Chemicals in menstrual products: A systematic review.

BACKGROUND: From menarche until menopause, the average menstruator will use over 11 000 tampons or sanitary pads. Vaginal and vulvar tissue is highly permeable, and chemicals are absorbed without undergoing first-pass metabolism. OBJECTIVES: To conduct a review of the literature to determine exposure to environmental chemicals in menstrual products. SEARCH STRATEGY: This review identified 15 papers over the past 10 years. SELECTION CRITERIA: Papers that measured chemicals in menstrual products and that measured human biomarkers of chemical exposure were included. Papers had to also be available in English. DATA COLLECTION AND ANALYSIS: Reviewers assessed the articles and data provided. Multiple chemical groups were found. MAIN RESULTS: Phthalates, volatile organic compounds, parabens, environmental phenols, fragrance chemicals, dioxins and dioxin-like compounds were detected in menstrual products. Research gaps were identified, including the lack of studies on newer products such as menstrual underwear and cups/discs. In addition to measuring chemicals in these products, future research should focus on clarifying the exposure per menstrual cycle to these chemicals to understand how menorrhagia and cycle length influence exposure from menstrual products. CONCLUSION: Menstrual products contained measurable levels of a range of endocrine disrupting chemicals including phthalates, phenols and parabens. This reflects a potentially important route of exposure to chemicals that can impact women's reproductive health.

Menstruating while homeless: navigating access to products, spaces, and services.

BACKGROUND: People experiencing homelessness (PEH) in the United States face substantial challenges related to menstruation, exacerbated by the COVID-19 pandemic. Limited access to period products, heightened stigma, and gynecological challenges contribute to increased hardships for PEH, highlighting the need for improved services and policies to address period equity and overall well-being for this vulnerable population. METHODS: We conducted semi-structured qualitative interviews with PEH (n = 12) and community healthcare and social service providers (e.g., case managers, shelter directors, community health workers, and nurses, n = 12) in Lafayette, Indiana, a city located between Indianapolis and Chicago in the United States. We used thematic analysis techniques for data analysis. RESULTS: PEH's limited access to products, services, and safe spaces hindered effective menstruation management within restrictive community contexts. Although community healthcare and service providers offered some support, complex interactions with the healthcare system, stigma, and limited access to spaces exacerbated barriers. The COVID-19 pandemic further intensified these difficulties by closing public spaces, worsening economic conditions, and straining service provider resources. CONCLUSIONS: Results highlight critical organizational and policy gaps in the United States for menstruation management resources and services, emphasizing the need for better integration into health and well-being programs for PEH. These insights will advance reproductive and public health research, shedding light on the disparities faced by PEH in managing menstruation in Indiana and contributing to the national discourse on addressing these barriers. Amid the complex landscape of public health, particularly during and after the pandemic, prioritizing menstrual health remains essential for all individuals' overall well-being, including those experiencing homelessness.

Menstrual products: culprits or bystanders in endometriosis and adenomyosis pathogenesis?

Products that may reduce menstrual flow from the endometrial cavity to the vagina (i.e. tampons and menstrual cups) could facilitate retrograde menstruation and the spillage of blood into the myometrium, two mechanisms which could be major determinants in endometriosis and adenomyosis pathogenesis. The aim of this narrative review is to summarize the evidence regarding the mechanical role menstrual products may have in the pathogenesis of these two conditions. Evidence in this regard is inconclusive. While Darrow and colleagues observed that 14 or more years of tampon use were associated with endometriosis (OR 3.6; 95% CI, 1.04-13.5); in Meaddough and colleagues' retrospective study, the percentage of women using pads only was significantly higher among those with endometriosis than among those without the condition (31% vs 22%). Three further groups failed to find an association between endometriosis/adenomyosis and any type of menstrual product. The only case that may be considered as a sort of proof-of-concept of the association between products potentially reducing anterograde menstrual flow and endometriosis was reported by Spechler and colleagues, who described the case of a 41 year-old who developed endometriosis after having used a menstrual cup on a regular basis. However, the number of studies on the subject is scarce, study populations are exiguous and a greater attention to temporality of endometriosis onset in relation to when women started habitually using a specific menstrual product is needed. Confounding variables including type and quantity of endocrine disruptors contained in menstrual products should also be addressed. At the present moment, no recommendation can be provided on the safety of one type of menstrual product compared to another.

Menstrual cup adoption among reproductive age women in India: a systematic review and meta-analysis.

This systematic review and meta-analysis aim to synthesize the information on menstrual cup adoption among reproductive-age women in India. A comprehensive search was conducted in four databases following PRISMA 2020 guidelines. A total of 18 articles were included in this review. The findings of the studies were described narratively, and meta-analysis and sensitivity analysis were also performed. The pooled prevalence of knowledge regarding menstrual cups among women in the included studies was 35 percent (CI: 0.23-.49). Just 5 percent (CI: 0.02-0.12) of women use menstrual cups. Only 24 percent (CI: 0.17-0.33) of the women who used menstrual cups reported leakage as one of the key barriers or issues to menstrual cup use. Nevertheless, 62 percent (CI: 0.42-0.78) of non-users have a pooled prevalence expressing willingness to use in the future. The price was found to be both a motivating and discouraging factor for using menstruation cups. Currently, menstrual cup use among Indian women and girls is very low. However, user reviews suggest that menstrual cups are an appealing and safer replacement for conventional period supplies. To fully realize the potential of menstruation cups, significant education, and awareness efforts are required to ensure proper usage. Furthermore, initiatives to lower the initial cost of menstruation cups are critical.

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.

Exploring consumer vulnerability in the consumption of menstrual products: Insights from a developing country.

Consumer experiences in the consumption of menstrual products and the factors that underpin consumer vulnerability in the consumption process have largely been overlooked in marketing research. This research addresses this gap by examining consumer experiences of vulnerability in the consumption of menstrual products in a developing country context. Data from in-depth interviews and netnography reveals women's embodied experiences of vulnerability, with structural barriers, such as regulatory gaps and exclusionary marketing practices adversely affecting the women's physical and emotional well-being. Contributions to consumer vulnerability literature and implications for health marketing and policy are discussed.

An Update on State Legislation Supporting Menstrual Hygiene Products in US Schools: A Legislative Review, Policy Report, and Recommendations for School Nurse Leadership.

Access to menstrual products is important to support adolescent health. Advocacy to increase access to menstrual products in schools is growing; however, ideal access requires policies that will require schools to support the menstrual health of menstruating students. We conducted a legislative review on the existence and status of state legislation related to the provision of menstrual products in US schools and categorized by state's political control (political party affiliation of governors and state legislature). Of 50 states and 6 territories, 21 had legislation to support menstrual products in schools, 7 had bills pending, 10 had bills failed, and 18 states had no policies introduced in the state legislature. States with Democrat control have significantly more menstrual product state laws compared to states with Republican control [z = 2.54, p = 0.01]. There is a need, especially in Republican states, to accelerate efforts to pass laws that will support menstrual product access in schools.

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

BACKGROUND: Traditionally, menstrual education has consisted of lectures directed toward women. The objective of this study was to design an innovative menstrual education (ME) program that reflects the needs of both young women and men, and verify its effectiveness. METHODS: A mixed-method design was used to determine the program needs and assess young adults' knowledge and perceptions of menstruation and menstrual products. Focus group interviews were conducted with 14 young adults, and 150 young adults participated in an online survey. After developing the ME program, 10 young adults participated in a study to verify its effectiveness. RESULTS: Interview results showed young adults wanted more information about menstrual products. The online survey revealed significant differences in knowledge based on participants' general characteristics and experience; exposure to menstruation and menstrual products positively impacted knowledge and perception. In addition, the results indicated young adults wanted ME content access via mobile and in-person modalities, designed for both genders, drawing on menstrual experts' knowledge. Based on these results, a multi-experimental menstrual education (MEME) program was designed and included: hands-on exposure to 60 menstrual products, product demonstrations with a female perineal model, a YouTube video created by the researchers, a true-or-false quiz, and question-and-answer sessions with menstrual experts. CONCLUSIONS: This study clarified the requirements of an innovative menstrual education program. It led to high satisfaction among participants, and improved knowledge and perceptions of menstruation and menstrual products. The online survey showed a correlation between the extent of received ME, and respondents' perception of menstrual products. This implied that a MEME program could change perceptions when conducted systematically; by extension it could ameliorate menstruation challenges attributed to poverty. Future research could further verify the effectiveness of the MEME program, using a larger sample, and examine its suitability for incorporation into official ME curricula at universities and companies. TRIAL REGISTRATION: This trial was registered in a Clinical Research Information Service in Korea linked with the World Health Organization's International Clinical Trial Registry Platform (WHO's ICTRP) (no. KCT0004715 ), Registered 07 Feb 2020.

Acceptability of menstrual products interventions for menstrual hygiene management among women and girls in Malawi.

BACKGROUND: A key challenge for menstruating girls and women in low-resource countries is the inadequate and unreliable supply of menstrual products. Although development partners are implementing menstrual product interventions to address this challenge in Malawi, there is a paucity of information on the distribution of menstrual products and the acceptability of these interventions among users. METHODS: We conducted in-depth interviews with girls (n = 20) and women (n = 26) and 4 focus group discussions (FGDs) with women (n = 35) and 7 FGDs with girls (n = 60) to explore the acceptability of menstrual products interventions in 8 districts. Teachers (n = 12), community leaders (n = 6), community health workers (n = 8) and service providers (n = 9) were also interviewed to explore implementation issues and their views regarding the effect of menstrual products interventions on girls and women. Data were analyzed using content analysis. RESULTS: Common menstrual products being promoted include locally made reusable pads, commercially made disposable pads and menstrual cups. Overall, adult women preferred reusable pads and young girls preferred disposable pads. Reported benefits of using any type of material distributed included enhanced cleanliness and reduced school absenteeism for girls. While community leaders and teachers applauded the use of disposable menstrual products they expressed concern that they are not affordable for an average Malawian and bemoaned the indiscriminate disposal of used disposable pads. Women and girls highlighted their lack of facilities to effectively wash and dry reusable pads. Service providers bemoaned poor coordination and the lack of national standards to regulate the quality of menstrual products distributed at national level. Improved inclusion of males and health workers could enhance the sustainability of programmes. CONCLUSION: While the available menstrual products interventions are acceptable among participants, we note several challenges including affordability, poor disposal methods, lack of attention on sanitation facilities and the lack of standard protocols to regulate the quality of menstrual products. Recommendations to address these issues are reported.

Menstrual Products: Attitudes About Taxation and Safety.

Background: This study explored factors associated with the differences between women and men in attitudes, norms, and the support of taxation of menstrual products (MPs) and menstrual-adjacent products. It also investigated the use of these products in women. Methods: Young adults from 18 to 30 years of age were recruited via social media, listserve emails, and flyers placed throughout a university campus. Following cognitive interviewing, a survey investigated attitudes, beliefs, and behaviors associated with MPs. Results: Individuals self-identified as men or women. Women (n = 154) had more positive general attitudes, less positive safety attitudes, and less support for taxation of MPs than men (n = 43). Regression analyses indicated that factors, such as race, age, attitudes, norms, and taxation, were associated with product use. Conclusions: Attitudes about safety and taxation differ for men and women. Tax policies and attitude-shifting interventions need to be tailored to their audience, and our study can inform that effort.

Perspectives on prior preparation for menstrual experience from women and female health workers in Malawi.

BACKGROUND: While studies have explored various aspects of menstruation, an evident gap remains in the literature concerning the perspectives of young women and female health workers. By shedding light on this unexplored terrain, the study provides novel insights that can inform targeted interventions and foster a more inclusive understanding of menstrual health. As such, this investigation stands at the forefront of academic endeavour in menstrual health research, making an original and valuable impact in the field. OBJECTIVES: The objective of this study was to explore the experiences of reproductive-aged women during menstruation in Malawi. The specific objectives were to examine the experiences of reproductive-age women related to menstrual preparation, identify factors influencing the choice of menstrual products for women in Malawi, and identify the public health implications of menstrual products. DESIGN: This cross-sectional study employed qualitative research methods to explore the acceptance and implementation of menstrual cups as a feminine hygienic product for women in Malawi. METHODS: The study involved focus group discussions and interviews with reproductive-age women aged 18-54 years and health providers at Bwaila and Mitundu family clinics and Lighthouse HIV management centres. Thematic content analysis was performed using NVivo 12. Ethical approval was obtained from the College of Medicine Research and Ethics Committee (P.08/21/3379). RESULTS: Education on menstruation is provided as early as 10 years before menarche by sisters, friends, mothers, aunties and grandmothers. Parents remain silent on menstrual issues. Commonly used menstrual products include disposable pads, cloths, reusable pads and cotton wool. While a few mentioned using tampons, pieces of blankets and flex foam, the majority demonstrated widespread ignorance about menstrual cups. Mentors or counsellors, affordability, accessibility, comfort and disposal issues influence women's choice of products being used. CONCLUSION: Parents need to break the silence on menstrual issues. Messages on menstruation and menstrual products are explicit in forming female adolescents what to expect with menarche, how to manage menses including health-related impacts, and ways of mitigating menses-related misconceptions, discrimination and stigma, and could be incorporated into the primary school curriculum. Safe menstrual products are accessible free of charge or at a subsidised cost.

A multimodality review of gynecologic devices in the pelvis.

There are a wide variety of gynecologic devices encountered on pelvic imaging which may not be the focus or primary reason for imaging. Such devices include pessaries, menstrual products, radiation therapy devices, tubal occlusion devices, and contraceptive devices, including intrauterine devices and intravaginal rings. This manuscript offers a comprehensive review of multimodality imaging appearances of gynecologic devices encountered on pelvic imaging and discusses device indications, positioning, and complications.

Understanding autistic youths' menstrual product preferences and caregivers' product choices.

LAY ABSTRACT: There is little research exploring the menstrual product preferences of autistic youth, especially those who recently started their period. Study authors surveyed caregivers' choice of menstrual products for their autistic children. They provided popular menstrual materials to autistic youth to try, then asked them which product(s) they preferred, did not try, and why they did not try it. Caregivers selected sensory impact as the most important feature they consider when choosing a menstrual product for their child, and youth participants preferred to use period underwear. Therefore, autistic youth may benefit from purchasing and using period underwear, and caregivers, clinicians, and companies should consider the impact of menstrual product features, like sensory sensitivities, on young autistic menstruators and how best to support them.

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.

Transforming adolescent menstrual health through policy: the role of value added tax exemptions in improving access to sanitary products.

In Namibia, the Value Added Tax (VAT) Amendment Act 2022, which reclassified the supply of sanitary pads as zero-rated, has significant implications for adolescent girls' menstrual health and education. The policy change responds to the need to address period poverty by making essential menstrual products more accessible and affordable. Menstruation is a normal biological process, and access to sanitary products is a human right. Taxing menstrual products reinforces gender inequalities and raises concerns about the basic rights and dignity of women and girls. The VAT-free policy creates a system to reduce the financial burden on girls and women, making it easier for them to manage their periods safely and with dignity. It has the potential to reduce absenteeism from school, ultimately improving educational outcomes for adolescent girls. However, VAT exemptions alone are insufficient to address the broader accessibility issues that impact menstrual hygiene. Evidence-based policies that focus on the availability and affordability of a full range of sanitary products, in conjunction with regulatory mechanisms for price and quality control, are necessary to ensure that menstrual products are safe, affordable, and accessible for all.

Period Poverty: How School Nurses Can Support Menstrual Health and Hygiene.

Lack of access to menstrual products, menstrual hygiene, and education, also known as period poverty, is a widespread issue and disproportionately impacts low-income, rural, Black, Latinx, Indigenous, and People of Color. Period poverty along with period symptoms, such as heavy and painful periods, contribute to school absenteeism impacting school connectedness and student success. The purpose of this article is to bring awareness to period poverty and encourage school nurses to intervene in individual schools, communities, and far-reaching policy spaces utilizing their expertise to secure resources. School nurses can assist in implementing interventions throughout the school year to increase student engagement, success, and overall menstrual health wellness. Through added engagement of stakeholders such as student groups, school staff and administrators, and community organizations, school nurses can help shift the narrative from a position of oppression around menstrual health to a position of empowerment.

A pilot survey of students' menstrual attitudes, experiences, and needs on an urban university campus.

BACKGROUND: In the United States, many menstruators face barriers to period management, such as period poverty, or the lack of access to relevant knowledge and affordable menstrual products. Our current understanding of the social, emotional, and physical impacts of period poverty on students in post-secondary institutions is largely limited. OBJECTIVES: The purpose of this pilot study is to assess period poverty, period-related class disruption, and avoidance of menstrual hygiene management on campus among students and to identify recommendations for action at the University of Illinois Chicago and other urban universities. DESIGN: An online cross-sectional study from February to May 2023. METHODS: Enrolled students who were at least 18 years old completed an anonymous, self-administered online survey. Through descriptive statistics and chi-square tests in SAS version 9.4, we analyzed the sociodemographic, academic, and menstrual characteristics of those who had a period in the past 12 months. We also performed a thematic analysis of students' open-ended responses regarding their menstrual experiences on campus. RESULTS: Of our sample (N = 106), 17.1% of students have faced period poverty, 55.8% experienced period-related class disruption, and 47.5% avoided changing their menstrual products on campus. The relationships between the three menstrual experiences were statistically significant. In the open responses, students reported that their personal experiences with menstruation were largely painful and disruptive. We identified the following themes: (1) inadequate water, sanitation, and hygiene facilities; (2) understocked, empty, or non-existent menstrual product dispensers; (3) a desire for additional resources for menstruation; and (4) the unpredictability of menstruation. CONCLUSION: Our findings indicate that students continue to face obstacles to menstruation management due to inadequate support related to menstrual infrastructure, products, and pain. We outline several recommendations for university/college institutions to prioritize a more inclusive and supportive educational environment for all students.

Students' experiences of menstrual periods while on an urban university campusIn the United States, many girls, women, and other menstruators encounter challenges while managing their menstrual periods. Such barriers include period poverty, or the inability to afford resources and menstrual products such as tampons or pads. In this study, we explored how period poverty impacts college/university students. We shared an online survey with 106 students who were older than 18 years, had a period in the last 12 months, and attended the University of Illinois Chicago. We asked them about their menstrual, social, and academic experiences. We found that approximately one in six students could not afford menstrual products at some point in their lives, over half missed all or portions of class due to their period, and about one in two students avoided changing their menstrual products on campus. The relationships between these three menstrual experiences were statistically significant. Many students also reported that periods were largely painful, disruptive, and unpredictable and that their campus had few physical resources and more obstacles to managing menstruation. From our findings, we identified several steps that universities and colleges can take to prioritize a more inclusive and supportive educational environment for all students.

Exploring Menstrual Hygiene Practices and Awareness of Menstrual Cups Among Nursing Professionals: A Cross-Sectional Survey.

BACKGROUND: Menstrual hygiene management poses significant challenges globally, with widespread reliance on disposable sanitary pads contributing to health risks and environmental degradation. Sustainable alternatives like menstrual cups offer promising solutions but face barriers to adoption, including myths and misconceptions. Educational interventions are crucial in promoting eco-friendly menstrual hygiene practices. MATERIAL AND METHODS: A descriptive cross-sectional survey was conducted at All India Institute of Medical Sciences (AIIMS), Nagpur (Central India) among nursing officers from January to February 2022. A structured questionnaire assessed the demographic characteristics, menstrual hygiene practices, knowledge of menstrual cups, and attitude toward their use. RESULTS: Of the 101 participants, the majority were between the age group of 25 and 40 years (71, 70.3%) and were educated up to a Bachelor of Science degree in nursing (79, 78.21%). Overwhelmingly, 97 (96.03%) of the nursing officers used non-biodegradable sanitary pads. Frequent need to change and staining were cited as common difficulties. Although 97 (96.04%) of the participants had heard of menstrual cups, knowledge gaps existed regarding suitability for nulliparous women, material composition, cost, and lifespan. Despite expressing a desire for better alternatives by 56 (55.4%) participants, only one (0.99%) reported current menstrual cup usage, with 60 (59.4%) participants indicating future readiness to use. CONCLUSION: Discovering nurses' menstrual hygiene habits, this study sheds light on their reliance on disposable pads over menstrual cups. Improving the acceptability of menstrual cups hinges on addressing current knowledge gaps such as their feasibility for use by nulliparous women, ease of insertion, cost, and environmental sustainability. Despite hurdles like misinformation, participants show openness to embracing new options with the right guidance and education.

The Use of "Natural" Substances for Menstrual Hygiene: A Case Report of an Embedded Vaginal Sea Sponge.

BACKGROUND: In early adolescence, irregular menstrual bleeding patterns are common and are frequently due to anovulatory cycles or bleeding disorders. As such, the diagnosis of a vaginal foreign body might initially be missed. CASE: We describe a 14-year-old adolescent female presenting with ongoing irregular menstrual spotting despite reassuring laboratory workup and ultrasonography. She was found to have an embedded vaginal sea sponge eroding through the vaginal wall. On further discussion, she reported using a natural sea sponge for menstrual blood absorption. SUMMARY AND CONCLUSION: In cases of persistent vaginal spotting, vaginal foreign body should be considered in the differential diagnosis. Use of nontraditional menstrual hygiene products could lead to medical complications and negative health outcomes in adolescents.

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.