Short and long-term menstrual, reproductive, and mental health outcomes after the intrauterine use of chitosan tamponade or the Bakri balloon for severe postpartum hemorrhage: an observational study

OBJECTIVE

This retrospective follow-up study analyzes the effect of intrauterine postpartum hemorrhage (PPH) therapy on menstrual, reproductive, and mental health outcomes.

METHODS

All women who delivered at a university hospital between 2016 and 2021 with PPH and who needed intrauterine therapy were included. A questionnaire on well-being, menses, fertility, and reproductive outcomes was mailed to the patients. Those who did not reply were surveyed by telephone.

RESULTS

A total of 214 women treated with chitosan-covered gauze (group A) and 46 women treated with a balloon tamponade (group B) were recruited, and their short-term courses were analyzed. For long-term follow-up, 71 women of group A (33%) and 21 women of group B (46%) could be reached. A total of 89% of group A and 95% of group B had regular menstrual bleeding in the most recent 12 months; 27% (group A) and 29% (group B) were trying to conceive again, and all of them did so successfully. There were 12 deliveries, 3 ongoing pregnancies, 3 miscarriages, and 2 terminations of pregnancies (TOP) in group A and 4 deliveries, 1 miscarriage, and 2 TOPs in group B. More than half of our study participants was sorted into grade II or III of the Impact of Events Scale, indicating they experienced clinical impacts in the form of psychological sequelae. One-quarter of patients had symptoms of post-traumatic stress disorder.

CONCLUSION

Chitosan gauze as well as balloon tamponade appear to have few adverse effects on subsequent menstrual and reproductive function. Women after PPH are at increased risk of long-term adverse psychological outcomes.

The effect of level of anxiety about climate change on the use of feminine hygiene products

OBJECTIVE

The purpose of this study was to evaluate the relationship between women's menstrual hygiene product use and their level of concern around climate change as well as to identify the variables influencing this relationship.

METHODS

In all, 978 women between the ages of 18 and 49 who were of reproductive age participated in this descriptive cross-sectional study. The CHERRIES criteria were followed in conducting the online survey. Data were gathered using the "personal information form" and the Climate Change Anxiety Scale for Women's Health The data were analyzed using descriptive analysis, multiple linear regression, and logistic regression.

RESULTS

Women were more prone to using throwaway goods than eco-friendly, sanitary goods when their climate change worry level was lower. Age, education level, region of residence, and the intensity of menstrual bleeding have an impact on the hygiene products used during the menstrual cycle, whereas environmental pollution in the area of residence and a woman's allergy status have an impact on the level of climate change anxiety concerning a woman's health.

CONCLUSION

Women who are worried about how climate change will affect their health prefer to purchase sustainable/eco-friendly items. Starting in adolescence, women can receive advice about the use of sustainable products from health experts who are primarily responsible for women's health.

Elementary School Nurses' Perceptions Regarding Menstruation Education: An Exploratory Study

Menarche can be a difficult transition for young people. With appropriate education, youth can feel more positively about the menstrual experience. Since many elementary teachers are not equipped with menstrual health knowledge, the education falls to the school nurse. However, it is unknown if school nurses feel comfortable communicating about menstruation with young people. The purpose of this study was to explore school nurses' perceptions regarding menstrual health education in elementary schools (grades K-5).An online mixed-methods survey was established using Qualtrics. Through snowball sampling, 30 elementary school nurses responded. Using the Integrated Behavioral Model (IBM) as a framework, a deductive semantic thematic analysis was used to identify themes for each question.Data suggested that elementary school nurses would participate in professional development regarding menstrual health and hygiene. School health nurses are receiving limited knowledge/skills surrounding pedagogy and are not familiar with cultural differences when it comes to menstrual health.

Menstrual Blood Donation for Endometriosis Research: A Cross-Sectional Survey on Women's Willingness and Potential Barriers

An anonymous online survey in French was used to assess if endometriosis patients would be as ready as unaffected women to donate their menstrual blood for biological research on endometriosis and evaluate potential barriers to such donation. It was distributed in September 2022 by social media and two mailing lists, including a French patient organization. The questionnaire assessed participant age and brief medical history (hormonal contraception, endometriosis diagnosis, type of endometriosis), menstrual experience (menstrual blood abundance, dysmenorrhea), and whether participants would donate menstrual blood. Women who self-declared with an established endometriosis diagnosis versus no endometriosis were compared. Seven hundred seventy-eight women answered the survey. Among women with menstruation (n = 568), 78% are willing to donate menstrual blood for research. Importantly, this proportion was higher in women who declared having an established endometriosis diagnosis (83%, n = 299) compared to self-declared unaffected women (68%, n = 134, p < 0.001). The previous use of a menstrual cup and dysmenorrhea were significantly associated with the willingness to donate menstrual blood, while the use of hormonal contraception was significantly associated with an unwillingness to donate. Only the previous use of the menstrual cup had a predictive value for menstrual blood donation. No significant relationship was observed between menstrual blood donation and age, heavy menstrual bleeding and in endometriosis patients, endometriosis subtypes. In conclusion, women affected or not by endometriosis are largely willing to donate their menstrual blood for research on endometriosis, dysmenorrhea is not a barrier for donation, and women who use a menstrual cup are the more likely to donate.

Factors influencing menstrual regularity among female workers: a cross-sectional analysis study

BACKGROUND

Regularity of menstrual cycles is an important indicator of women's health and fertility, and female workers are exposed to several factors, such as sleep disorders, stress, and shift work, that affect their menstrual regularity. This makes it necessary to comprehensively identify the determinants of menstrual regularity. Therefore, this study identified the factors affecting menstrual regularity among female workers from physiological, psychological, and situational dimensions based on the theory of unpleasant symptoms.

METHODS

This was a secondary analysis of the 2010-2012 Korea National Health and Nutrition Examination Survey and utilized the data of 2418 female workers. Based on the theory of unpleasant symptoms, physiological factors included age, age at menarche, childbirth experience, body mass index, and sleep duration. Psychological factors included stress level, depressive mood, and suicidal ideation. Situational factors included education level, household income, consumption of alcohol, engagement in smoking, and work schedule. The χ²-test and hierarchical logistic regression analysis were performed, reflecting the complex sample design.

RESULTS

Age at menarche, childbirth experience, and body mass index among physiological factors and education level and work schedule among situational factors were found to be related to menstrual regularity. A higher risk of menstrual irregularities was found among those who had given birth (versus those who had not), had a high age at menarche (versus those with a low age at menarche), were obese (versus those who had a normal body mass index), had elementary school-level or lesser educational achievements (versus those with college graduate-level or higher educational achievements), and who had a shift work schedule (versus those with a fixed schedule).

CONCLUSIONS

Intervention is needed for female workers who have these risk factors, and special attention must be paid to female workers who have a shift work schedule. Additionally, since body mass index can be controlled, intervention concerning body mass index is necessary to reduce menstrual irregularity.

Clients' expectations and experiences with providers of menstrual regulation: a qualitative study in Bangladesh

BACKGROUND

Menstrual Regulation (MR) has been legal in Bangladesh since 1979 in an effort to reduce maternal mortality from unsafe abortion care. However, access to high-quality and patient-centered MR care remains a challenge. This analysis aimed to explore what clients know before going into care and the experience itself across a variety of service delivery sites where MR care is available.

METHODS

We conducted 26 qualitative semi-structured interviews with MR clients who were recruited from three different service delivery sites in Dhaka, Bangladesh from January to March 2019. Interviews explored client expectations and beliefs about MR care, the experience of the care they received, and their perception of the quality of that care. We conducted a thematic content analysis using a priori and emergent codes.

RESULTS

Clients overall lacked knowledge about MR care and held fears about the damage to their bodies after receiving care. Despite their fears, roughly half the clients held positive expectations about the care they would receive. Call center clients felt the most prepared by their provider about what to expect during their MR care. During counseling sessions, providers at in-facility locations reinforced the perception of risk of future fertility as a result of MR and commonly questioned clients on their need for MR services. Some even attempted to dissuade nulliparous women from getting the care. Clients received this type of questioning throughout their time at the facilities, not just from their medical providers. The majority of clients perceived their care as good and rationalized these comments from their providers as coming from a caring place. However, a handful of clients did report bad care and negative feelings about their interactions with providers and other clinical staff.

CONCLUSION

Providers and clinical staff can play a key role in shaping the experience of clients accessing MR care. Training on accurate knowledge about the safety and effectiveness of MR, and the importance of client communication could help improve client knowledge and person-centered quality of MR care.

How autistic women are aware of their body and take care of their health? Focus on menstruation cycles and gynecological care

Objective

The combination of femininity and inequality is an increasingly studied in the field of social medicine, even more if the girls or women in question experience conditions of disability or neurodivergence. The onset of menstruation, menarche, constitutes a significant and transformative event in women's lives comprising a true and proper watershed in mental and reproductive health and sexual welfare. The onset of menstruation has a profound effect not just for girls but, in the case of disabled girls, for the whole family. In this scoping review, we have researched the literature in studies which consider the issue of menstruation and autism. The works in scientific literature have been selected which, in the last 5 years, investigated the issue of menstrua-tion for autistic girls and/or women.

Results

Selected studies, although few in number, have all equally evidenced the total lack of in-depth understanding of this theme, notwithstanding the fact that females, girls and women with autism would benefit from specialized services if these existed. Families, girls and women involved, moreover, although not experiencing menstruation per se in a negative light, note a deterioration in their condition particularly in respect of sensorial perception and the intensification of anxious depressive instances. This work highlights the need to deepen the aspects concerning the period in autistic girls/women, up to now the question appears to have been little studied, investigated in an uneven way. We propose a social medical program to improve sexual-affective knowledge and body awareness in autistic people.

Exploring the practice of Iranian adolescent females during menstruation and related beliefs: a qualitative study

BACKGROUND

Menstruation is a natural occurrence that women experience during their reproductive years and may encounter many years throughout their lifespan. Many adolescent females lack accurate knowledge about menstruation, so they may face issues from receiving incorrect information from unreliable sources. Our study aimed to investigate the practices and beliefs surrounding menstruation among Iranian adolescent females.

METHODS

This qualitative study was conducted using conventional content analysis. A purposeful sampling method was used to select 18 adolescent females from secondary and high schools located in the three regions of Neyshabur City-Iran. Data were collected through in-depth, semi-structured interviews.

RESULTS

Three main themes were extracted, consisting of lifestyle and related beliefs, lake of support, and awareness and information.

CONCLUSIONS

misconceptions and wrong behaviors during menstruation indicate that the lake of knowledge an traditional factors influence adolescent girls' health. The study provides the basis for intervention planning in this regard and different levels (individual, intrapersonal, health systems, and community).

Protocol for the Adolescent Menstrual Experiences and Health Cohort (AMEHC) Study in Khulna, Bangladesh: A Prospective cohort to quantify the influence of menstrual health on adolescent girls' health and education outcomes

BACKGROUND

Menstrual health is essential for gender equity and the well-being of women and girls. Qualitative research has described the burden of poor menstrual health on health and education; however, these impacts have not been quantified, curtailing investment. The Adolescent Menstrual Experiences and Health Cohort (AMEHC) Study aims to describe menstrual health and its trajectories across adolescence, and quantify the relationships between menstrual health and girls' health and education in Khulna, Bangladesh.

METHODS AND ANALYSIS

AMEHC is a prospective longitudinal cohort of 2016 adolescent girls recruited at the commencement of class 6 (secondary school, mean age=12) across 101 schools selected through a proportional random sampling approach. Each year, the cohort will be asked to complete a survey capturing (1) girls' menstrual health and experiences, (2) support for menstrual health, and (3) health and education outcomes. Survey questions were refined through qualitative research, cognitive interviews and pilot survey in the year preceding the cohort. Girls' guardians will be surveyed at baseline and wave 2 to capture their perspectives and household demographics. Annual assessments will capture schools' water, sanitation and hygiene, and support for menstruation and collect data on participants' education, including school attendance and performance (in maths, literacy). Cohort enrolment and baseline survey commenced in February 2023. Follow-up waves are scheduled for 2024, 2025 and 2026, with plans for extension. A nested subcohort will follow 406 post-menarche girls at 2-month intervals throughout 2023 (May, August, October) to describe changes across menstrual periods. This protocol outlines a priori hypotheses regarding the impacts of menstrual health to be tested through the cohort.

ETHICS AND DISSEMINATION

AMEHC has ethical approval from the Alfred Hospital Ethics Committee (369/22) and BRAC James P Grant School of Public Health Institutional Review Board (IRB-06 July 22-024). Study materials and outputs will be available open access through peer-reviewed publication and study web pages.

The effect of perceived stress on menstrual complaints in university students

Studies have examined the effect of stress on dysmenorrhea and premenstrual syndrome. For this reason in this study, it was aimed to determine the impact of stress on menstrual symptoms (adverse effects, abdominal pain, and coping methods). This descriptive and correlational study was conducted with 351 university students in Turkey by sharing the link to the questionnaire on online social media platforms. It was determined that those whose income was equal to their expenses had lower menstrual symptoms, having a chronic disease and smoking increased menstrual symptoms (F = 3.19/p = .04; t = 2.33/p = .02; t = 3.96/p = .00). The study identified that there was a positive low-level correlation (r: 0.25, p < .01) between the Perceived Stress Scale-14 and the Menstruation Symptom Questionnaire, and the 6.5 percent change in menstrual symptoms was explained by perceived stress. In the study, it is thought that stress affects the experience of menstrual symptoms. Therefore, it is believed that by providing training on stress and effective coping methods by midwives and nurses, menstrual symptoms can be reduced, contributing to women's health. For future studies, it is recommended to examine the effects of stress coping methods training on stress and menstrual complaints.

Periods Shouldn't Bring Any Adolescents' World to a Full Stop. Period. An Online Survey of Adolescents' Experience of Menstruation

STUDY OBJECTIVE

Few studies have explored what specific outcome measures contained in assessment tools for period and pelvic pain are most relevant to adolescents. Co-design is a valuable method of ensuring input from those with lived experience. The Longitudinal Study of Teenagers with Endometriosis Periods and Pelvic Pain in Australia (LongSTEPPP) Co-Design Periods Survey comprised an anonymous online survey of adolescents' experience of menstruation to inform patient-reported outcome measures for the larger 5-year project.

METHODS

Adolescents aged 12-18 years whose periods had commenced at least 3 months previously and with demonstrated capacity to consent were invited to participate in an online survey. Recruitment was primarily via social media channels.

RESULTS

Of the 1811 adolescents who participated, 85% reported that periods had a "moderate" or greater impact on their life. Pain (90.7%), heavy flow (56.2%), and worry about leakage (49%) were common reasons for missed activities. Menstrual symptoms were wide-ranging and included cramping, nausea, poor energy, and impacts on mood. When asked where adolescents sought assistance with their periods, 39.8% had seen their general practitioner, 21.3% their school nurse, and almost 1 in 10 had consulted a mental health practitioner (9.3%). To manage menstrual symptoms, heat packs (66.0%), over-the-counter medications (55.8%), and prescription medications (28.6%) were used.

CONCLUSION

We found a lack of menstrual health awareness in adolescents. Periods had a significant effect on their lives, and adolescents commonly missed activities. In managing menstruation, a wide range of practitioners were consulted. Nearly a third were prescribed medication to manage their periods. These findings have directed the longitudinal study as to how best to capture outcome measures that reflect the impact of periods on adolescents.

Urinary and reproductive tract infection symptoms and menstrual hygiene practices in refugee camps in Jordan: A cross-sectional study

BACKGROUND

Urinary tract infections and reproductive tract infections pose significant health risks, particularly among women living in challenging conditions. Unhygienic menstrual practices can exacerbate these risks, impacting physical and psychological well-being.

OBJECTIVES

This study assessed the association between unhygienic menstrual care and self-reported urinary tract infection/reproductive tract infection symptoms among refugee women. In addition, it explored the association between these symptoms and mental health, specifically depressive symptoms.

DESIGN

This study adopted a cross-sectional observational design.

METHODS

This study was conducted between January and March 2023, involving 387 reproductive-age refugee women. Data collected included sociodemographic information and urinary tract infection/reproductive tract infection symptoms. In addition, we used the Menstrual Practice Needs Scale to evaluate menstrual hygiene practices and the Patient Health Questionnaire-9 for depressive symptoms. Statistical analysis was performed using Python version 3.9.12.

RESULTS

Of 387 refugee women, 92.25% reported having urinary or reproductive tract infection symptoms in the previous 3 months. Factors like older age (odds ratio = 1.764, 95% confidence interval = 1.083-2.873, p-value = 0.023), lower family income (odds ratio = 0.327, 95% confidence interval = 0.138-0.775, p-value = 0.011), lower educational level (odds ratio = 0.222, 95% confidence interval = 0.068-0.718, p-value = 0.012), and being married (odds ratio = 0.328, 95% confidence interval = 0.188-0.574, p-value < 0.001) were significantly associated with urinary or reproductive tract infection risk. Difficulties obtaining menstrual products and thus reusing them increased the odds of urinary or reproductive tract infection diagnosis (odds ratio = 2.452, 95% confidence interval = 1.497-4.015, p-value < 0.001). Women with urinary or reproductive tract infection symptoms exhibited higher Patient Health Questionnaire-9 scores than those without (12.14 ± 5.87 vs 9.99 ± 5.86, p-value < 0.001, respectively).

CONCLUSION

This study highlights a high prevalence of urinary or reproductive tract infection symptoms among refugee women residing in camps in Jordan, which was associated with poor menstrual hygiene practices and depressive symptoms. To reduce the urinary tract infection/reproductive tract infection burden in marginalized communities, public health initiatives should enhance healthcare accessibility, provide reproductive education, and promote holistic well-being practices for refugee women.

School nurses and menstrual communication: Destigmatizing the stigma among adolescents

OBJECTIVE

The purpose of this study is to understand how school nurses, often the first line of defense for menstruating adolescents, use communication to assist adolescents in destigmatizing menstruation.

DESIGN

I conducted semi-structured narrative interviews with nine nurses employed in a large school district in Northeast Indiana.

METHODS

Interviews were coded, categorized, and used a phronetic iterative approach.

RESULTS

Analysis determines that nurses assist menstruating students using steps toward accepting menstruation and suggesting ways to avoid menstrual stigmatization.

CONCLUSION

This study suggests that school nurses use positive language to assist students in handling their menstruation problems, develop allyships with parents and other teachers, and stress menstrual education. This study highlights the need for more funding for menstrual products and additional school nurses.

Examining menstrual health experiences in Philadelphia, PA: A qualitative investigation

BACKGROUND

While menstruation is a physiologic process, it remains highly stigmatized. Despite the sheer number of menstruators, menstruation is a highly individualized experience, with wide variation in duration, symptoms, and management. This wide variability lends itself to large disparities in access to menstruation management products and subsequently the lived experience of menstruators.

OBJECTIVES

The research team sought to understand lived menstrual experiences, symptoms, management tactics, and commonly used and desired resources among 20 cisgendered women aged 18-45 years in Philadelphia.

DESIGN

This project was a qualitative research study.

METHODS

We used a collaborative, community-based participatory research approach with No More Secrets, a Philadelphia-based grassroots sexuality awareness and menstrual health hub. Semi-structured telephone interviews were used to gain insight into general menstruation-related experiences, communication, worries, and concerns, with subsequent thematic analysis via Key Words in Context approach.

RESULTS

Four themes emerged following analysis: cycle characteristics, menstruation management, coping resources, and future resources. Participants largely spoke about their menses as a negative experience, asked for more comprehensive, verified sources of information and needed greater access to menstrual management supplies.

CONCLUSION

Menstruation is a highly individualized experience with a large variety in knowledge, menstrual product use, and individual needs. Despite the individuality of menstruation, our community-based research shows that there is a dire need for interventions that promotes knowledge and access to menstrual care.

"Just" a painful period: A philosophical perspective review of the dismissal of menstrual pain

Science and society typically respond to dysmenorrhea-or painful menstrual cramps-as a normal, natural, and inevitable part of menstruation. This normalization has greatly contributed to the systemic dismissal of painful menstrual cramps. Stigma, secrecy, and the expectation to "cope" fuel the normalization of menstrual pain. In this article, I argue that the normalization of menstrual pain restricts the ability to share an excruciating menstrual pain in a way that would otherwise elicit alarm or concern. This can cause clinicians to downgrade menstrual pain, and even menstruating persons to downgrade their own pain. I refer to the dismissal of menstrual pain as an example of a pain-related motivational deficit. A pain-related motivational deficit describes instances in which an utterance fails to motivate due to societal practices and ideas that make it difficult to recognize the import of the embodied experience being shared.

Understanding period poverty and stigma: Highlighting the need for improved public health initiatives and provider awareness

Period poverty affects millions of people who menstruate, but there is limited research to fully understand the scope and impact. Societal stigmas and cultural taboos negatively affect menstruation, a natural, biologic process. When unable to afford or find appropriate menstrual products, individuals may resort to alternative, poorer quality items, which increase their risk of infections. In addition, lack of products may cause individuals to miss events and have negative emotions. Implicit sexism and gender inequality are notable through the high cost of essential period products. Uncomfortable environments prevent patients from openly discussing menstruation with health care providers, who may lack training to competently assess needs and address barriers. Period poverty is a public health issue that not only needs to be addressed by our health care providers but also through increased education in schools and changes in local and federal legislation. In this paper, we discuss the financial, physical, and mental health impacts of period poverty and describe our experience creating a period pantry at a free medical clinic.

Menstrual attitudes in adult women: A cross-sectional study on the association with menstruation factors, contraceptive use, genital self-image, and sexual openness

BACKGROUND

Menstruation is a central part of the everyday life of most women, and menstrual attitudes may impact health and well-being.

OBJECTIVES

This article aimed to map menstrual attitudes among adult women and examine factors associated with these attitudes, such as aspects of menarche and current menstruation, and rarely studied factors, such as genital self-image and sexual openness.

STUDY DESIGN

A cross-sectional online survey.

METHOD

A sample of 1470 women, aged 18-50 years, were recruited through social media sites. The Menstrual Self-Evaluation Scale was used to measure three different attitudes: menstruation as natural, shameful, and bothersome. Multiple linear regression analysis was used to investigate the relationship between each attitude and factors related to menarche and current menstruation, contraceptive use, genital self-image (assessed by Female Genital Self-Image Scale), and sexual openness (Personal Comfort with Sexuality Scale). Sociodemographic variables were included into the models as covariates.

RESULTS

Agreeing with the attitude of menstruation as something natural was predicted primarily by positive emotions at menarche, experiencing less menstrual pain, using no or nonhormonal contraception, and having a positive genital self-image. Perceiving menstruation as bothersome was predicted by a lower educational level, experiencing stronger menstrual pain, having more perimenstrual psychological symptoms, and using hormonal contraceptives. Menstruation as something shameful was chiefly predicted by lower sexual openness and a negative genital self-image.

CONCLUSION

Many women held attitudes about menstruation as both something natural and bothersome. Menarche and current menstruation experiences, and contraceptive method, played central roles in shaping attitudes toward menstruation as natural and bothersome. Viewing menstruation as shameful stood out from other attitudes by indicating a triad of self-objectified shame that includes menstruation, sexuality, and genital self-image. Further research into the relationships between menstruation, contraceptive use, sexuality, and body image is needed to enhance our understanding of women's menstrual health.

Menstrual health matters. Period

Menstrual health is composed of physical and psychosocial factors and fundamental to the well-being of menstruating individuals. Clinicians are urged to assess markers of menstruation as a vital sign, informing potential current and future health risks. Period poverty, or lack of access to menstrual hygiene products, sanitation, and clinical support, is a concern worldwide, particularly for vulnerable populations. As global health authorities and professional medical associations call for menstrual health as a priority, pharmacists are well-positioned to contribute solutions through access, education, advocacy, and research.

"For men, by men": Menstrual victimization and the weaponization of period products in carceral settings

BACKGROUND

The literature on menstruation defines period poverty as the inability to access sufficient period products, education, and sanitary facilities needed to manage menstruation healthily and effectively. While research has identified shortcomings of healthcare in the carceral setting, period poverty behind bars has remained largely absent from criminal legal discourse.

OBJECTIVES

The current study examines the interplay of period poverty and carceral control to introduce the novel concept of menstrual victimization, defined as the physical, emotional, and financial victimization that results from period poverty perpetuated through carceral control.

METHODS

The study uses qualitative content analysis to systematically gather and code journalistic accounts pertaining to the menstrual experiences of incarcerated and previously incarcerated females, criminal justice practitioners, and journalists. The analysis uses literary pieces (n = 99), which were coded deductively and guided by concepts related to structural violence and radical feminist criminology.

RESULTS

The findings shed light on the unique structural harms incarcerated menstruators face and reveal the dearth of needed empirical research on period poverty in carceral spaces. The narratives in the sample revealed how manufactured scarcity of period products within carceral spaces is used as a means of oppression by institutional agents. The emergent themes highlight how the intersection of period poverty and carceral control led to menstrual victimization characterized through shame, humiliation, control, and coercion.

CONCLUSION

Potential outcomes associated with understanding menstrual victimization in the carceral setting are discussed, including reducing menstrual stigma, disseminating health education, minimizing health disparities, and ultimately, shifting modes of holding accountability away from oppressive, retributive, and controlling tactics.

Period Poverty from a Public Health and Legislative Perspective

Period poverty is a global issue that needs to be addressed as a public health crisis. It is directly related to Sustainable Health Goals three, four, five, six, and eight. Period poverty adversely affects the health of anyone capable of menstruating, which is nearly half of the world population, at the physiological, emotional, and psychosocial level. Biases, cultural beliefs, ethical reproductive justice issues, social stigma, and systemic factors contribute to period poverty. Every month, certain menstruators are disproportionately impacted by period poverty and struggle to access basic hygienic necessities. Important stakeholders include not only the individual who experiences menses but also educators and school systems, healthcare professionals, policymakers, public health officials, and researchers. Everyone has a role in addressing period poverty by voting for officials that proactively support legislation, policy, and programs at all levels to effectively advocate for menstrual equity and address barriers contributing to period poverty. This includes policies that increase access to menstrual hygiene products, safe menstrual management methods, and reproductive and women's health education. Programs globally that focus on capacity building and sustainability strategies can be used as models to reduce period poverty, thereby fostering a sense of empowerment and menstruators' sense of autonomy, dignity, and equality.

"They had the lunch lady coming up to assist": The experiences of menarche and menstrual management for adolescents with physical disabilities

BACKGROUND

Menarche is a pivotal time in an adolescent's life but can be experienced differently by those with physical disabilities. Parents typically serve as the primary educators and support for their daughters during this time. Little is known about the parent's perspective of their daughter's experience preparing for menarche and learning to manage menses.

OBJECTIVE

We sought to understand the parent's perspective of the experience of their daughter with a physical disability around menarche and their preferences for health care provider support.

METHODS

Individual semi-structured interviews were conducted with 21 parents of a daughter with a physical disability ages 7-26. Interviews were coded by 2 reviewers using Grounded Theory, with disagreements resolved by consensus.

RESULTS

Six themes emerged regarding the parent's perception of the experiences, including 1) variation in emotional responses to menarche, 2) parent's perception of their daughter's experience with menses and menstrual symptoms, 3) cross-section of disability and menstrual management, 4) menstrual management at school, 5) parental knowledge correlating to daughter's preparation for menarche, and 6) desires for health care provider support.

CONCLUSIONS

All parents reported that their daughters faced challenges during menarche, ranging from emotional distress to dealing with the inaccessibility of hygiene products. Managing periods at schools was particularly burdensome. Parents who were better educated about what to expect were better able to prepare their daughters, but had difficulties finding informed, supportive providers. Health care providers should provide both anticipatory guidance and holistic, respectful, and equitable options for the management of menstrual symptoms.

Building menstrual health and hygiene-supportive environments: exploring teachers' experience in rural Western Kenya

Introduction

Existing school environments and staff play a critical role in Menstrual Health and Hygiene (MHH) for school aged girls in middle and low-income countries. This paper leverages teachers' perspectives on menstruation and the impact of the Menstrual Solutions (MS) study, an open cluster randomized controlled feasibility study to determine the impact of puberty education, nurses support, and menstrual product provision on girls' academic performance and emotional well-being.

Methods

Seventeen focus group discussions were conducted from October 2012 through November 2013 with teachers at six participating schools, held at three different time points during the study period.

Results

Key themes that emerged were emotions and blood, absenteeism, the role of teachers in MHH, and the impact of sensitization. Teachers noted that poor MHH had an impact on school attendance, transparency and openness with teachers, and student behavior in class. It was reported that adolescent girls would absent themselves for 3-5 days during their menstrual cycle depending on what materials they could use, and they would often shy away from teachers, when possible, only speaking to them about their menses if it was urgent or they needed to go home. Emotions such as fear and embarrassment were commonly associated with bleeding. At the midpoint and end of the study, teachers noted that the puberty education and menstrual product provision (where applicable) had a positive impact on girls' attendance, attention, and comfort in the classroom. Girls became more open with both male and female teachers about their menses, and more comfortable and confident in the classroom among all classmates.

Discussion

This research highlights the importance of building an MHH-supportive environment with multiple school personnel within schools to develop a gender-equitable environment for girls to learn confidently without undue interference. Teachers are key adults in adolescent girls' lives, having the potential to foster an environment that empowers girls with greater autonomy to manage their menses. This highlights a need to consider their perspectives in intervention development. Sensitization of teachers and puberty education across both genders are key components to developing the MHH-supportive environment in schools.

Development and validation of the Self-Efficacy in Addressing Menstrual Needs Scale (SAMNS-26) in Bangladeshi schools: A measure of girls' menstrual care confidence

OBJECTIVE

Qualitative studies have described girls' varying levels of confidence in managing their menstruation, with greater confidence hypothesized to positively impact health, education, and social participation outcomes. Yet, measurement of this and other psychosocial components of adolescent girls' menstrual experiences has been weak in global health research, in part due to a dearth of appropriate psychometric tools. We describe the development and validation of the Self-Efficacy in Addressing Menstrual Needs Scale (SAMNS-26).

METHODS

We conducted nine focus group discussions with girls in schools in rural and urban Bangladesh to identify tasks involved in menstrual self-care. This informed our creation of an initial pool of 50 items, which were reviewed by menstrual health experts and refined through 21 cognitive interviews with schoolgirls. Using a self-administered survey, we administered 34 refined items plus additional validation measures to a random sample of 381 post-menarcheal girls (ages 9-17) and retested a subsample of 42 girls two weeks later. We examined the measure's dimensionality using exploratory factor analysis and assessed internal consistency, temporal stability, and construct validity.

RESULTS

Exploratory factor analysis suggested a 26-item scale comprising three correlated sub-scales: the 17-item Menstrual Hygiene Preparation and Maintenance (α = 0.86), the 5-item Menstrual Pain Management (α = 0.87), and the 4-item Executing Stigmatized Tasks (α = 0.77). Sub-scales exhibited good temporal stability. SAMNS-26 scores correlated negatively with measures of anxiety, and girls who preferred to stay at home during their periods had lower SAMNS-26 scores than those who did not.

CONCLUSION

The SAMNS-26 provides a reliable measure of a schoolgirl's confidence in her capabilities to address her menstrual needs. There is initial evidence to support the measure's construct validity in the Bangladesh context as indicated by its relationships with other factors in its theorized nomological network. The tool enables incorporation of self-efficacy into multivariate models for exploring the relationships among antecedents to menstrual experiences and hypothesized impacts on health, wellbeing, and education attainment. Further testing of the tool is recommended to strengthen evidence of its validity in additional contexts.

Menstrual health interventions, schooling, and mental health problems among Ugandan students (MENISCUS): study protocol for a school-based cluster-randomised trial

BACKGROUND

Menstrual health is an increasingly recognised public health issue, defined as complete physical, mental, and social well-being in relation to the menstrual cycle. The MENISCUS trial aims to assess whether a multi-component intervention addressing physical and emotional aspects of menstrual health improves educational attainment, mental health problems, menstrual management, self-efficacy, and quality of life among girls in secondary school in Uganda.

METHODS

The study is a parallel-arm cluster-randomised controlled trial with 60 schools (clusters) in Wakiso and Kalungu districts, with a mixed-methods process evaluation to assess intervention fidelity and acceptability and economic and policy analyses. The schools will be randomised 1:1 to immediate intervention or to optimised usual care with delayed intervention delivery. The intervention includes creation of a Menstrual Health Action Group at schools and NGO-led training of trainers on puberty education, development of a drama skit, delivery of a menstrual health kit including reusable pads and menstrual cups, access to pain management strategies including analgesics, and basic improvements to school water, sanitation, and hygiene facilities. Baseline data will be collected from secondary 2 students in 2022 (median age ~15.5 years), with endline after 1 year of intervention delivery (~3600 females and a random sample of ~900 males). The primary outcomes assessed in girls are (i) examination performance based on the Mathematics, English, and Biology curriculum taught during the intervention delivery (independently assessed by the Uganda National Examinations Board) and (ii) mental health problems using the Total Difficulties Scale of the Strengths and Difficulties 25-item questionnaire. Secondary outcomes are menstrual knowledge and attitudes in girls and boys and, in girls only, menstrual practices, self-efficacy in managing menstruation, quality of life and happiness, prevalence of urogenital infections, school and class attendance using a self-completed menstrual daily diary, and confidence in maths and science.

DISCUSSION

The trial is innovative in evaluating a multi-component school-based menstrual health intervention addressing both physical and emotional aspects of menstrual health and using a "training of trainers" model designed to be sustainable within schools. If found to be cost-effective and acceptable, the intervention will have the potential for national and regional scale-up.

TRIAL REGISTRATION

ISRCTN 45461276 . Registered on 16 September 2021.

'You don't just do it because someone else said so': Menstrual practices and women's agency in the Hindu diaspora of Trinidad

Meanings of menstruation are deeply embedded in culture and religion. The current dominant narrative presents menstrual practices as restrictions and often describes Hindu women as 'subjected to' these practices, characterising them as the oppressed victims of their religion. This article seeks to complicate this oversimplified narrative by exploring women's motivations, choices and decisions related to menstrual practices in a small-scale study based on semi-structured interviews and focus groups with women in the Hindu-Trinidadian diaspora. Our findings indicate that the women we interviewed exercise agency in the cognitive, emotional, religious and socio-cultural spheres. Many of them accept the ritual 'impurity' but overwhelmingly restrict this label to the spiritual sphere and separate it from their menstruating bodies. Many reject the idea that the practices are restrictive or stigmatising. They do not understand religion as the source of menstrual stigma but instead value or accept menstrual practices as part of what it means to be a Hindu woman-motivated by religious observance and/or the desire to be part of a community that upholds tradition. These varied manifestations of women's agency challenge the understanding of menstrual practices as necessarily-and-always oppressive and call for acknowledging the nuance and complexity of women's lives.

Puberty- and Menstruation-Related Stressors Are Associated with Depression, Anxiety, and Reproductive Tract Infection Symptoms Among Adolescent Girls in Tanzania

BACKGROUND

Puberty and menstruation are significant stressors for adolescent girls and young women in low-resource settings in sub-Saharan Africa. However, little is known about the impact of these stressors on girls' mental health and reproductive health.

METHODS

In 2018, a cross-sectional self-report survey was conducted with 581 adolescent girls and young women between 13 to 21 years old who had reached menarche and were attending secondary school in Moshi, Tanzania. Structural equation modeling was used to examine the relationships of puberty-related stressors and menstruation-related stressors (menstrual deficits, movement/activity difficulties, and menstrual symptoms) to depression, anxiety, and the likelihood of reporting reproductive tract infection (RTI) symptoms.

RESULTS

Puberty-specific stressors, menstrual symptoms, and menstrual deficits were associated with depression and anxiety. Movement/activity difficulties were associated with anxiety. Increases in menstrual symptoms, menstrual deficits, puberty stressors, and depression were associated with an increased likelihood of reporting a lifetime RTI. However, the relationship of puberty stressors and depression with RTIs was no longer significant in two of three models after correcting for Type I error.

CONCLUSIONS

Overall, puberty- and menstruation-related stressors were associated with mental health and symptoms of reproductive tract infections. This suggests there is an important relationship between stressors specific to adolescent girls and young women during puberty, mental health, and reproductive health. There is a need for adolescent-tailored interventions to reduce the negative impact of stressors among girls transitioning through puberty in sub-Saharan Africa.

Co-development and piloting of a menstrual, sexual and reproductive health intervention to improve social and psychological outcomes among secondary schoolgirls in Northern Tanzania: the PASS MHW study protocol

INTRODUCTION

Poor menstrual health negatively impacts psychosocial and physical health, and subsequently leads to poor school outcomes, but the effort to improve adolescent girls' menstrual health in Tanzania remains fragmented. This study aimed to develop and pilot a scalable, comprehensive menstrual, sexual and reproductive health (MSRH) intervention within Tanzanian government structures to improve MSRH practices and perceptions and the overall school climate to ensure the psychosocial well-being and optimal school participation and performance among secondary schoolgirls.

METHODS AND ANALYSIS

This study will be conducted in three phases. Phase I will be a formative research to iteratively refine an existing puberty and menstrual health intervention, and to collaboratively design strategies to embed the intervention into government structures thereby promoting scalability. In Phase II, we will pilot and evaluate the refined intervention and implementation strategies using a mixed-methods design to assess (1) feasibility, acceptability and sustainability; and (2) effect on MSRH practices and perceptions and the overall school climate. In Phase III, we will synthesise the research findings in collaboration with the national, regional and district government and non-government stakeholders.

ETHICS AND DISSEMINATION

This pilot study will provide evidence-based recommendations for a comprehensive, complex menstrual and puberty intervention within secondary schools in Tanzania that can be further tested for broader effectiveness across a larger population. Papers, policy briefs and both regional/international conference presentations are planned to reach academic and non-academic groups. Protocol, tools and consent have been reviewed and approved by the independent Tanzanian national ethics committee (NIMR/HQ/R.8a/Vol.IX/3647) and the LSHTM Observational/Interventions Research Ethics Committee (LSHTM Ethics Ref: 22854). The project will involve adolescents, and procedures will be followed to ensure that we obtain permission and consent of parents and guardians and assent from all adolescents below 18 years of age that will be enrolled in the study.

Drivers of menstrual material disposal and washing practices: A systematic review

Background

Disposal and washing facilities and services for menstrual materials are often designed based upon technical specifications rather than an in-depth understanding of what drives peoples’ choices of practices.

Objectives and data sources

This systematic review identified and summarised the main behavioural drivers pertaining to the choice of disposal and washing practices of menstrual materials through the thematic content analysis and study appraisal of 82 publications (80 studies) on menstrual health and hygiene published since 1999, reporting the outcomes of primary research across 26 countries.

Results

Disposal and washing behaviours are primarily driven by the physical state of sanitation facilities; however, this is intrinsically linked to taboos surrounding and knowledge of menstruation.

Implications

Using reasons given for disposal and washing practices by menstruators or those who know them well, or inferred by authors of the reviewed studies, we identify the key considerations needed to design facilities and services which best suit the desired behaviours of both planners and those who menstruate.

Inclusivity

The term menstruators is used throughout to encompass all those mentioned in the studies reviewed (girls and women); although no studies explicitly stated including non-binary or transgender participants, this review uses inclusive language that represents the spectrum of genders that may experience menstruation.

Registration

The review protocol is registered on PROSPERO: 42019140029.

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.

A harmful religio-cultural practice (Chhaupadi) during menstruation among adolescent girls in Nepal: Prevalence and policies for eradication

Background

Chhaupadi is a deeply rooted tradition and a centuries-old harmful religio-cultural practice. Chhaupadi is common in some parts of Karnali and Sudurpaschim Provinces of western Nepal, where women and girls are considered impure, unclean, and untouchable in the menstrual period or immediately following childbirth. In Chhaupadi practice, women and girls are isolated from a range of daily household chores, social events and forbidden from touching other people and objects. Chhaupadi tradition banishes women and girls into menstruation huts’, or Chhau huts or livestock sheds to live and sleep. These practices are guided by existing harmful beliefs and practices in western Nepal, resulting in poor menstrual hygiene and poor physical and mental health outcomes. This study examined the magnitude of Chhaupadi practice and reviewed the existing policies for Chhaupadi eradication in Nepal.

Methods

We used both quantitative survey and qualitative content analysis of the available policies. First, a quantitative cross-sectional survey assessed the prevalence of Chhaupadi among 221 adolescent girls in Mangalsen Municipality of Achham district. Second, the contents of prevailing policies on Chhaupadi eradication were analysed qualitatively using the policy cube framework.

Results

The current survey revealed that most adolescent girls (84%) practised Chhaupadi in their most recent menstruation. The Chhaupadi practice was high if the girls were aged 15–17 years, born to an illiterate mother, and belonged to a nuclear family. Out of the girls practising Chhaupadi, most (86%) reported social and household activities restrictions. The policy content analysis of identified higher-level policy documents (constitution, acts, and regulations) have provisioned financial resources, ensured independent monitoring mechanisms, and had judiciary remedial measures. However, middle (policies and plans) and lower-level (directives) documents lacked adequate budgetary commitment and independent monitoring mechanisms.

Conclusion

Chhaupadi remains prevalent in western Nepal and has several impacts to the health of adolescent girls. Existing policy mechanisms lack multilevel (individual, family, community, subnational and national) interventions, including financial and monitoring systems for Chhaupadi eradication. Eradicating Chhaupadi practice requires a robust multilevel implementation mechanism at the national and sub-national levels, including adequate financing and accountable systems up to the community level.

The Relationship between Menstrual Pattern and Menstrual Attitude Dimensions in Reproductive-age Women

Objective: Women's attitudes towards menstruation play a critical role in shaping their body and psychosocial integrity. Menstruation is affected by some bio-psychosocial factors; therefore, more in-depth understanding is needed to cope better with the consequent difficulties. This study aimed to investigate the relationship between menstrual patterns and menstrual attitude dimensions in reproductive-age women. Methods: An observational cross-sectional study was conducted on 170 women referred to the urban health centers of Torbat Heydariyeh, Iran, from January 2019 to December 2019.  The Menstrual Attitudes Questionnaire (MAQ) and Verbal Multidimensional Scoring (VMS) systems were used to collect the required data. The features of the menstrual cycle were also recorded. Results: The overall response rate was 96.74%. Women with dysmenorrhea perceived menstruation as a more debilitating, bothersome, and predictable event and less denied any menstrual effect (p=0.001). The results also revealed that the subjective menstrual blood loss was associated with higher levels of perceiving menstruation as a natural (p=0.008), bothersome (p=0.026), and anticipatory event (p=0.021) and reporting less denial of any menstrual effect (p=0.001). Moreover, women rated menstruation as a more bothersome event by increasing the menstrual bleeding length (p=0.014). There was no significant relationship between the other features of the menstrual cycle with menstrual dimensions (p>0.05). Conclusion: The findings of this study suggest that women's attitudes towards menstruation was associated with menstrual pain, length, and subjective volume of menstrual flow.  These factors could be used to modify women's attitudes towards the natural phenomenon of menstruation. Keywords: Attitude; Menstruation; Dysmenorrhea; Menarche; Menorrhagia.

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.

Living with Pain and Looking for a Safe Environment: A Qualitative Study among Nursing Students with Dysmenorrhea

Dysmenorrhea refers to chronic pain associated with menstruation that is often accompanied by other symptoms. Primary dysmenorrhea (PD) occurs without any associated pelvic disease. Nonetheless, it may negatively affect women's quality of life. Among university students, dysmenorrhea decreases academic performance and is a cause of absenteeism. The purposes of our study were to describe how nursing students experienced PD and the changes affecting their body and mood. A qualitative case study was performed among 33 nursing students with PD. Data were collected through five focus groups (with two sessions each) and 10 researchers' field notes. We used a video meeting platform to conduct the focus groups. A thematic analysis was performed, and the Standards for Reporting Qualitative Research and the Consolidated Criteria for Reporting Qualitative Research guidelines were followed. Three main themes emerged from the data: (a) living with dysmenorrhea, with two subthemes: menstruation and pain; (b) body changes and mood swings; and (c) seeking a safe environment, with three subthemes: safe environment, unsafe environment, and key safety aspects. Students considered menstruation to be negative and limiting, causing physical and mood changes, making them feel less attractive, and conditioning their way of dressing and relating.

Exploring the Unmet Needs of Parents of Adolescent Girls with Heavy Menstrual Bleeding and Dysmenorrhea: A Qualitative Study

STUDY OBJECTIVE

To provide insight into the unmet needs of parents of adolescents with heavy menstrual bleeding or dysmenorrhea, in the context of their daughters' menstrual concerns.

DESIGN

Qualitative interview study using semi-structured interviews.

SETTING

Gynecology outpatient clinic at The Royal Children's Hospital, Melbourne, Australia.

PARTICIPANTS

Parents of adolescent girls with heavy menstrual bleeding or dysmenorrhea recruited from an adolescent gynecology clinic between May and August 2018.

INTERVENTIONS

In depth, semi-structured interviews with 24 parents whose daughters had heavy menstrual bleeding or dysmenorrhea. Data were analyzed using a grounded theory approach.

MAIN OUTCOME MEASURES

Themes derived from interview transcripts about the supportive care needs of parents.

RESULTS

Thirteen themes emerged in the interviews across 4 areas of need: (1) experiences with healthcare, (2) informational needs, (3) support and acceptance, and (4) financial impacts. Across the interviews, parents identified a need for greater awareness and education among parents and daughters, health professionals, and the broader community.

CONCLUSION

This research confirmed that parents play a significant role in daughters' menstrual health care and have a series of unmet needs. Strategies and interventions specifically targeting these parents may be warranted.

Unmet Needs and Experiences of Adolescent Girls with Heavy Menstrual Bleeding and Dysmenorrhea: A Qualitative Study

STUDY OBJECTIVE

To identify and examine the key areas of need and explore the experiences of adolescent girls with heavy menstrual bleeding and/or dysmenorrhea.

DESIGN AND SETTING

Qualitative interview study using semi-structured interviews. Gynaecology outpatient clinic at The Royal Children's Hospital, Melbourne, Australia.

PARTICIPANTS

Adolescent girls (12-18 years; mean age, 14.8 ± 1.5 years) presenting with heavy menstrual bleeding and/or dysmenorrhea at the clinic (N = 30).

INTERVENTIONS AND MAIN OUTCOME MEASURES

In-depth semi-structured interviews were conducted between May and August 2018. Interview data were thematically analyzed using a grounded theory approach. Themes covered experiences and unmet needs of adolescent girls with heavy menstrual bleeding and/or dysmenorrhea.

RESULTS

A total of 12 themes were identified, and covered the impact of symptoms, experiences, and/or unmet needs of these adolescents. Key themes highlighting experiences and unmet needs related to (1) coordination of healthcare, (2) day-to-day coping, (3) school, and (4) information surrounding menstrual issues. From these themes, 7 unmet needs emerged and were organized under 3 key areas of need: (1) treatment, management, and care, (2) improvements in the school environment, and (3) menstrual health as a gendered issue.

CONCLUSION

Menstrual concerns can have a profound physical and psychosocial impact on adolescents. Effective school-based menstrual education programs may be key in reducing stigma, fear, and shame surrounding menstruation, in teaching positive management strategies and in encouraging adolescents to seek help for their menstrual concerns.

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.

A Psychosocial Lens on an Indigenous Initiative to Address Menstrual Health and Hygiene in Indian Villages

This article outlines the grassroot level work of Project Sakhi which creates awareness about menstrual hygiene and has set up self-sustaining production units of low-cost sanitary napkins in rural India. The first section of the article focuses on project Sakhi: its genesis, organizational dynamics, and the complementary use of traditional methods such as folk songs and the modern social media marketing strategies to sustain the project. The eco-friendly incinerator - Ashuddhinashak designed by the founder is illustrated. The second section of this paper focuses on an understanding of the founders' perspectives in the context of the challenges they faced working in interior rural India and the perspectives of the key stakeholders such as the women employees, adolescent school girls, and an associated NGO worker. The impact of the project has been discussed in the context of five aspects: health, employment, revenue generation, environmental considerations, and sustainability of the model in the Indian context.

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.

Confidence to manage menstruation at home and at school: findings from a cross-sectional survey of schoolgirls in rural Bangladesh

This study investigated girls' confidence to undertake menstrual management tasks at home and in school environments using cross-sectional data from a survey of 1,359 schoolgirls in Bangladesh. At home, 57% of girls reported they were 'very confident' undertaking tasks to manage their menstrual bleeding, while this figure was only 7% at school. We assessed personal, interpersonal and environmental contributors for each context. The use of sanitary pads was positively associated with confidence to manage menstruation at home, while other menstrual hygiene practices were unrelated. In multivariable models, features of sanitation facilities such as cleanliness and the presence of a bin were associated with increased confidence at home. At school, supportive policies, such providing permission to use the toilet when needed, were associated with greater confidence. Talking to a friend about menstruation was positively associated with confidence at school, while at home having discussed menstruation with parents predicted lower confidence. Findings provide quantitative support for the role of multiple independent predictors in girls' confidence to manage menstruation highlighted by qualitative studies. There is unlikely to be a single 'silver bullet' to improving menstrual experience.

"I Thought I Was Dying:" (Un)Supportive Communication Surrounding Early Menstruation Experiences

Menstruation is a salient, and sometimes scary, communication topic for young women. The present study reports on the early communication experiences about menstruation from 165 women using open-ended survey data. Through the framework of supportive communication, findings reveal that a discrepancy occurs between the health and practical information and needs to which young people who menstruate desire access, and their social and emotional needs. The present study indicates an inadequacy of both aspects of menstruation communication from important others in childhood and adolescence. Themes of boundary management, impersonal, silence, and accidents also characterize early communication experiences about menstruation. Our participants identified a desire for conversations that normalize menstruation as typical and acceptable, validate period pain and prescribe management tactics, and describe the existence of feminine hygiene products other than pads and tampons. Limitations and directions for future research are discussed.

Absenteeism during Menstruation among Nursing Students in Spain

Absenteeism can clearly have a negative impact on academic performance among university students. Certain experiences or symptoms such as menstrual pain are very common in women and can lead to absenteeism. The current study was aimed at examining the presence of menstrual experiences or symptoms and their impact upon absenteeism among healthy (illness-free) female university nursing students in Spain. A total of 299 students participated in this research, which was a descriptive cross-sectional, observational study. An ad hoc online questionnaire was used based on sociodemographic and gynecological data, together with the noted menstrual experiences; the most prevalent of which were bloating, which affected 87.3% of students; dysmenorrhea and irritability, which affected 76.3%; and fatigue, which affected 70.6%. Students with dysmenorrhea had a 6.95 higher (odds ratio (OR) 6.95; 95% confidence interval (CI) 3.39-14.25) odds of absenteeism; in those who reported dizziness, the odds of absenteeism was 4.82 times higher (OR 4.82; 1.76-13.23); in those who manifested nausea and vomiting, the percentage of absenteeism was 3.51 higher (OR 3.51; 95% CI 1.51-8.15); in those who presented sleep alterations, the odds were 2.95 higher (OR 2.95; 95% CI 1.39-6.25); and for those who felt depressed the odds were 2.18 times higher (OR 2.18; 95% CI 1.21-3.94) Absenteeism was found to be more likely in women with dysmenorrhea. However, in addition, higher odds of absenteeism were also found in women with nausea and vomiting, dizziness, sleep disorders, and those who feel depressed. These menstrual experiences can be considered a relevant problem among young women, leading to absenteeism, and a negative influence on academic performance. It is essential to raise awareness of the socioeconomic impact of absenteeism and establish new strategies for improving menstrual experiences.

The myth of menstruation: how menstrual regulation and suppression impact contraceptive choice

BACKGROUND

Women in the US have access to various hormonal contraceptive methods that can regulate menstruation. This study examined the attitudes and perceptions of reproductive-aged women toward contraceptive methods, including how menstrual regulation and suppression preferences influenced contraceptive choice.

METHODS

Data collection used a mixed-methods approach, including 6 focus groups (n = 61), individual interviews (n = 18), and a web-based survey (n = 547).

RESULTS

Participants described contraceptive method preferences that allowed monthly bleeding and daily control, expressing concerns about long-acting reversible contraception (LARC) because of decreased user involvement. Some participants noted LARC improved their menstrual control. Many participants felt menstruation was healthy, whereas suppression was abnormal and resulted in negative health outcomes. Though participants indicated LARC as beneficial (M = 4.99 ± 1.66), convenient (M = 5.43 ± 1.68), and healthy (M = 4.62 ± 1.69), they chose combined oral contraceptives due to convenience.

CONCLUSIONS

Findings suggest women need more information about menstrual regulation and suppression before selecting a contraceptive method, specifically in relation to LARC versus combined oral contraception. Framing menstrual suppression as healthy and natural may improve perceptions of long-term health consequences related to LARC. Providers should discuss menstrual suppression safety to ensure selection of contraceptive options aligning with women's preferences and needs.

Menstrual health communication among Indian adolescents: A mixed-methods study

Background

Research in health communication frequently views it as an information dissemination strategy, thus neglecting the intricacies involved in communicating a sensitive topic such as menstruation. The social patterning in menstrual communication, a taboo in India, and its consequent health-effects on adolescents are under-studied.

Methods

We studied the social determinants of menstrual communication influencing menstrual- health through semi-structured interviews of 21 boys and girls each, 12 key-respondent interviews, followed by a cross-sectional survey of 1421 adolescents from Nashik district, India. We thematically analysed the qualitative data and fit multivariable logistic regression to model risk ratios.

Findings

We found social disparities in adolescents’ experiences of communication taboo regarding menstruation. While boys curbed their curiosity about the topic, girls too faced resistance to their experience-sharing and treatment-seeking for menstrual illnesses. The inequality in menstruation-related communication was evident as more boys than girls faced avoidance to their questions [IRR at 95%CI: 2.75 (2.04, 3.71)]], and fewer tribal than rural girls were communicated severe taboos (OR at 95% CI: 0.18 (0.09, 0.36))]. Girls who had been communicated severe (versus no/mild) taboos reported greater stress about menstrual staining (IRR at 95% CI: 1.31 (1.10, 1.57)], emphasizing the health consequences of such communication inequalities.

Conclusions

Our study highlights the need to address gender and setting-specific communication experiences of adolescents in India, a patriarchal society. The inequality in communication needs attention as it creates unequal patterns in Indian adolescents’ menstrual health and experiences, which may manifest as inequities in reproductive health-related outcomes even in their adult-lives.

'It's like a burden on the head': Redefining adequate menstrual hygiene management throughout women's varied life stages in Odisha, India

There has been growing recognition of menstrual hygiene management (MHM) as a significant public health issue. However, research has predominately focused on the experiences of adolescent girls in school settings. The purpose of this research is to examine detailed accounts of menstruation for women in rural Odisha, India at various life stages with a view toward improving international monitoring of MHM. Focus group discussions and in-depth interviews were conducted to understand women’s experiences of menstruation across four life stages (unmarried women, recently married women, married women, and older women). Thematic analysis was used to identify menstruation-related challenges and needs. We found women voiced needs that aligned with those captured by the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) definition for MHM: access to clean materials, privacy for changing materials, soap and water for bathing, and disposal facilities for materials. However, we also found women require materials that are not only clean but comfortable and reliable; soap and water for more than bathing; privacy for the full spectrum of menstruation-related practices, not just when changing; and disposal facilities that are private and safe, not just accessible. Additionally, we identified needs that extend beyond the existing definition: pain management, social support, and an enabling sociocultural environment. Overall, women representing all life stages discussed menstruation challenges, including bathing, pain, and washing, drying, and storing cloth materials. Cloth management challenges were most acute for unmarried and recently married women, who were concerned that practices could reveal their menstrual status and harm their reputations, thus informing their preference for disposable materials, if attainable. We propose a revised definition of adequate MHM for this population that more comprehensively captures their needs. This definition may also prove useful for other populations, future research, creating measures of assessment, and guiding interventions and program priorities.

Productivity loss due to menstruation-related symptoms: a nationwide cross-sectional survey among 32 748 women

OBJECTIVE

To evaluate age-dependent productivity loss caused by menstruation-related symptoms, measured in absenteeism (time away from work or school) and presenteeism (productivity loss while present at work or school).

METHODS

Design/setting: internet-based, cross-sectional survey conducted in the Netherlands from July to October 2017.

PARTICIPANTS

32 748 women aged 15-45 years, recruited through social media.

OUTCOME MEASURES

self-reported lost productivity in days, divided into absenteeism and presenteeism; impact of menstrual symptoms; reasons women give when calling in sick; and women's preferences regarding the implications of menstruation-related symptoms for schools and workplaces.

RESULTS

A total of 13.8% (n=4514) of all women reported absenteeism during their menstrual periods with 3.4% (n=1108) reporting absenteeism every or almost every menstrual cycle. The mean absenteeism related to a woman's period was 1.3 days per year. A total of 80.7% (n=26 438) of the respondents reported presenteeism and decreased productivity a mean of 23.2 days per year. An average productivity loss of 33% resulted in a mean of 8.9 days of total lost productivity per year due to presenteeism. Women under 21 years were more likely to report absenteeism due to menstruation-related symptoms (OR 3.3, 95% CI 3.1 to 3.6). When women called in sick due to their periods, only 20.1% (n=908) told their employer or school that their absence was due to menstrual complaints. Notably, 67.7% (n=22 154) of the participants wished they had greater flexibility in their tasks and working hours at work or school during their periods.

CONCLUSIONS

Menstruation-related symptoms cause a great deal of lost productivity, and presenteeism is a bigger contributor to this than absenteeism. There is an urgent need for more focus on the impact of these symptoms, especially in women aged under 21 years, for discussions of treatment options with women of all ages and, ideally, more flexibility for women who work or go to school.

Women's and girls' experiences of menstruation in low- and middle-income countries: A systematic review and qualitative metasynthesis

BACKGROUND

Attention to women's and girls' menstrual needs is critical for global health and gender equality. The importance of this neglected experience has been elucidated by a growing body of qualitative research, which we systematically reviewed and synthesised.

METHODS AND FINDINGS

We undertook systematic searching to identify qualitative studies of women's and girls' experiences of menstruation in low- and middle-income countries (LMICs). Of 6,892 citations screened, 76 studies reported in 87 citations were included. Studies captured the experiences of over 6,000 participants from 35 countries. This included 45 studies from sub-Saharan Africa (with the greatest number of studies from Kenya [n = 7], Uganda [n = 6], and Ethiopia [n = 5]), 21 from South Asia (including India [n = 12] and Nepal [n = 5]), 8 from East Asia and the Pacific, 5 from Latin America and the Caribbean, 5 from the Middle East and North Africa, and 1 study from Europe and Central Asia. Through synthesis, we identified overarching themes and their relationships to develop a directional model of menstrual experience. This model maps distal and proximal antecedents of menstrual experience through to the impacts of this experience on health and well-being. The sociocultural context, including menstrual stigma and gender norms, influenced experiences by limiting knowledge about menstruation, limiting social support, and shaping internalised and externally enforced behavioural expectations. Resource limitations underlay inadequate physical infrastructure to support menstruation, as well as an economic environment restricting access to affordable menstrual materials. Menstrual experience included multiple themes: menstrual practices, perceptions of practices and environments, confidence, shame and distress, and containment of bleeding and odour. These components of experience were interlinked and contributed to negative impacts on women's and girls' lives. Impacts included harms to physical and psychological health as well as education and social engagement. Our review is limited by the available studies. Study quality was varied, with 18 studies rated as high, 35 medium, and 23 low trustworthiness. Sampling and analysis tended to be untrustworthy in lower-quality studies. Studies focused on the experiences of adolescent girls were most strongly represented, and we achieved early saturation for this group. Reflecting the focus of menstrual health research globally, there was an absence of studies focused on adult women and those from certain geographical areas.

CONCLUSIONS

Through synthesis of extant qualitative studies of menstrual experience, we highlight consistent challenges and developed an integrated model of menstrual experience. This model hypothesises directional pathways that could be tested by future studies and may serve as a framework for program and policy development by highlighting critical antecedents and pathways through which interventions could improve women's and girls' health and well-being.

REVIEW PROTOCOL REGISTRATION

The review protocol registration is PROSPERO: CRD42018089581.

Endogenous Oxytocin Levels in Relation to Food Intake, Menstrual Phase, and Age in Females

CONTEXT

Oxytocin regulates a range of physiological processes including eating behavior and oxytocin administration reduces caloric intake in males. There are few data on oxytocin and eating behavior in healthy females or on the response of endogenous oxytocin to food intake and its relationship to appetite in humans.

OBJECTIVES

To determine the postprandial pattern of oxytocin levels, the relationship between oxytocin and appetite, and the impact of menstrual cycle phase and age on oxytocin levels in females.

DESIGN

Cross-sectional.

SETTING

Clinical research center.

PARTICIPANTS

Fifty-five healthy females (age 10 to 45 years).

INTERVENTIONS

A standardized mixed meal was administered.

MAIN OUTCOME MEASUREMENTS

Blood sampling for oxytocin occurred at fasting and at 30, 60, and 120 minutes postmeal. Appetite was assessed using Visual Analogue Scales pre- and postmeal.

RESULTS

Mean fasting oxytocin levels were 1011.2 ± 52.3 pg/mL (SEM) and decreased at 30 and 60 minutes postmeal (P = 0.001 and P = 0.003, respectively). Mean oxytocin levels decreased19.6% ± 3.0% from baseline to nadir. Oxytocin area under the curve was lower in the early to midfollicular menstrual cycle phase (P = 0.0003) and higher in younger females (P = 0.002). The percent change in oxytocin (baseline to nadir) was associated with postprandial hunger (rs = -0.291, P = 0.03) and fullness (rs = 0.345, P = 0.009). These relations remained significant after controlling for calories consumed, menstrual cycle status, and age (P = 0.023 and P = 0.0001, respectively).

CONCLUSIONS

Peripheral oxytocin levels in females decrease after a mixed meal and are associated with appetite independent of menstrual phase, age, and caloric intake, suggesting that endogenous oxytocin levels may play a role in perceived hunger and satiety.

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.

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.

Do Water, Sanitation and Hygiene Conditions in Primary Schools Consistently Support Schoolgirls' Menstrual Needs? A Longitudinal Study in Rural Western Kenya

Many females lack access to water, privacy and basic sanitation—felt acutely when menstruating. Water, sanitation and hygiene (WASH) conditions in schools, such as access to latrines, water, and soap, are essential for the comfort, equity, and dignity of menstruating girls. Our study was nested within a cluster randomized controlled pilot feasibility study where nurses provided menstrual items to schoolgirls. We observed the WASH conditions of 30 schools from June 2012–October 2013 to see if there were any changes in conditions, to compare differences between study arms and to examine agreement between observed and teacher-reported conditions. Data came from study staff observed, and school teacher reported, WASH conditions. We developed scores for the condition of school facilities to report any changes in conditions and compare outcomes across study arms. Results demonstrated that soap availability for students increased significantly between baseline and follow-up while there was a significant decrease in the number of “acceptable” latrines. During the study follow-up period, individual WASH indicators supporting menstruating girls, such as locks on latrine doors or water availability in latrines did not significantly improve. Advances in WASH conditions for all students, and menstrual hygiene facilities for schoolgirls, needs further support, a defined budget, and regular monitoring of WASH facilities to maintain standards.