Menstruation: science and society.

Women's health concerns are generally underrepresented in basic and translational research, but reproductive health in particular has been hampered by a lack of understanding of basic uterine and menstrual physiology. Menstrual health is an integral part of overall health because between menarche and menopause, most women menstruate. Yet for tens of millions of women around the world, menstruation regularly and often catastrophically disrupts their physical, mental, and social well-being. Enhancing our understanding of the underlying phenomena involved in menstruation, abnormal uterine bleeding, and other menstruation-related disorders will move us closer to the goal of personalized care. Furthermore, a deeper mechanistic understanding of menstruation-a fast, scarless healing process in healthy individuals-will likely yield insights into a myriad of other diseases involving regulation of vascular function locally and systemically. We also recognize that many women now delay pregnancy and that there is an increasing desire for fertility and uterine preservation. In September 2018, the Gynecologic Health and Disease Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development convened a 2-day meeting, "Menstruation: Science and Society" with an aim to "identify gaps and opportunities in menstruation science and to raise awareness of the need for more research in this field." Experts in fields ranging from the evolutionary role of menstruation to basic endometrial biology (including omic analysis of the endometrium, stem cells and tissue engineering of the endometrium, endometrial microbiome, and abnormal uterine bleeding and fibroids) and translational medicine (imaging and sampling modalities, patient-focused analysis of menstrual disorders including abnormal uterine bleeding, smart technologies or applications and mobile health platforms) to societal challenges in health literacy and dissemination frameworks across different economic and cultural landscapes shared current state-of-the-art and future vision, incorporating the patient voice at the launch of the meeting. Here, we provide an enhanced meeting report with extensive up-to-date (as of submission) context, capturing the spectrum from how the basic processes of menstruation commence in response to progesterone withdrawal, through the role of tissue-resident and circulating stem and progenitor cells in monthly regeneration-and current gaps in knowledge on how dysregulation leads to abnormal uterine bleeding and other menstruation-related disorders such as adenomyosis, endometriosis, and fibroids-to the clinical challenges in diagnostics, treatment, and patient and societal education. We conclude with an overview of how the global agenda concerning menstruation, and specifically menstrual health and hygiene, are gaining momentum, ranging from increasing investment in addressing menstruation-related barriers facing girls in schools in low- to middle-income countries to the more recent "menstrual equity" and "period poverty" movements spreading across high-income countries.

Future Directions of Research and Care for Urinary Incontinence: Findings from the National Institute of Diabetes and Digestive and Kidney Diseases Summit on Urinary Incontinence Clinical Research in Women.

PURPOSE: Female urinary incontinence is prevalent, costly and morbid. Participants in a NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) sponsored summit reviewed findings from NIH (National Institutes of Health) funded clinical research on urinary incontinence in women and discussed the future of urinary incontinence research. MATERIALS AND METHODS: The NIDDK convened the Summit on Urinary Incontinence Clinical Research in Women on March 14, 2014. Participants representing a broad range of clinical expertise reviewed completed NIH sponsored urinary incontinence related studies, including results from community based epidemiological studies such as the BACH (Boston Area Community Health) Survey and from randomized clinical trials such as PRIDE (Program to Reduce Incontinence by Diet and Exercise), and studies conducted by the Pelvic Floor Disorders Network and the Urinary Incontinence Treatment Network. RESULTS: BACH Survey results improved our understanding of precursors, incidence, prevalence and natural history of urinary incontinence in a diverse group of women. The Pelvic Floor Disorders Network study found that anticholinergic medications and onabotulinumtoxinA are efficacious for treating urge urinary incontinence, and Burch colposuspension and retropubic mid urethral polypropylene slings are efficacious for decreasing stress urinary incontinence following pelvic organ prolapse surgery in women with potential stress urinary incontinence. The Urinary Incontinence Treatment Network study found that fascial slings were better than colposuspension, and that retropubic and transobturator mid urethral polypropylene slings were equivalent for stress urinary incontinence. In patients with stress urinary incontinence a preoperative urodynamic study was noninferior to basic office examinations for surgical outcome. The addition of behavioral intervention did not allow female patients to discontinue antimuscarinics for urge urinary incontinence. PRIDE showed that modest weight reductions significantly decreased urinary incontinence. CONCLUSIONS: Strategies for future research on urinary incontinence should include a focus on early disease, risk factor identification, better phenotyping, incorporation of new technologies, patient centered research and prevention.

Design of a Tool Capable of Assessing Environmental Sociocultural Physical Factors Influencing Women's Decisions on When and Where to Toilet Within Real-World Settings: Protocol for the Build and Usability Testing of a Mobile App for Use by Community-Dwelling Women.

BACKGROUND: Although surveys and apps are available for women to report urination and bladder symptoms, they do not include their decisions regarding toileting. Real-world factors can interfere with toileting decisions, which may then influence bladder health. This premise lacks data per want of a robust data collection tool. OBJECTIVE: The Prevention of Lower Urinary Tract Symptoms (PLUS) research consortium engaged a transdisciplinary team to build and test WhereIGo, a mobile data collection app for Android and iOS. The design goal was a comprehensive reporting system for capturing environmental, sociocultural, and physical factors that influence women's decisions for toileting. Aims include having (1) an innovative feature for reporting physiologic urge sensation when "thinking about my bladder" and shortly before "I just peed," (2) real-time reporting along with short look-back opportunities, and (3) ease of use anywhere. METHODS: The development team included a plain language specialist, a usability specialist, creative designers, programming experts, and PLUS scientific content experts. Both real-time and ecological momentary assessments were used to comprehensively capture influences on toileting decisions including perceived access to toileting, degree of busyness or stress or focus, beverage intake amount, urge degree, or a leakage event. The restriction on the maximal number of taps for any screen was six. PLUS consortium investigators did pilot-testing. Formal usability testing relied on the recruitment of community-dwelling women at four PLUS research sites. Women used the app for 2 consecutive days. Outcome measures were the system usability scale (SUS; 0-100 range) and the functional Mobile Application Rating Scale (1-5 range). These scales were embedded at the end of the app. The estimated a priori sample size needed, considering the SUS cut point score set at ≥74, was 40 women completing the study. RESULTS: Funding was provided by the National Institute of Diabetes and Digestive and Kidney Diseases since July 2015. The integrity of the build process was documented through multiple 5-minute videos presented to PLUS Consortium and through WhereIGo screenshots of the final product. Participants included 44 women, with 41 (93%) completing data collection. Participants ranged in age from 21 to 85 years, were predominantly non-Hispanic White (n=25, 57%), college-educated (n=25, 57%), and with incomes below US $75,000 (n=27, 62%). The SUS score was 78.0 (SE 1.7), which was higher than 75% of the 500 products tested by the SUS developers. The mean functional Mobile Application Rating Scale score was 4.4 (SE 0.08). The build and informal acceptability testing were completed in 2019, enrollment for formal usability testing completed by June 2020, and analysis was completed in 2022. CONCLUSIONS: WhereIGo is a novel app with good usability for women to report toileting decisions, urination, and fluid intake. Future research using the app could test the influence of real-time factors on bladder health. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/54046.

Sexual Health Behaviors by Age 17 and Lower Urinary Tract Symptoms at Age 19: PLUS Research Consortium Analysis of ALSPAC Data.

PURPOSE: We examined how antecedent sexual health factors affect lower urinary tract symptoms (LUTS) in adolescent women. METHODS: We analyzed 1,941 adolescent women from the Avon Longitudinal Study of Parents and Children at age 19. At ages 15 and 17, participants reported use of oral contraceptives (OCs), history of sexual intercourse, number of sexual partners, and condom use. At age 19, The Bristol Female Lower Urinary Tract Symptoms questionnaire quantified the frequency over the past month: stress incontinence, any incontinence, urgency, sensation of incomplete emptying, bladder pain, and urinary tract infection. Multivariable regression models examined associations between sexual health behaviors reported at ages 15 and 17 and six LUTS reported at age 19, after controlling for covariates. RESULTS: Commonly reported LUTS at age 19 were past-month stress incontinence (26.8%), bladder pain (26.3%), any urine leakage (22.1%), and urinary tract infection (15.4%). OC use by age 17 was associated with urgency (odds ratio [OR] = 1.62, 95% confidence interval [CI] 1.19-2.20), incomplete emptying (OR = 1.62, 95% CI = 1.17-2.26), bladder pain (OR = 1.45, 95% CI = 1.15-1.83), and urinary tract infections (OR = 1.68, 95% CI = 1.28-2.21) at age 19 after adjustment for covariates. However, associations were attenuated after adjustment for condom use and number of sexual partners. Sexual intercourse by age 17 was associated with 1.53-2.65 increased odds of LUTs categories except incontinence, with lower confidence interval boundaries > 1.0. Associations were stronger among women with ≥ 3 sexual partners (vs. 0) by age 17. DISCUSSION: We found longitudinally assessed associations between OC use, sexual intercourse, and number of sexual partners during adolescence and LUTS at age 19.

A Pelvic Health Curriculum in School Settings: The Effect on Adolescent Females' Knowledge.

STUDY OBJECTIVE: In this pilot study we ascertained baseline knowledge of pelvic anatomy and function among female adolescents and tested the educational effectiveness of a pelvic health curriculum among female adolescent students with the hypothesis that teaching pelvic anatomy, muscle, and organ function, and pelvic hygiene increases pelvic health knowledge. DESIGN: Intervention-control group, community-based effectiveness study. SETTING: Three Chicago area schools with racial minority and low-income student populations were selected as study sites. PARTICIPANTS: One hundred sixty-eight students with a mean age of 14.1 (±0.1) years. Most (69%) self-reported race as black or African American; 23.8% reported Hispanic ethnicity. INTERVENTIONS: Pelvic health teachers delivered 6 weekly, 1-hour classes (intervention group, n = 103; control group, n = 65). A comparison control group received standard curricula (physical education or science). MAIN OUTCOME MEASURES: Knowledge change was measured using the Adolescent Bladder and Pelvic Health Questionnaire. We used χ2 tests to compared bivariate differences between study arms and generalized equation estimate to test for before and after change across groups. RESULTS: Baseline pelvic anatomy and function knowledge was minimal. The level of anatomical knowledge was very low with few in either group correctly able to identify where urine exits the body or the number of openings in the vulva. After intervention, significant increases in knowledge included pelvic floor muscle awareness in the control and intervention group (20% vs 89%; P < .001), pelvic floor muscle exercise benefit (31% vs 78%; P < .001), and knowledge that urine loss was abnormal (25.4% vs 60%; P < .001). More participants correctly identified organs within the pelvic structure, the vagina (21.5% vs 51.5%; P < .001), pelvic floor (16.9% vs 57.3%; P < .001), and the bladder (12.3% vs 42.7%; P < .001). CONCLUSION: In this study we identified pelvic-related knowledge deficits among female adolescents and suggest that short-term pelvic health educational intervention results in significant knowledge acquisition.

A pelvic floor fitness program for older women with urinary symptoms: a feasibility study.

OBJECTIVE: To determine the feasibility of an adapted pelvic fitness and educational program to control urinary incontinence (UI) and overactive bladder (OAB) symptoms in women older than 65 years. DESIGN: Feasibility study. SETTING: Residential independent-living facilities. PARTICIPANTS: Forty-three study subjects, limited to women 65 years and older residing in or using an independent-living facility, who self-reported that they had symptoms of UI or OAB. METHODS: Study participants volunteered to participate in a 6-week pelvic fitness class. Classes were held at 3 different independent-living sites. Forty-three women in 4 different treatment groups with 9-15 women per group completed the adapted group pelvic fitness and education instruction, which was provided twice a week for 6 weeks. At one site, in addition to the treatment group, an education-only group met; in this group, 14 women received an alternate intervention consisting of only one educational session and a booklet presenting the didactic content without specific muscle isolation or training. MAIN OUTCOME MEASUREMENTS: In addition to demographics, standardized assessments using validated instruments were obtained before the first class and after the last class, including general health, self-reported bladder function, quality of life, and the timed up-and-go test. RESULTS: Most participants (97%) were white, with a mean age of 83 years (range, 67-95 years). Most participants in the treatment groups (83%) reported symptom improvement. Statistically significant improvements in OAB and bladder symptoms were found after 6 weeks in the treatment groups, based on visual analog scale scores (P = .0058) for bothersomeness of bladder symptoms, the total score of the Urogenital Distress Inventory, Short Form (P ≤ .0001), and the total score of the Incontinence Impact Questionnaire, Short Form (P = .0036). CONCLUSIONS: A group pelvic floor fitness program combined with pelvic health education is a promising approach to reduce urinary symptoms and improve the quality of life of older women living with OAB or UI symptoms.

Knowledge and perceptions of pelvic floor disorders among african american and latina women.

OBJECTIVE: : The objective of this study was to explore knowledge, barriers to seeking sociocultural perceptions of pelvic floor disorders (PFDs) among African American (AA) and Latina (LA) community-dwelling women. METHODS: : Thirty-two women participated in 4 focus groups. The sample included AA and LA women aged 24 to 77 years. Focus groups were stratified by age and race/ethnicity. Discussion questions included knowledge of and related health needs and barriers to seeking care with respect to PFDs, urinary incontinence, and pelvic organ prolapse. Demographics and basic knowledge and experience with PFDs were also captured by survey. RESULTS: : Several significant themes emerged from the data. AA and LA women had general misconceptions about PFDs and were unaware of PFDs causes, symptoms, and available treatments. Women were eager to receive more information, particularly prevention information that could be shared with their daughters. A major barrier to seeking care was the pattern of placing family demands before their own health needs. CONCLUSIONS: : Findings suggest that there is a gap in information on PFDs among AA and LA women, yet a demand for information exists. Sociocultural perspectives discerned from focus group with AA and LA women can be used to tailor educational information and materials on PFDs. Findings may increase health provider awareness of the unique sociocultural barriers to seeking care for AA and LA women and improve patient education on PFDs.