanitation of their living spaces during Chhaupadi, and assessed the perceptions of local adult stakeholders towards the practice of Chhaupadi.

Methods

We collected data from 107 adolescent girls using a self-administered survey in two local schools in Achham. We also conducted a focus group discussion with seven girls, held key informant interviews, and observed the girls’ living spaces during Chhaupadi, using a checklist. Descriptive statistics of the quantitative survey and thematic analyses of qualitative interviews are presented.

Results

The majority of the girls (n = 77, 72%) practiced exile, or Chhaupadi, during their menstruation, including 3 (4%) exiled to traditional Chhau sheds, 63 (82%) to livestock sheds, and 11 (14%) to courtyards outside their home. The remaining girls (n = 30, 28%) stayed inside the house, yet practiced some form of menstrual taboos. Of the 77 observed living spaces where the girls stayed during exile, only 30% (n = 23) had a toilet facility. Most exiled girls (97.4%) were restricted from eating dairy products. Participants reported having various psychological problems, including lonliness and difficulty sleeping while practicing Chhaupadi. Three of the girls were physically abused; nine were bitten by a snake. Notably high proportions of the living spaces lacked ventilation/windows (n = 20, 26%), electricity (n = 29, 38%), toilets (n = 54, 70%) and a warm blanket and mattress for sleeping (n = 29, 38%). Our qualitative findings supported our quantitative results.

Conclusions

Chhaupadi has been condemned by human rights organizations. While the government has banned the practice, implementation on the ban is proceeding slowly, especially in far-western Nepal. Thus, as a temporary measure, public health professionals must work towards promoting the health and safety of Nepalese women and girls still practicing Chhaupadi.

Menstrual and reproductive factors and risk of vertebral fractures in Japanese women: the Japan Public Health Center-based prospective (JPHC) study

This large-scale population-based cohort study in Japan was conducted to clarify the effects of menstrual and reproductive factors on the risk of later-life vertebral fractures in women. Significant associations were seen for later menarche, irregular menstruation, and shorter reproductive years, corresponding to the effect of reproductive hormonal disturbance on bone metabolism.

INTRODUCTION

This study investigated the association between menstrual and reproductive factors and the risk of later-life vertebral fractures in women.

METHODS

Participants were 43,652 women aged 40-69 years who were followed in the 10-year survey of the Japan Public Health Center-based prospective (JPHC) study. Menstrual/reproductive factors were as follows: age at menarche and menopause, menstrual regularity and cycle length, natural or surgical menopause, years since menopause, reproductive years, parity, age at first birth, number of births, breastfeeding, and female hormone use. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by logistic regression analysis with adjustment for well-known fracture risk factors and menstrual/reproductive factors.

RESULTS

During the 10-year period, 250 women reported first onset of vertebral fractures. Menarche at ≥16 years [OR (95% CI) = 2.08 (1.24-3.48)] compared to ≤ 13 years and irregular menstruation [1.42 (1.01-2.00)] compared to regular menstruation showed significantly higher adjusted ORs. Longer reproductive years had significant inverse association [0.96 (0.92-0.99)] in menopausal women. Women with both menarche ≥ 15 years and irregular menstruation had higher adjusted ORs (95% CI) [2.37 (1.51-3.73) in all women, 2.25 (1.35-3.76) in menopausal women] compared to women without these, and both factors had significant interaction, particularly in menopausal women (additive p = 0.025, multiplicative p = 0.0499).

CONCLUSIONS

Menstrual and reproductive factors, corresponding to the effect of reproductive hormonal disturbance on bone metabolism, might affect the risk of later-life vertebral fractures.

Effectiveness of mobile application for menstrual management of working women in Japan: randomized controlled trial and medical economic evaluation

AIMS

Hormonal imbalances can affect a woman's physical and mental condition, impacting her daily life and productivity. A mobile application, "Karada-no-kimochi", predicts the menstrual cycle based on recorded data, and provides the information regarding menstruation. This study investigates the effectiveness of the application from health condition and labor productivity loss perspectives, and evaluates its cost-effectiveness for employed women in Japan.

MATERIALS AND METHODS

A randomized controlled trial (RCT) was performed to compare the use of the application and non-intervention in female workers (20-45 years) based on an online survey. A discrete-event model based on the RCT data, published literature, and claims data was used for the cost-effectiveness analysis.

RESULTS

The intervention and non-intervention groups comprised 612 and 914 women, respectively. In the intervention group, the incidences of depression (0.16%) and dysmenorrhea (0.33%) were significantly lower than those of the non-intervention group (0.77% and 1.31%, respectively) in the third month. While labor productivity and absenteeism varied, presenteeism showed almost no change across groups. The quality-adjusted life year in the intervention group was 6.84 (0.07 higher than that in the non-intervention group). By analyzing medical expenses and making assumptions regarding productivity, we estimated that the aggregate of medical expenses, productivity loss, and application fee for the intervention group could be lower than that of the non-intervention group by over JPY 130,000 (USD 1,170, as of December 2017) per individual.

LIMITATIONS

The subjects included were willing or relatively willing to use the application. Because all outcomes were based on online surveys, the results depended on the objectivity and preciseness of the reports provided by users, and those with severe symptoms might not provide reports.

CONCLUSIONS

The results suggest that using the application is cost-effective and might reduce the incidence of dysmenorrhea and depression.

Effect of baseline menstrual bleeding pattern on copper intrauterine device continuation

BACKGROUND

Heavy menstrual bleeding is a leading cause of copper intrauterine device discontinuation. Thus, girls and women with heavy baseline menstrual bleeding may be at increased risk for early copper intrauterine device discontinuation.

OBJECTIVE

Our objective was to assess if there was an association between baseline menstrual bleeding pattern prior to intrauterine device insertion and discontinuation rate at 12 months among study participants who chose copper intrauterine device at baseline.

STUDY DESIGN

We performed a secondary analysis of the Contraceptive CHOICE Project, a prospective observational cohort study of 9256 girls and women offered no-cost contraception for 2-3 years. Included in our study were participants who chose copper intrauterine device for contraception and for whom method continuation data at 12 months were available. Prior to contraception initiation, participants were asked to qualify their menstrual bleeding over the past year as: light, moderate, moderately heavy, or heavy. Light bleeding corresponded to using ≤10 pads/tampons per period. Moderate, moderately heavy, and heavy bleeding corresponded to 11-20 pads/tampons, 21-30 pads/tampons, and >30 pads/tampons per period, respectively. Subjects were then categorized into either a "heavy" baseline group (those reporting moderately heavy or heavy bleeding at baseline), or a "not heavy" group (those reporting light or moderate bleeding). The 12-month continuation rate for each group was then calculated using Kaplan-Meier survival function, and hazard ratio for risk of discontinuation was evaluated using a Cox proportional hazard model to determine if moderately heavy or heavy bleeding at baseline was associated with early discontinuation.

RESULTS

Of the 918 girls and women meeting the inclusion criteria for this analysis, 165 were in the heavy baseline bleeding group, while 753 were in the not heavy bleeding group. The 12-month continuation rates for groups were similar: 80.2% (heavy) and 85.0% (not heavy; P = .24). Patients reporting either moderately heavy or heavy baseline bleeding were not at increased risk for early discontinuation of copper intrauterine device (hazard ratio, 1.21; 95% confidence interval, 0.88-1.66). Our sample size provided >90% power to detect a clinically important difference of 15% (assuming 20% discontinuation rate in not heavy bleeding group and a 35% discontinuation rate in the heavy bleeding group).

CONCLUSION

We did not find that girls and women who reported baseline moderately heavy or heavy menstrual bleeding were at increased risk for early discontinuation. Thus, we do not believe that girls and women with heavy menstrual bleeding should be discouraged from using this safe and highly effective form of contraception.

Subclinical inflammation in a case of menstruation-induced familial Mediterranean fever: A case report

RATIONALE

Because most patients with familial Mediterranean fever (FMF) have attacks without any prodromal symptoms, and since it is suggested that patients with FMF have subclinical inflammation even during remission, a daily continuous administration of colchicine is recommended for patients with FMF even during remission. However, it is possible that intermittent colchicine therapy only during FMF attacks prevents the attacks completely in patients with FMF with expectable attacks.

PATIENT CONCERNS

A 31-year-old Japanese woman suffered high fever and arthralgia lasting for 2 to 3 days after each menstrual period's start. She was admitted to our hospital, and colchicine was administered immediately after her next period's start, and the febrile attack was completely prevented.

DIAGNOSES

We eventually diagnosed typical FMF.

INTERVENTIONS

Her remission has been maintained by intermittent colchicine therapy.

OUTCOMES

The genetic analysis revealed the G304R heterozygous mutation in exon 2 of the MEFV gene. Cytokine analysis suggested subclinical inflammation during the remission period.

LESSONS

This case suggests that taking an extensive medical history (including the relationship between fever attack and menstruation) is important in the diagnosis of female patients with FMF. This case also suggests that a continuous administration of colchicine may have to be considered to regulate subclinical inflammation even in patients with FMF with completely expectable attacks.

A missing piece: the spiny mouse and the puzzle of menstruating species

We recently discovered the first known menstruating rodent. With the exception of four bats and the elephant shrew, the common spiny mouse (Acomys cahirinus) is the only species outside the primate order to exhibit menses. There are few widely accepted theories on why menstruation developed as the preferred reproductive strategy of these select mammals, all of which reference the evolution of spontaneous decidualisation prior to menstrual shedding. Though menstruating species share several reproductive traits, there has been no identifiable feature unique to menstruating species. Such a feature might suggest why spontaneous decidualisation, and thus menstruation, evolved in these species. We propose that a ≥3-fold increase in progesterone during the luteal phase of the reproductive cycle is a unique characteristic linking menstruating species. We discuss spontaneous decidualisation as a consequence of high progesterone, and the potential role of prolactin in screening for defective embryos in these species to aid in minimising implantation of abnormal embryos. We further explore the possible impact of nutrition in selecting species to undergo spontaneous decidualisation and subsequent menstruation. We summarise the current knowledge of menstruation, discuss current pre-clinical models of menstruation and how the spiny mouse may benefit advancing our understanding of this rare biological phenomenon.

There might be blood: a scoping review on women's responses to contraceptive-induced menstrual bleeding changes

INTRODUCTION

Concern about side effects and health issues are common reasons for contraceptive non-use or discontinuation. Contraceptive-induced menstrual bleeding changes (CIMBCs) are linked to these concerns. Research on women's responses to CIMBCs has not been mapped or summarized in a systematic scoping review.

METHODS

We conducted a systematic scoping review of data on women's responses to CIMBCs in peer-reviewed, English-language publications in the last 15 years. Investigator dyads abstracted information from relevant studies on pre-specified and emergent themes using a standardized form. We held an expert consultation to obtain critical input. We provide recommendations for researchers, contraceptive counselors, and product developers.

RESULTS

We identified 100 relevant studies. All world regions were represented (except Antarctica), including Africa (11%), the Americas (32%), Asia (7%), Europe (20%), and Oceania (6%). We summarize findings pertinent to five thematic areas: women's responses to contraceptive-induced non-standard bleeding patterns; CIMBCs influence on non-use, dissatisfaction or discontinuation; conceptual linkages between CIMBCs and health; women's responses to menstrual suppression; and other emergent themes. Women's preferences for non-monthly bleeding patterns ranged widely, though amenorrhea appears most acceptable in the Americas and Europe. Multiple studies reported CIMBCs as top reasons for contraceptive dissatisfaction and discontinuation; others suggested disruption of regular bleeding patterns was associated with non-use. CIMBCs in some contexts were perceived as linked with a wide range of health concerns; e.g., some women perceived amenorrhea to cause a buildup of "dirty" or "blocked" blood, in turn perceived as causing blood clots, fibroids, emotional disturbances, weight gain, infertility, or death. Multiple studies addressed how CIMBCs (or menstruation) impacted daily activities, including participation in domestic, work, school, sports, or religious life; sexual or emotional relationships; and other domains.

CONCLUSIONS

Substantial variability exists around how women respond to CIMBCs; these responses are shaped by individual and social influences. Despite variation in responses across contexts and sub-populations, CIMBCs can impact multiple aspects of women's lives. Women's responses to CIMBCs should be recognized as a key issue in contraceptive research, counseling, and product development, but may be underappreciated, despite likely - and potentially substantial - impacts on contraceptive discontinuation and unmet need for modern contraception.

Higher energy intake at dinner decreases parasympathetic activity during nighttime sleep in menstruating women: A randomized controlled trial

BACKGROUND

Previous studies have found more frequent increases in dietary intake and nonrestorative nocturnal sleep during the luteal phase than in the follicular phase, but few studies have investigated how increased energy intake at dinner influences sleep by considering the correlation between female hormone and cardiac autonomic nervous system (ANS) activity. This study examined the effects of energy intake at dinner on ANS activity during nighttime sleep in order to evaluate restorative sleep in healthy women. We also examined whether ANS activity is associated with female hormone dynamics.

METHODS

Twenty-four healthy collegiate women participated in this randomized crossover trial. Each was assigned to receive a High Energy Dinner (HED) or Low Energy Dinner (LED) treatment. Energy ratios of each test meal (breakfast, lunch, and dinner) to total energy intake were 1:1:2 and 1:2:1 for HED and LED treatments, respectively. Each participant wore an ECG recorder before dinner and removed it upon waking the next morning. Power spectral analysis of heart rate variability was used to calculate low frequency (LF), high frequency (HF), and total spectral power (TP). Cardiac sympathetic (SNS) and parasympathetic (PNS) nervous system activity were evaluated as LF/HF and HF/TP, respectively.

RESULTS

Mean HF/TP for the entire sleeping period was lower with HED treatment compared to LED treatment (41.7 ± 11.4 vs. 45.0 ± 12.13, P = .034). Intergroup comparisons of the initial 3-h sleeping period revealed that LF/HF (0.87 ± 0.82 vs. 0.66 ± 0.82, P = .013) and HF/TP (45.6 ± 13.9 vs. 51.5 ± 11.8, P = .002) were higher and lower, respectively, with HED treatment compared to LED treatment. Progesterone levels were positively correlated with LF/HF with LED treatment, and negatively correlated with HF/TP with both HED and LED treatments.

CONCLUSION

Higher energy intake at dinner increases and decreases SNS and PNS activities, respectively, resulting in nonrestorative nocturnal sleep. In addition, a negative correlation was observed between progesterone and PNS activity, highlighting the difficulty of increasing PNS activity during sleep in the luteal phase compared to the follicular phase.