By Maria Carmen Punzi (PSI/Europe), Odette Hekster (PSI/Europe), Chelsea Polis (Guttmacher Institute), Rubina Hussain (Guttmacher Institute) and Amanda Berry (Guttmacher Institute)

Image by Kimber Beck (www.bimberkeck.com)

Menstruation profoundly affects the way women and girls experience life, form their identities and make decisions about their bodies and sexualities. Despite how important menstruation is throughout girls and women’s lives, from the first bleed to menopause, public health organizations and funders working in the Sexual and Reproductive Health and Rights (SRHR) space seem to not sufficiently link the topics together. We argue that when we don’t recognize that the menstrual experience influences girls and women’s understanding and decision-making about their bodies and fertility, relationship with boys and men, and interaction with communities and families, we miss a unique opportunity to address their real needs and desires.

In countries like Ethiopia and Tanzania, when girls reach menarche, their families and communities believe they have engaged in sex and consider them ready to get married[1]. In Kenya, research revealed that young girls engage in transactional sex for access to menstrual products[2]. Many of the most common menstrual disorders, like endometriosis, are linked to infertility[3] and maternal morbidities. Finally, choices around contraception are often influenced by perceptions about the specific methods’ impact on fertility[4]^,[5], cycle irregularity[6], and girls’ beliefs and desires about the future and parenthood[7]. These examples show that when we work to provide girls with choices and information about reproductive health and contraception, we need to take their concerns about fertility and menstruation seriously, dispel myths or misinformation, counsel them appropriately and promote body literacy.

Despite the clear intersections between menstrual health and sexual and reproductive decision-making and behaviors, SRHR programs rarely – if ever – integrate menstrual health information and interventions after menarche. This overlooks how the reproductive cycle is a continuum[8]: while a woman’s bleeding experience only starts with menarche, it continues when she becomes sexually active and can change during her reproductive years, particularly if she goes through miscarriage or abortion. Women often have questions and concerns about menstruation throughout their lives, and while menstruation can be perceived as a burden, it is also an indicator and predictor of health[9]. Teaching girls and women how to track their cycles and symptoms can help with early diagnostics and encourage them to take control of their health.

Additionally, changes in menstrual bleeding – and the meanings girls and women attach to them – can influence decision-making about contraception, like a recent systematic scoping review[10] showed. The study revealed that views of contraceptive-induced menstrual bleeding changes (CIMBCs) vary widely, and that such changes can be influential in contraceptive decision-making processes, including contraceptive continuation. When a woman’s menstruation changes and becomes heavier, prolonged, less predictable or disappears altogether, it can impact multiple aspects of her daily life. It may make her fear infertility or illness, or hinder her participation in social, religious, domestic, and other activities. In the study, some women identified disruptions in menstruation as a disadvantage of hormonal contraception, because they considered menstruation to be a natural part of womanhood, a marker of health and fertility, as well as a reassurance of not being pregnant. Other women viewed amenorrhea (absence of menstruation) or less frequent or lighter menstruation as convenient and a liberation from menstruation-associated problems such as painful periods.

These insights align with what Population Services International (PSI)’s European network member, PSI-Europe, has uncovered in the last months. PSI-Europe partnered with the funding collaborative The Case for Her[11], to understand the role menstrual health plays across PSI’s network members and its potential to strengthen SRHR interventions. It became clear that, when given the chance to share their reproductive health concerns in clinics, on social media and during in-person conversations, girls and women often bring up menstruation, ask questions and share their worries – and misconceptions – about irregularity and pain. This shows that if we want to serve girls and women, and their SRHR needs, we cannot ignore the important role menstruation plays in how they think of their bodies, fertility and sex lives.

Women’s experiences and perceptions of menstruation and bleeding changes vary widely. Considering this, providers and health workers should ask women about their preferences regarding bleeding changes when selecting a contraceptive method[12]. Only by doing so can they counsel and inform users appropriately about contraceptive options that align with their desires for bleeding patterns as well as return to fertility.

To design and deliver programs that truly put clients at the center, professionals in the public health space, policy-makers and funders, need to recognize women’s lived experience of menstruation and bleeding changes, as key issues in contraceptive research, counseling, and product development, and more generally across SRHR interventions.

Menstrual health is as a topic of vital importance for the SRHR field, and when significantly integrated in programs, it can support girls and women in taking greater control of their health and bodies in every phase of their lives. It is time to call for more research on the linkages between menstrual health and SRHR; better access to counselling on additional contraceptive choices that take into account women’s preferences; and improved integration of menstrual health in SRHR interventions.

[1] Findings from PSI’s project Adolescent360 in Ethiopia and Tanzania, see: https://www.psi.org/2018/09/in-tanzania-long-acting-methods-are-for-girls-with-a-plan/

[2] Phillips-Howard, P. A., Otieno, G., Burmen, B., Otieno, F., Odongo, F., Odour, C., Laserson, K. F. (2015). Menstrual Needs and Associations with Sexual and Reproductive Risks in Rural Kenyan Females: A Cross-Sectional Behavioral Survey Linked with HIV Prevalence. Journal of Women’s Health, 24(10), 801-811.

[3] Harlow, S.D. & Campbell, O.M.R. (2000) Menstrual dysfunction: A missed opportunity for improving reproductive health in developing countries, Reproductive Health Matters, 8(15), 142-147.

[4] A Cross-Cultural Study of Menstruation: Implications for Contraceptive Development and Use. (1981). Studies in Family Planning, 12(1), 3.

[5] Polis, C., Hussain, R., & Berry, A. (2018). There might be blood: A scoping review on women’s responses to contraceptive-induced menstrual bleeding changes. Contraception, 98(4), 348.

[6] Danna, K., Jackson, A., Mann C., Harris, D. (2019). Lessons Learned from the Introduction of the Levonorgestrel Intrauterine System (LNG-IUS) in Zambia and Madagascar, see: http://www.wcgcares.org/wp-content/uploads/2019/04/EECO-LNG-IUS-Case-Study.pdf

[7] Findings from Adolescent 360 in Ethiopia and Tanzania

[8] Sommer, M., Phillips-Howard, P. A., Mahon, T., Zients, S., Jones, M., & Caruso, B. A. (2017). Beyond menstrual hygiene: Addressing vaginal bleeding throughout the life course in low and middle-income countries. BMJ Global Health, 2(2).

[9] Punzi, M.C. & Ljungberg, C. (2018). Consumer-Powered Healthcare For Her: What Menstrual Health Can Teach Us, see:  https://www.psi.org/2018/11/consumer-powered-healthcare-for-her-what-menstrual-health-can-teach-us/

[10] Polis et al., 2018

[11] The Case For Her is a nimble funding collaborative and investment portfolio that invests in two areas, Menstruation and Female Sexual Pleasure. See more at: http://thecaseforher.com

[12] Rademacher, K. H., Sergison, J., Glish, L., Maldonado, L. Y., Mackenzie, A., Nanda, G., & Yacobson, I. (2018). Menstrual Bleeding Changes Are NORMAL: Proposed Counseling Tool to Address Common Reasons for Non-Use and Discontinuation of Contraception. Global Health: Science and Practice, 6(3), 603-610.

Please note that blog posts are not peer-reviewed and do not necessarily reflect the views of SRHM as an organisation.