Period poverty, reuse needs, and depressive symptoms among refugee menstruators in Jordan's camps: a cross-sectional study.

BACKGROUND: Period poverty is a significant issue that impacts the physical and psychological well-being of menstruators worldwide which can further contribute to poor mental health outcomes. For menstruators living in refugee camps, access to menstrual hygiene products is often limited or non-existent, leading to increased anxiety, shame, and embarrassment. Therefore, this study aimed to assess the prevalence of the period poverty and to comprehensively analyze the association between period poverty, reusing menstrual products, and depressive symptoms among menstruators living in refugee camps in Jordan. METHODS: A cross-sectional study surveyed refugee menstruators living in camps in Jordan, aged post-menarche to pre-menopause. Data collection included socio-demographics, menstrual practices, and depressive symptoms using the Patient Health Questionnaire (PHQ-9). Period poverty was assessed through affordability and frequency of struggles with menstrual products. Chi-squared test, independent sample t-test, One Way Analysis of variance (ANOVA) followed by Post hoc, and logistic regression models were used in the analysis. RESULTS: The study included a diverse sample of 386 refugee menstruators living in camps in Jordan (mean age 32.43 ± 9.95, age range 13-55). Period poverty was highly prevalent, with 42.0% reporting monthly struggles to afford menstrual products, and 71.5% reusing menstrual products. Univariate analysis revealed that experiencing period poverty was significantly associated with a younger age of marriage, increased number of children, lower education level, lower mother and father education levels, unemployment, decreased monthly income, absence of health insurance, lower reuse need score, and increased PHQ-9 score (p < 0.05). Menstruators experiencing monthly period poverty were 2.224 times more likely to report moderate to severe depression compared to those without period poverty (95% CI 1.069-4.631, P = 0.033). CONCLUSION: This study highlights a significant association between period poverty and depressive symptoms among refugee menstruators in living in camps in Jordan, as high rates of period poverty were associated with a 2.2-fold increased likelihood of reporting moderate to severe depression. Addressing period poverty in refugee settings is crucial for mitigating depression risks and enhancing overall well-being.

Centring participant experience: a realist evaluation of a menstruator-friendly facility design project in a refugee settlement, Lebanon.

INTRODUCTION: Menstrual health in humanitarian contexts is a neglected topic. Its taboo nature presents difficulties for participants in menstrual health projects in these particularly challenging settings. Namely, their experiences may be concealed or overlooked in projects that are typically outcome focused. Realist Evaluation is a useful method to unearth and explore the hidden mechanisms and their causes, which lead to positive or negative participant experiences. The authors have applied this approach to a robust humanitarian menstrual health project to explore how to centre the emotional wellbeing of participants at all stages: prior to, during, and post-participation. STUDY SETTING: The project studied was led by the International Federation of Red Cross and Red Crescent Societies who piloted their adaptable manual for menstruator-friendly water, sanitation and hygiene (WaSH) facility design in humanitarian contexts. It was conducted by the Lebanese Red Cross in an informal tented settlement hosting Syrian refugees in Qaa, Lebanon. METHODS: The authors collected interview and focus group data on the contextual factors and processes within the project from nine project staff and 16 settlement inhabitants. They used a realist process of theory development, testing, and consolidation to understand how and under what circumstances the project inputs affected participants' wellbeing. RESULTS: The contextual factors and causal mechanisms promoting participant experience comprised individual (choices influencing and experience during participation), interpersonal (group dynamics and the role of non-menstruators), and organisational (expertise and knowledge, relationship to participants and cultural differences) factors. IMPLICATIONS: The research uses a case study from a renowned humanitarian organisation who provided a well-delivered project in a conducive environment to explore the mechanisms and contexts that can promote wider learning and refine understanding and programming in this under-researched and -theorised space. Specifically, it informs which contextual factors and project inputs must be present within a menstrual health project to ensure participant satisfaction whilst efficiently delivering well-designed menstruator-friendly WaSH facilities.

Menstrual characteristics and associations with sociodemographic factors and self-rated health in Spain: a cross-sectional study.

BACKGROUND: Evidence on how menstrual characteristics may differ based on socioeconomic factors and self-rated health is significantly scarce. The main aim of this study was to investigate the associations between menstrual characteristics, sociodemographic factors and self-rated health among women and people who menstruate (PWM) aged 18-55 in Spain. METHODS: This cross-sectional study includes data from an online survey collected in March-July 2021 across Spain. Descriptive statistical analyses and multivariate logistic regression models were performed. RESULTS: The analyses included a total of 19,358 women and PWM. Mean age at menarche was 12.4 (SD = 1.5). While 20.3% of our participants experienced a menstrual abundance over 80 ml, 64.1% reported having menstrual blood clots; 6.4% menstruated for longer than 7 days. 17.0% had menstrual cycles that were shorter than 21 days or longer than 35 days. Reports of moderate (46.3%) and high (22.7%) intensity menstrual pain were common. 68.2% of our participants experienced premenstrual symptoms in all or most cycles. The odds for lighter menstrual flow, shorter bleeding days and menstrual cycles were higher as age increased, and amongst participants with less educational attainment. Caregivers presented higher odds for abundant menstrual flow and longer menstruations. Reporting financial constraints and a poorer self-rated health were risk factors for abundant menstrual flow, menstrual blood clots, shorter/longer menstruations and menstrual cycles, premenstrual symptoms, moderate and intense menstrual pain. CONCLUSIONS: This study suggests that age, educational attainment, caregiving, experiencing financial hardship and a poorer self-rated health may shape or mediate menstrual characteristics. It thus highlights the need to investigate and address social inequities of health in menstrual research.

Menstrual cycle characteristics, perceived impact on performance, and barriers to communication: Perspectives of high-performance adolescent athletes in Singapore.

The purpose of this study was to examine the menstrual cycle (MC) characteristics, explore the impact on performance, and identify barriers to and facilitators of MC-related communication among high-performance female adolescent athletes in Singapore. Ninety athletes (15.4 ± 1.8 years) from multiple sports completed an online questionnaire. Eighty-four athletes were postmenarcheal (menarcheal age 11.9 ± 1.3 years), including two who were using an oral contraceptive pill (OCP). Secondary amenorrhea, current or history of, was self-reported in 16% of athletes. Sixty-two percent and 67% of non-OCP athletes perceived that the MC affected their ability to train and compete, respectively. Athletes preferred speaking to a parent (85%) and a female figure (67%) about MC-related concerns. Through thematic analysis, three barriers to communication were constructed: (1) pervasive menstrual stigma, (2) constraints of the training environment, and (3) the low value placed on MC-related conversations. Two facilitators of communication were constructed: (1) respect athletes' individual experiences as menstruating girls and (2) foster a safe space for MC-related conversations. Findings demonstrated that menstrual irregularities are common in adolescent athletes and screening for MC disorders, particularly primary amenorrhea should be undertaken in this population, with clear support pathways for management including symptom mitigation. To support athletes in raising MC-related concerns when needed, structured communication pathways that consider individual preferences and involve a (female) point of contact should be established within the training environment. Improving menstrual health literacy among adolescent athletes before any misinformation or negative perceptions are firmly established may contribute to longevity in their athletic careers.

Evaluation of knowledge, attitude, practices and effectiveness of menstrual hygiene interventions in rural schools from Lilongwe, Malawi.

BACKGROUND: Menstrual hygiene management (MHM) is associated with the menstrual process in women and adolescent girls who face cultural and financial challenges in rural areas of many developing countries. As part of the pilot study, we assessed the sustainability and effectiveness of the approaches and lessons learned from the MHM project intervention in rural areas of Lilongwe, Malawi. METHODS: Rural primary schools (n = 4) were purposively selected where an MHM intervention was implemented in Lilongwe, Malawi. The study employed a mixed-method research design. Assessments and data collection were performed through surveys of learners, literature reviews, key informant interviews (KIIs) (n = 90), and 20 focus group discussions (FGDs). The study participants included boys and adolescent girls (n = 100, 11-19 years; grades 5-8), teachers, mother groups, and community leaders from the selected schools. RESULTS: All the schools had water sanitation and hygiene facilities and latrines (45% improved, 54% ventilated improved pit latrines - VIPs) that promoted menstrual hygiene for adolescent girls. However, two of the schools studied (50%, n = 4) did not have separate washrooms for changing sanitary materials. There was a slight increase in latrine coverage in Kabuthu zone communities (90% at baseline versus 93.4% at midterm). However, the coverage dropped to 85.7% at the final evaluation, which was attributed to too much rain received in the area that damaged most of the latrines. There was a significant reduction (p < 0.05) in the number of girls failing to attend classes due to menstruation (70% at baseline versus 14% at final evaluation). Furthermore, the project resulted in the majority of girls (94.4%) having access to school. There was a strong uptake and adoption of sanitary products (reusable pads and menstrual cups) among adolescent girls of all age groups. The study has demonstrated that the inclusion of key stakeholders such as health workers, parents, mother groups and community leaders promoted the uptake and sustainability of reusable pads and menstrual cups and MHM interventions and programs. CONCLUSION: The MHM project implementation improved adolescent girls' education in the area. The inclusion of boys and other key stakeholders in the health education talks addressed issues of stigma and discrimination. The study, therefore, calls for comprehensive training on MHM and hygiene education to remove discrimination and harmful cultural practices.

High uptake of menstrual health information, products and analgesics within an integrated sexual reproductive health service for young people in Zimbabwe.

BACKGROUND: Despite being integral to women's well-being, achieving good menstrual health (MH) remains a challenge. This study examined MH services uptake (including information, analgesics, and a choice of MH products - the menstrual cup and reusable pads) and sustained use of MH products within an integrated sexual and reproductive health intervention for young people in Zimbabwe. METHODS: This mixed-methods study was nested within a cluster randomised trial of integrated sexual and reproductive health services (CHIEDZA) for youth in three provinces (Harare, Mashonaland East, and Bulawayo). The study collected qualitative and quantitative data from 27,725 female clients aged 16-24 years, who accessed CHIEDZA from April 2019 - March 2022. Using a biometric (fingerprint recognition) identification system, known as SIMPRINTS, uptake of MH information, products, and analgesics and other services was tracked for each client. Descriptive statistics and logistic regression were used to investigate MH service uptake and product choice and use over time, and the factors associated with these outcomes. Thematic analysis of focus group discussions and interviews were used to further explore providers' and participants' experiences of the MH service and CHIEDZA intervention. RESULTS: Overall, 36,991 clients accessed CHIEDZA of whom 27,725 (75%) were female. Almost all (n = 26,448; 95.4%) took up the MH service at least once: 25433 took up an MH product with the majority (23,346; 92.8%) choosing reusable pads. The uptake of cups varied across province with Bulawayo province having the highest uptake (13.4%). Clients aged 20-24 years old were more likely to choose cups than reusable pads compared with those aged 16-19 years (9.4% vs 6.0%; p < 0.001). Over the implementation period, 300/1819 (16.5%) of clients swapped from the menstrual cup to reusable pads and 83/23346 (0.4%) swapped from reusable pads to the menstrual cup. Provision of the MH service encouraged uptake of other important SRH services. Qualitative findings highlighted the provision of free integrated SRH and MH services that included a choice of MH products and analgesics in a youth-friendly environment were key to high uptake and overall female engagement with SRH services. CONCLUSIONS: High uptake demonstrates how the MH service provided much needed access to MH products and information. Integration of MH within an SRH intervention proved central to young women accessing other SRH services.

Menarche and reproductive health in Spanish Roma women from a reproductive justice perspective: a qualitative study.

OBJECTIVES: This study aimed to explore the perceptions of Roma women about their experience of menarche and reproductive health considering the principles of reproductive justice. DESIGN: Qualitative study based on semi-structured interviews with Roma women ages 18 through 67 in different neighborhoods in the southeast of Spain. Using a thematic analysis, we analyzed experiences related to menarche and menstruation and their significance for reproductive health, the preparation for the phase of menarche and intergenerational support. RESULTS: The Roma women interviewed shared their approach to the experiences of menarche and menstruation as children in their family environments with a focus on access to information provided by other women in the family and community for reproductive health management. In their discourses we observed that the onset of menstruation supposes a rupture in the public and private spaces of girls and women. CONCLUSIONS: The results of this study suggest that women and girls do not gain access to information that contributes to their reproductive wellbeing through their experience of menarche. Access to resources and skills to manage biological changes in adolescents could contribute to reducing the impact of cultural myths, false ideas and taboos that prevent advocacy and empowerment on issues of reproductive justice.

This study shows that the public spaces surrounding Roma women do not provide the tools and resources to promote and maintain their wellbeing and reproductive health after the onset of this important time. Sexual and reproductive health is not addressed during the time of childhood nor adolescence. Roma women lack a framework with an established discourse on reproductive justice, along with the necessary institutional resources. Preparation for and follow-up of the onset of menstruation among Roma women could be a key for their health. These results coincide with qualitative studies carried out in women from different cultural origins, in which menarche and menstruation are experienced as a transcendental fact. In other contexts, similar to Roma women, this stage in women's health lacks resources and information and an adequate approach from the perspective of reproductive health, which conditions the menstrual, sexual and reproductive health of women across their lifespan. Roma women experience menarche as a significant change in the life of a woman. They describe having lived the process as an abandonment of childhood and the beginning of an adult life, one that is implicitly linked to maternity and couple relationships. The results show that they defend the continuity of childhood among the new generation. Roma women express that they experienced menarche as an event that was traumatic, embarrassing and confusing. Menarche and menstruation are attended to in private and among the family, and masculine figures do not participate. The mother is the only transmitter of information and support during the process.

Perspectives on menstrual policymaking and community-based actions in Catalonia (Spain): a qualitative study.

BACKGROUND: Menstrual research and policymaking have become imperative worldwide. It is necessary that these are informed by women and people who menstruate (PWM) alongside expert professionals and activists. METHODS: The main aim of this study was to identify and propose policies and community-based actions to address menstrual inequity and promote menstrual health in Catalonia (Spain). This study consisted of two qualitative studies: (a) 34 individual photoelicitation interviews with women and PWM, (b) a World Café study with 22 professionals and activists. Sampling for both studies was purposive and selective. Recruitment was conducted through healthcare centres, social media, key contacts, and snowball sampling techniques. Data were collected in December 2020-September 2022, and analysed using Framework Analysis. RESULTS: Participants considered the implementation of menstrual policies that address the taboo and stigma of menstruation to be crucial. They stressed the need for menstrual education, which should be integrated into formal education curricula. Participants, and especially women and PWM, highlighted the need to improve the access and quality of healthcare services, so that the menstrual cycle and menstruation are seen as health indicators. Health professionals should encourage agentic informed decisions, hence why both participant groups considered menstrual health education amongst health professionals to be pivotal. Taking action to improve the access and affordability of menstrual products was also imperative for participants, especially for socioeconomically vulnerable populations. Participants agreed on guaranteeing fully equipped menstrual management facilities, and and professionals discussed gender-neutral and sex-segregated bathrooms. Workplace menstrual policies to accommodate and ensure menstrual self-care were also suggested. CONCLUSIONS: Our study highlights the need for multi-dimensional menstrual policies. These should include actions to address menstrual taboo and stigma, to promote menstrual education that goes beyond the hegemonic biomedical prism, to improve the access and quality of menstrual health services, along with policies ensuring adequate menstrual management facilities in public spaces and the access to menstrual products. Policymaking should also focus on how to ensure menstrual management and care in workplaces. Menstrual policies and community-based actions should be framed within intersectionality, to consider how societal structures of power and oppression influence menstrual experiences.

RESUMEN: INTRODUCCIóN: Siendo la investigación y la implementación de políticas menstruales imprescindibles, es necesario que estos procesos estén informados por mujeres y personas que menstrúan (PM), así como por profesionales expertas y activistas. MéTODOS: El objetivo principal de este estudio fue identificar y proponer políticas y acciones comunitarias para abordar la inequidad menstrual y promover la salud menstrual en Cataluña (España). Este estudio consistió en dos estudios cualitativos: (a) 34 entrevistas individuales de fotoelicitación con mujeres y PM, (b) un World Café con 22 profesionales y activistas. El muestreo para ambos estudios fue intencional y selectivo. El reclutamiento se realizó a través de centros de salud, redes sociales, contactos clave y técnicas de bola de nieve. Los datos se recogieron entre diciembre de 2020 y septiembre de 2022 y se analizaron mediante Framework Analysis. RESULTADOS: Las participantes consideraron crucial la implementación de políticas menstruales para abordar el tabú y el estigma menstrual. Destacaron la necesidad de una educación menstrual, que debería integrarse en los currículums escolares. Las participantes, y especialmente las mujeres y PM, resaltaron la necesidad de mejorar el acceso y la calidad de los servicios de salud, de manera que el ciclo menstrual y la menstruación sean consideradas indicadores de salud. Mencionaron que el personal sanitario debe fomentar las decisiones informadas, de ahí que ambos grupos de participantes consideraran fundamental la educación sobre la salud menstrual entre los profesionales de la salud. También, para las participantes fue imperativo asegurar el acceso y asequibilidad de productos menstruales, especialmente para las poblaciones socioeconómicamente vulnerabilizadas. Las participantes estuvieron de acuerdo en la necesidad de garantizar espacios equipadas para el manejo menstrual, y se llevaron a cabo debates entre las profesionales sobre los baños inclusivos y segregados por sexo. También se sugirieron y debatieron políticas menstruales en entornos laborales, para adaptar y garantizar el autocuidado menstrual. CONCLUSIONES: Nuestro estudio destaca la necesidad de políticas menstruales multidimensionales. Estas deberían incluir acciones para abordar el tabú y el estigma menstrual, promover una educación menstrual que vaya más allá de la perspectiva biomédica hegemónica, mejorar el acceso y la calidad de los servicios de salud menstrual, junto con políticas para garantizar la disponibilidad de instalaciones adecuadas para el manejo menstrual en espacios públicos, así como el acceso a productos menstruales. La creación de políticas también debería centrarse en cómo garantizar el manejo y los cuidados menstruales en entornos laborales. Finalmente, estas políticas menstruales y acciones comunitarias deben enmarcarse desde la interseccionalidad, para considerar cómo las estructuras y poderes sociales operan e influyen en las experiencias menstruales.

Mixed-Method, Multilevel Clustered-Randomized Control Trial for Menstrual Health Disparities.

Menstrual cycle characteristics are largely considered unmodifiable reproductive factors, a framing that prevents exploration of the ways structural factors interfere with menstrual health. Given the role of structural factors like healthy food and healthcare access on reproductive health and the grave need for structural interventions to known reproductive health disparities that disproportionately target cisgender women racialized as Black, it is imperative that science begin to examine how structural factors influence menstrual health. To explore such research, we employ critical race theory and intersectionality to illustrate what a structural intervention to improve menstrual cycle health could look like. Centering those with the greatest need, persons racialized as Black and/or LatinX living in food and healthcare deserts in Northern Manhattan, our illustrative sample includes four groups of persons who menstruate (e.g., cisgender girls and women) that are pre-menarche, pre-parous, postpartum, or perimenopausal. We describe a hypothetical, multilevel clustered-randomized control trial (cRCT) that provides psychoeducation on racism-related trauma and free delivered groceries to both treatment and control groups, while randomizing 30 clusters of housing associations to receive either sexual health clinics at their housing association or free vouchers for healthcare. We embed mixed methods (diaries, interviews, surveys, mobile apps, observation) into the design to evaluate the effectiveness of the 1-year intervention, in addition to determining the impact on participants through their perspectives. Through this illustration, we provide a novel example of how structural interventions can apply mixed methods to evaluate effectiveness while delivering services to populations impacted by multiple structural factors. We demonstrate how qualitative and quantitative approaches can be paired in clustered RCTs and how a living logic model can empirically incorporate the population perspective into more effective interventions. Lastly, we reveal how sensitive menstrual health is to structural factors and how upstream improvements will trickle down to potentially reduce health disparities in reproductive health.

Improving menstrual health knowledge among girls from Iran: the effectiveness of educational health belief model.

Menstrual health education is one of the important aspects of health education during adolescence in girls. The aim of this study was to evaluate the effectiveness of the Health Belief Model (HBM) on promoting Knowledge of menstrual health in female students of Fasa City, Fars Province, Iran. This quasi-experimental study was done on 200 high school girls (100 experimental and 100 control groups) who were selected using a random sampling method in Fasa City, Fars Province, Iran, in 2019-2020. The educational intervention for the experimental group consisted of 6 training sessions of 50-55 minutes through lectures, Q & A, group discussion, educational posters and pamphlets, videoclips, and PowerPoint. A scale of this study consisted of two parts; demographic information, and HBM constructs were used to determine the behaviors of menstrual health in two (before and 3 months after intervention) times. The mean age of students in the experimental and control groups was 13.40 ± 0.68 and 13.34 ± 0.72 years. The results showed that before the educational intervention, there was no significant difference between the experimental and control groups in terms of knowledge, perceived sensitivity, perceived severity, perceived benefits, perceived barriers, self-efficacy, cues to action and performance; however, three months after the intervention, the experimental group showed a significant increase in each of the mentioned variables except the perceived barriers. Based on the present study, education based on the health belief model structures is effective in improving Knowledge of menstrual health and this model can be used to prevent and reduce the symptoms of premenstrual syndrome.

Assessing the impact of hormonal contraceptive use on menstrual health among women of reproductive age - a systematic review.

BACKGROUND: Contraceptive methods are well-established in their ability to prevent pregnancy and increase individual agency in childbearing. Evidence suggests that contraceptives can also be used to treat adverse conditions associated with menstruation, including abnormal and prolonged uterine bleeding, heavy menstrual bleeding, painful menstruation, endometriosis, uterine fibroids, and premenstrual dysphoric disorders.This review investigates the effects of contraceptive techniques such as contraceptive pills, and long-acting reversible contraceptives (e.g. intrauterine devices, implants) on menstrual morbidity. METHODS: Over ten databases with no geographical boundaries were searched from inception until October 2023. Study designs were one of the following types to be included: parallel or cluster randomised controlled trials, controlled clinical trials, controlled before and after studies, interrupted time series studies, cohort or longitudinal analyses, regression discontinuity designs, and case-control studies. Ten team members screened the papers in pairs with a Kappa score of more than 7, and Covidence was used. Conflicts were resolved by discussion, and the full papers were divided among the reviewers to extract the data from eligible studies. RESULTS: Hormonal contraceptives are considered a well-tolerated, non-invasive, and clinically effective treatment for abnormal and prolonged uterine bleeding, heavy menstrual bleeding, painful menstruation, endometriosis, uterine fibroids, and premenstrual dysphoric disorders. Our studies investigating quality of life or well-being in women with heavy menstrual bleeding, endometriosis, or uterine fibroids have found improvements in all dimensions assessed. CONCLUSIONS: Hormonal contraceptives significantly reduce pain, symptom severity, and abnormal bleeding patterns associated with women who suffer from heavy menstrual bleeding, endometriosis, and uterine fibroids.

Hormonal contraceptives significantly reduce pain, symptom severity, and abnormal bleeding patterns associated with women who suffer from heavy menstrual bleeding, endometriosis, and uterine fibroids. Findings can inform clinical practice and policy decisions to ensure that women have access to safe and effective contraceptive options that promote both reproductive and non-reproductive health.

Menstruation and social inequities in Spain: a cross-sectional online survey-based study.

BACKGROUND: Available research suggests that menstrual inequity has an impact on (menstrual) health outcomes and emotional wellbeing. It is also a significant barrier to achieve social and gender equity and compromises human rights and social justice. The aim of this study was to describe menstrual inequities and their associations with sociodemographic factors, among women and people who menstruate (PWM) aged 18-55 in Spain. METHODS: A cross-sectional survey-based study was conducted in Spain between March and July 2021. Descriptive statistical analyses and multivariate logistic regression models were performed. RESULTS: A total of 22,823 women and PWM were included in the analyses (Mean age = 33.2, SD = 8.7). Over half of the participants had accessed healthcare services for menstruation (61.9%). The odds for accessing menstrual-related services were significantly higher among participants with university education (aOR: 1.48, 95% CI, 1.13-1.95). Also, 57.8% reported having had partial or no menstrual education pre-menarche, with odds being higher among participants born in non-European or Latin American countries (aOR: 0.58, 95% CI, 0.36-0.93). Lifetime self-reported menstrual poverty was between 22.2-39.9%. Main risk factors for menstrual poverty were identifying as non-binary (aOR: 1.67, 95% CI, 1.32-2.11), being born in non-European or Latin American countries (aOR: 2.74, 95% CI, 1.77-4.24), and not having a permit to reside in Spain (aOR: 4.27, 95% CI, 1.94-9.38). Completed university education (aOR: 0.61, 95% CI, 0.44-0.84) and no financial hardship < 12 months (aOR: 0.06, 95% CI, 0.06-0.07) were protective factors for menstrual poverty. Besides, 75.2% reported having overused menstrual products due to lack of access to adequate menstrual management facilities. Menstrual-related discrimination was reported by 44.5% of the participants. Non-binary participants (aOR: 1.88, 95% CI, 1.52-2.33) and those who did not have a permit to reside in Spain (aOR: 2.11, 95% CI, 1.10-4.03) had higher odds of reporting menstrual-related discrimination. Work and education absenteeism were reported by 20.3% and 62.7% of the participants, respectively. CONCLUSIONS: Our study suggests that menstrual inequities affect a high number of women and PWM in Spain, especially those more socioeconomically deprived, vulnerabilised migrant populations and non-binary and trans menstruators. Findings from this study can be valuable to inform future research and menstrual inequity policies.

RESUMEN: INTRODUCCIóN: Investigación previa disponible indica que la inequidad menstrual tiene un impacto en los resultados de salud (menstrual) y en el bienestar emocional. Es también una barrera para la equidad social y de género. El objetivo de este estudio es evaluar la inequidad menstrual y las asociaciones con factores sociodemográficos, en mujeres y personas que menstrúan entre 18-55 años en España. MéTODOS: Este es un estudio transversal, basado en una encuesta, llevado a cabo en España entre marzo y julio de 2021. Se realizaron análisis descriptivos y modelos de regresión logística multivariados.  RESULTADOS: Los análisis se realizaron con los datos de 22,823 mujeres y personas que menstrúan. Más de la mitad de las participantes habían accedido a servicios sanitarios para la menstruación (60.5%). La probabilidad de acceder a servicios sanitarios para la menstruación fue significativamente más alta en participantes con educación universitaria (aOR: 1.48, 95% CI, 1.13-1.95). El 57.8% informó no haber tenido educación menstrual o que ésta fuera parcial, pre-menarquia; la probabilidad fue más alta en participantes que no habían nacido en países europeos o latinoamericanos (aOR: 0.58, 95% CI, 0.36-0.93). La pobreza menstrual durante el ciclo vital se reportó en el 22.2-39.9% de las participantes. Los principales factores de riesgo fueron identificarse como persona no binaria (aOR: 1.67, 95% CI, 1.32-2.11), nacer en países fuera de Europa o Latinoamérica (aOR: 2.74, 95% CI, 1.77-4.24), y no tener papeles para residir en España (aOR: 4.27, 95% CI, 1.94-9.38). Tener estudios universitarios (aOR: 0.61, 95% CI, 0.44-0.84) y no haber reportado problemas económicos en los últimos 12 meses (aOR: 0.06, 95% CI, 0.06-0.07) fueron factores protectores para la pobreza menstrual. Además, el 74.6% indicó haber sobreutilizado productos menstruales por no haber tenido acceso a espacios adecuados para el manejo menstrual. El 42.6% de las participantes comunicaron experiencias de discriminación menstrual. Participantes no binarios (aOR: 1.88, 95% CI, 1.52-2.33) y aquellas que no tenían papeles (aOR: 2.11, 95% CI, 1.10-4.03) presentaron una mayor probabilidad de indicar discriminación menstrual. El absentismo laboral y escolar fue indicado por el 18.3% y el 56.6% de las participantes respectivamente. CONCLUSIONES: Nuestro estudio sugiere que la inequidad menstrual afecta a un número significativo de mujeres y personas que menstrúan en España y, especialmente, a aquellas en situaciones de mayor deprivación socioeconómica, algunos colectivos vulnerabilizados de personas migradas, y a personas no binarias y trans que menstrúan. Los resultados de este estudio pueden ser útiles para investigación futura, así como para el desarrollo de políticas públicas de equidad menstrual.

Spatiotemporal change in socioeconomic inequality in hygienic menstrual product use among adolescent girls in India during 2015-2019.

BACKGROUND: The use of hygienic products, such as sanitary napkins, tampons, and menstrual cups, to absorb menstrual blood is vital for the health and well-being of adolescent girls in India. However, the degree of inequity in the use of such products among this subpopulation remains inadequately explored. To fill this critical knowledge gap, this study aims to investigate the spatiotemporal dynamics of hygienic product use among adolescent girls in India from 2015 to 2020. METHODS: In this cross-sectional study, we analyzed data from 117,749 to 114,839 adolescent girls aged 15-19, obtained from two consecutive rounds of the National Family Health Survey (NFHS) conducted in India during 2015-16 and 2019-21. Our approach involved utilizing Erreygers' Concentration Index (ECI) and Concentration Curve to quantitatively assess and visually represent socioeconomic inequality in hygienic product usage. Additionally, we investigated the spatiotemporal variation in this inequality over the study period and decomposed the ECI to identify the key contributing factors. RESULTS: The findings reveal that hygienic product usage among adolescent girls in India has increased by 13 percentage points (PP), from 37% in 2015-16 to 50% in 2019-21. This increase is also visible across all household wealth quintiles. However, the bottom quintiles experienced a greater rise (+ 15 to 16 PP) than the top quintile (+ 8 PP). During the study period, the ECI reduced marginally, from 0.48 in 2015-16 to 0.43 in 2019-21. However, the extent of this reduction varied across different states. The greatest reduction in ECI was recorded in Punjab (-0.23 points), Telangana (-0.16 points), and West Bengal (-0.14 points). In contrast, there were a number of states with high socioeconomic inequality (ECI > 0.30) in 2015-16, where inequality reduction was minimal (< 0.05 points) over the study period. This included more developed states of Kerala, Karnataka, Maharashtra and Gujarat and relatively less developed states of Odisha, Jharkhand, Chhattisgarh, Uttar Pradesh, and Assam. Some states, such as Bihar and Madhya Pradesh, recorded an increase in socioeconomic inequality over the study period, with ECI rising to 0.31 and 0.46 (highest in the country) in 2019-21. The decomposition analysis revealed that the inequality in using hygienic products was primarily explained by place of residence, exposure to mass-media, education, and region of residence. CONCLUSIONS: The findings suggest the need for targeted policies to reduce existing socioeconomic inequality in the usage of hygienic products among adolescent girls in India. Specifically, interventions should target regions with low use of hygienic products, economically disadvantaged groups, and poor and vulnerable populations. State-specific policies and programs are also necessary to address the disparities in socioeconomic inequality. Additionally, efforts to reduce inequality should address the underlying factors contributing to inequality.

Exploring diagnosis and treatment of premenstrual dysphoric disorder in the U.S. healthcare system: a qualitative investigation.

BACKGROUND: Premenstrual Dysphoric Disorder (PMDD) is a premenstrual condition that affects 3-8% of the US population, yet knowledge on treatment and consistent diagnostic testing is lacking. While research concerning the epidemiology and pharmaceutical treatments for this condition has increased, there is a lack of qualitative studies on the experiences of patients who live with this condition. The aim of this study was to explore the diagnostic and treatment experiences of PMDD patients in the U.S. healthcare system and identify barriers to diagnosis and treatment. METHODS: This study uses a feminist framework with qualitative phenomenological methods. We recruited participants who identified as having PMDD, regardless of official diagnosis, through online forums within the U.S. PMDD community. The study conducted 32 in depth interviews with participants on their experiences with PMDD diagnosis and treatment. Thematic analysis methods revealed key barriers within the diagnostic and care process including patient, provider, and societal barriers. RESULTS: This study presents a PMDD Care Continuum that represents the timeline of participant experiences beginning from symptom onset towards official diagnosis, treatments, and ongoing management of the condition. Participant experiences demonstrated that much of the diagnostic and treatment processes were burdened on the patient, and that successful navigation within the healthcare system was dependent on high levels of self-advocacy. CONCLUSIONS: This was the first study to describe the qualitative experiences of patients who identified as having PMDD in the U.S. Further research is needed to refine and operationalize diagnostic criteria and treatment guidelines for PMDD.

Reusable period products: use and perceptions among young people in Victoria, Australia.

BACKGROUND: Reusable menstrual products have expanded the choices available for menstrual care and can offer long-term cost and environmental benefits. Yet, in high-income settings, efforts to support period product access focus on disposable products. There is limited research to understand young people's product use and preferences in Australia. METHODS: Quantitative and open-text qualitative data were collected through an annual cross-sectional survey of young people (aged 15-29) in Victoria, Australia. The convenience sample was recruited through targeted social media advertisements. Young people who reported menstruating in the past 6 months (n = 596) were asked questions about their menstrual product use, use of reusable materials, product priorities and preferences. RESULTS: Among participants, 37% had used a reusable product during their last menstrual period (24% period underwear, 17% menstrual cup, 5% reusable pads), and a further 11% had tried using a reusable product in the past. Reusable product use was associated with older age (age 25-29 PR = 3.35 95%CI = 2.09-5.37), being born in Australia (PR = 1.74 95%CI = 1.05-2.87), and having greater discretionary income (PR = 1.53 95%CI = 1.01-2.32). Participants nominated comfort, protection from leakage and environmental sustainability as the most important features of menstrual products, followed by cost. Overall, 37% of participants reported not having enough information about reusable products. Having enough information was less common among younger participants (age 25-29 PR = 1.42 95%CI = 1.20-1.68) and high school students (PR = 0.68 95%CI = 0.52-0.88). Respondents highlighted the need for earlier and better information, challenges navigating the upfront cost and availability of reusables, positive experiences with reusables, and challenges for use, including cleaning reusables and changing them outside the home. CONCLUSIONS: Many young people are using reusable products, with environmental impacts an important motivator. Educators should incorporate better menstrual care information in puberty education and advocates should raise awareness of how bathroom facilities may support product choice.

Spanish menstrual literacy and experiences of menstruation.

There is growing recognition of the important role menstrual health plays in achieving health, education, and gender equity. Yet, stigmatisation and taboo remain present and negative emotions like fear and shame dominate the narrative when speaking about periods. This paper analyses how formal and informal menstrual education is received in Spain, to understand the role of menstrual health literacy in the way menstruation is experienced, and to identify what information would be useful to integrate into formal menstrual education. An online survey with more than 4000 participants (aged between 14 and 80, both people who will/do/have previously menstruate/d and those who do not menstruate) was conducted. Data was gathered using the digital platform Typeform, descriptive and inferential statistical analyses were performed with SPSS software and qualitative data was thematically analysed using Nvivo. Many participants declared not having received sufficient information on menstruation prior to menarche, particularly about how to physically manage it. Furthermore, negative emotions like shame, worry, and fear were recurrently reported to describe menarche; this has not changed between generations. Interestingly, we saw an increase in stress and sadness with an increase in perceived knowledge of the reproductive role of menstruation. We did observe a reduction in negative emotions when people who menstruate perceived they had sufficient information on how to manage their first bleeding. It is recommended that menstrual education beyond reproductive biology, particularly including how to physically manage periods, is integrated into school curricula. Menstrual education of everyone - including those who do not menstruate-can improve how periods are experienced in Spain.

More than blood: app-tracking reveals variability in heavy menstrual bleeding construct.

BACKGROUND: Heavy menstrual bleeding (HMB) is associated with impaired quality of life and may signal serious health problems. Unresolved challenges in measuring menstrual bleeding and identifying HMB have hampered research and clinical care. Self-reported bleeding histories are commonly used but these may be influenced by recall bias, personal beliefs regarding "normal" flow volume, and the experience of other physical symptoms or disruptions to daily life. The potential usefulness of menstrual-tracking mobile applications, which allow real-time user-entered data recording, for assessing HMB has not been studied. We evaluated recall bias in reported period duration, the relationship of tracked period duration and daily flow volume to subsequently reported period heaviness, variation in quality of life associated with increasing period heaviness, and the advantages and limitations of using app-tracked data for clinical and research purposes. METHODS: An online questionnaire was distributed to current users of Clue, a commercially available menstrual health tracking app, asking them to characterize their last period. We compared responses to the user's corresponding Clue app-tracked data. The study sample comprised 6546 U.S.-based users (aged 18-45 years). RESULTS: Increasing reported heaviness was associated with increasing app-tracked period length and days of heavy flow, impaired quality-of-life (especially body pain severity), and disrupted activities. Of those reporting having had a heavy/very heavy period, ~ 18% had not tracked any heavy flow, but their period length and quality-of-life indicators were similar to those who had tracked heavy flow. Sexual/romantic activities were the most affected across all flow volumes. Compared to app-tracked data, 44% recalled their exact period length; 83% recalled within ± 1 day. Overestimation was more common than underestimation. However, those with longer app-tracked periods were more likely to underestimate period length by ≥ 2 days, a pattern which could contribute to under-diagnosis of HMB. CONCLUSION: Period heaviness is a complex construct that encapsulates flow volume and, for many, several other bleeding-associated experiences (period length, bodily impairments, disruptions of daily activities). Even very precise flow volume assessments cannot capture the multi-faceted nature of HMB as experienced by the individual. Real-time app-tracking facilitates quick daily recording of several aspects of bleeding-associated experiences. This more reliable and detailed characterization of bleeding patterns and experiences can potentially increase understanding of menstrual bleeding variability and, if needed, help to guide treatment.

The top 100 cited articles in menstrual health among adolescent girls: a citation analysis.

BACKGROUND: Menstrual health is an important public health concern where it is still considered a taboo, and adolescent girls often lack knowledge about menstrual health, face limited access to sanitation facilities, and struggle with the affordability of sanitary materials. Every year numerous articles are published; however, only a few of them would be influential in the evolution of a particular field. The number of citations received by an article serves as a quality factor for the impact of the article in a particular field. Citation analysis analyses the relationship between citations received by articles. From the literature search, no citation analysis was conducted on menstrual health. Hence the objective of the study was to identify the articles which received hundred or more citations and also to identify the leading countries, journals, study designs, and departments conducting research on menstrual health. METHODS: Citation analysis was done with search terms pertaining to adolescent and menstrual health using Google Scholar as a database in Publish or Perish software. The articles retrieved were exported to Microsoft Excel. Articles that received a hundred or more citations were screened for the type of article, department, and country where the study was conducted. A descriptive analysis of the hundred or more cited articles was done in Microsoft Excel. RESULTS: A total of 982 articles pertaining to menstrual health among adolescent girls were retrieved. There were hundred articles with hundred and more citations pertaining to the menstrual health of adolescent girls. Cross-sectional study design, Obstetrics and Gynaecology department, India and USA countries, and PLOS ONE journal had the most citations in research on menstrual health among adolescent girls. The top ten articles were on menorrhagia, menstrual hygiene practices, Water, Sanitation and hygiene (WASH), stigma on menstruation, and education on menstrual health. CONCLUSION: The hundred cited articles on menstrual health among adolescent girls were mainly from high-income countries and were of more observational in nature than interventional. Thus, highlighting the need to strengthen experimental studies on the menstrual health of adolescent girls in Lower-middle-income countries.

Menstrual health is an important public health entity where menstrual health management remains poor among adolescent girls in lower-middle-income countries. From the literature, it has been observed that there is a lack of research pertaining to menstrual health. Research-related performances are evaluated through various objective measures; one of them is the number of citations received by the articles, which implicates the impact of the article in a particular field. Hence the objective of our study was to enlist the articles pertaining to menstrual health on adolescent health, which received hundred and more citations. The most common study design, department, country, and journal were determined from articles that received hundred and more citations. The study results showed that the Cross-sectional study design, Obstetrics and Gynaecology department, India and USA countries, and PLOS ONE journal conducted research with the highest number of articles having hundred and more citations. The top ten articles included research pertaining to domains such as menorrhagia, menstrual hygiene practices, Water, Sanitation, and hygiene (WASH), stigma on menstrual health, and education on menstrual health, which are imperative with respect to adolescent girls' menstrual health. From the current citation analysis, it is evident that there is a need for strengthening research on menstrual health, which will generate evidence-based interventions and help policymakers implement necessary policies for adolescent health.

Experience of menstruation with the use of reusable menstrual products: a qualitative study among menstruators in Israel.

Menstruation is an embodied experience that influences menstruators' perceptions of the self and body. The stigma surrounding menstruation and its negative representation in popular culture has consequences for women's sexual and reproductive health. In this study, semi-structured interviews were conducted with forty 18-50 year old participants who used reusable menstrual products to examine their experience of menstruation and how their use of these products shaped their self-body image. Data were analysed using thematic analysis. Participants commonly reported physical, medical and emotional improvement in menstrual experience and improved acceptance of the menstrual body alongside changes in feeling towards menstrual products and related issues. The participants described menstruation, menstrual blood, and the menstrual body more positively than before, reported a high comfort level with and in their bodies, and rejected common representations of menstruation. Findings suggest that using reusable menstrual products can contribute to body appreciation. Given these benefits, further research is needed to assess how knowledge of alternative menstrual products can stimulate positive views about the menstruating body and contribute to menstrual health.

Evaluation of Menstrual Cycle Tracking Behaviors in the Ovulation and Menstruation Health Pilot Study: Cross-Sectional Study.

BACKGROUND: Menstrual cycle tracking apps (MCTAs) have potential in epidemiological studies of women's health, facilitating real-time tracking of bleeding days and menstrual-associated signs and symptoms. However, information regarding the characteristics of MCTA users versus cycle nontrackers is limited, which may inform generalizability. OBJECTIVE: We compared characteristics among individuals using MCTAs (app users), individuals who do not track their cycles (nontrackers), and those who used other forms of menstrual tracking (other trackers). METHODS: The Ovulation and Menstruation Health Pilot Study tested the feasibility of a digitally enabled evaluation of menstrual health. Recruitment occurred between September 2017 and March 2018. Menstrual cycle tracking behavior, demographic, and general and reproductive health history data were collected from eligible individuals (females aged 18-45 years, comfortable communicating in English). Menstrual cycle tracking behavior was categorized in 3 ways: menstrual cycle tracking via app usage, that via other methods, and nontracking. Demographic factors, health conditions, and menstrual cycle characteristics were compared across the menstrual tracking method (app users vs nontrackers, app users vs other trackers, and other trackers vs nontrackers) were assessed using chi-square or Fisher exact tests. RESULTS: In total, 263 participants met the eligibility criteria and completed the digital survey. Most of the cohort (n=191, 72.6%) was 18-29 years old, predominantly White (n=170, 64.6%), had attained 4 years of college education or higher (n= 209, 79.5%), and had a household income below US $50,000 (n=123, 46.8%). Among all participants, 103 (39%) were MCTA users (app users), 97 (37%) did not engage in any tracking (nontrackers), and 63 (24%) used other forms of tracking (other trackers). Across all groups, no meaningful differences existed in race and ethnicity, household income, and education level. The proportion of ever-use of hormonal contraceptives was lower (n=74, 71.8% vs n=87, 90%, P=.001), lifetime smoking status was lower (n=6, 6% vs n=15, 17%, P=.04), and diagnosis rate of gastrointestinal reflux disease (GERD) was higher (n=25, 24.3% vs n=12, 12.4%, P=.04) in app users than in nontrackers. The proportions of hormonal contraceptives ever used and lifetime smoking status were both lower (n=74, 71.8% vs n=56, 88.9%, P=.01; n=6, 6% vs n=11, 17.5%, P=.02) in app users than in other trackers. Other trackers had lower proportions of ever-use of hormonal contraceptives (n=130, 78.3% vs n=87, 89.7%, P=.02) and higher diagnostic rates of heartburn or GERD (n=39, 23.5% vs n=12, 12.4%, P.03) and anxiety or panic disorder (n=64, 38.6% vs n=25, 25.8%, P=.04) than nontrackers. Menstrual cycle characteristics did not differ across all groups. CONCLUSIONS: Our results suggest that app users, other trackers, and nontrackers are largely comparable in demographic and menstrual cycle characteristics. Future studies should determine reasons for tracking and tracking-related behaviors to further understand whether individuals who use MCTAs are comparable to nontrackers.