Menstruation in the USA

Abstract

Purpose of review:

Menstruation touches all spheres of human society, including psychology, education, business, policy, race, and religion. This narrative review aims to describe the relationship menstruation holds with these spaces.

Recent findings:

First, menstruation plays many roles in psychology — premenstrual syndrome affects psychological wellbeing and in turn, psychological stress impacts menstruation. Functional hypothalamic amenorrhea can result when stress hormones inhibit the Hypothalamus-Pituitary-Ovarian axis. Furthermore, menstruation has many implications for all aged individuals, especially adolescents and those who are menopausal. These implications underscore the importance of proper education surrounding menstruation, which can be achieved via social media, school systems, family, and clinicians. However, menstrual health education is highly variable depending on the state and family that someone is raised in. Additionally, menstruation can pose a financial burden as menstrual products can be expensive and access to these products is limited for those who are homeless, incarcerated, and low-income. Recent public policy measures in various states have aimed to achieve “menstrual equity,” by requiring public schools to supply free menstrual products in bathrooms. Furthermore, racial disparities exist with menstrual disorders. Uterine fibroids occur more frequently in Black menstruators compared to White menstruators, and Black women experience worse outcomes overall with fibroids and endometriosis management. Finally, analysis of religion and its relationship to menstruation underscores the immense stigma and “impurity” associated with menstruation.

Summary:

Overall, this review highlights the universality of menstruation in society. As a “fifth vital sign”, there is significant room for improvement in terms of education, research, and cultural acceptance of menstruation. Future research should explore interventions to reduce these gaps.

Introduction

Menstruating individuals make up a significant proportion of the global population, with approximately 1.8 billion menstruating monthly across the world[1]. In 2022, the World Health Organization (WHO) called for three actions with regards to menstrual health: 1) for menstrual health to be framed with the lens of health and human rights as opposed to solely a matter of hygiene 2) for menstruating individuals to have access to menstruation information, education, and products, and 3) for menstrual health and related support activities be included in relevant government plans and budgets with measured performance [2]. This call to action by WHO follows years of activism from grass-roots organizations around the globe, especially with increasing conversation about the prohibitory costs and stigma surrounding menstruation and menstrual products. One study in the United States found that 64% of women were unable to afford necessary menstrual hygiene products in the previous year [3]. Inadequate menstrual hygiene has been associated with infections, poor quality of life, and a decline in school performance and attendance [4–6]. Activism around menstrual equity aims to establish menstruation as a key aspect of health for a large proportion of the population and to remove governmental, cultural, and educational barriers to proper menstrual hygiene. Similarly, the American College of Obstetricians and Gynecologists (ACOG) states that clinicians should consider menstruation as an additional vital sign for children and adolescents as it is a critical metric of health [7].

Menstruation affects children, women, transgender men, and non-binary persons in the United States. Understanding the relationship between menstruation and various aspects of the country will increase efficacy of interventions for menstrual management and equity. This review aims to describe how menstruation, an integral component of gynecologic health, interacts with various components of society in the United States, including psychology, education, business, policy, race, and religion. An overview of the various angles through which we can understand menstruation can be seen in Figure 1.

Fig. 1.

Overview of the interrelationship between Menstruation and Society

Psychologic Aspects of Menstruation

Stress and Menstruation – How premenstrual syndrome affects psychologic well-being

Menstruation is associated with many symptoms including heavy bleeding, dysmenorrhea, and perimenstrual mood disorders [8]. About 12% of women report having premenstrual disorders, premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD), which are defined as psychiatric or somatic symptoms that develop during the luteal phase of the menstrual cycle and resolve after menstruation [9]. Specifically, PMS is when an individual has at least one affective symptom and one somatic symptom that causes dysfunction in social, academic, or work performance [9]. PMDD is defined as having at least 5 symptoms in the week before menses with improvement in symptoms after menstruation [9]. These various disorders can interfere with an individual’s work, education or social life, leaving a psychological impact [8].

Stress and Menstruation - How psychologic stress affects menstruation

The menstrual cycle is often used as a reproductive vital sign that can help patients and physicians understand if there is a hormone imbalance and if the hypothalamic-pituitary-ovarian axis is intact [10]. The hypothalamic-pituitary-ovarian axis describes the hormonal changes responsible for menstruation to occur (Figure 2). The functioning of this axis is important for menstruation, and psychological and physiologic stress can impact it and cause amenorrhea.

Fig 2.

Stress and Hypothalamus-Pituitary-Ovarian Axis

Psychological and physical stress are responses coordinated by the hypothalamic-pituitary-adrenal axis where glucocorticoids, cortisol, epinephrine, and norepinephrine are released in response to a stressor [11]. These hormones can directly inhibit the axis at all three levels leading to irregular menstruation and functional hypothalamic amenorrhea (FHA) [11]. FHA can be secondary to high stress levels, low weight, and excessive exercise [12]. Additionally, amenorrhoeic women with FHA show increased indicators of stress, depression, and reduced self-esteem and self-image compared to eumenorrheic women [13].

Menstruation and Psychiatric Disorders

Given the noted relationship between stress and menstruation, there has been recent research into the association between premenstrual disorders (PMD) and high-risk genetic profiles for psychiatric and autism spectrum disorders. Evidence suggests the pathophysiology of both PMD and psychiatric disorders are similar. A 2023 study found genetic risk for major psychiatric disorders (i.e. depression, bipolar disorder, schizophrenia) was associated with the presence of premenstrual disorders[14]. Furthermore, with relation to pregnancy, PMD is an important risk factor for post-partum depression [15]. In terms of eating disorders, a key finding of malnutrition is the lack of menses — detection of amenorrhea before weight loss as an indication of disordered eating could lead to earlier intervention [16]. In addition, the presence of amenorrhea, especially in adolescents, has an impact on bone density, placing patients with anorexia nervosa at higher risk of osteoporosis and fractures[16]. Overall, knowledge of these associations is important for public health interventions to reduce morbidity and mortality of psychiatric illness.

Menarche

Menarche, or the start of menstruation, is often a key moment of adolescence. Though menstruation is often taught in school as a normal event, it is also taught to be hidden [17]. Teachers in a Midwest school district shared their perceptions of school-based menstruation education as negative, stressful, embarrassing, and focused on concealment [18]. An analysis of 10,000 tweets from users ages 13–25 showed that the vast majority of discussions about menstruation on Twitter are negative and surrounded by shame [19]. Research suggests individuals actually gain little knowledge about menstruation from their school lessons, and this lack of knowledge, in addition to stigmatization in schools, perpetuates widespread negativity, contributing to body shame and self-objectification [17]. Adolescents therefore often feel embarrassment and shame when starting menstruation, which can continue into adulthood and complicate their relationship with their bodies and others. In fact, negative attitudes and expectations around menstruation may also contribute to feelings of lack of agency in sexual decision-making in the future [17].

Menopause

Menopause is the permanent cessation of menses for 12 months resulting in estrogen deficiency. It often occurs naturally at a median age of 51, but can also occur earlier in an individual’s life. Menopause can also be induced by medical causes such as oophorectomy, hysterectomy, chemotherapy, and pelvic radiotherapy. [20][21][22]. Four out of five menopausal individuals experience psychological or physical symptoms during their menopausal period [23].

There is a positive association between menopause and depression and anxiety. Studies have shown menopausal individuals are 1.3 to 3 times more likely to develop a depressed mood compared to premenopausal individuals even after adjusting for variables like a history of depression, vasomotor symptoms and poor sleep [23,24]. Risk factors include personal history of depression, surgical menopause, adverse life events, and negative attitudes due to menopause and ageing [23]. Individuals with a history of depression are five times more likely to have a depressive episode during their menopause transition [23]. Furthermore, the likelihood of a menopausal individual developing anxiety is similar to that of depression [25]. Studies show premenopausal individuals with low anxiety levels are more likely to report high anxiety levels as they transition into menopause while those with already established high anxiety are likely to maintain their anxiety levels into menopause [25].

Sexual function also decreases in menopause due to hormonal and age-related changes [26]. The sexual functioning in menopausal individuals is not a well-researched topic, but it is important for physicians and medical providers to talk to their patients about any sexual function changes they may be experiencing. Sexual function changes can contribute to stress, anxiety, and depression during the menopausal period, and psychologic factors and disorders developed during menopause may also contribute to decreased sexual desire [27].

Transgender and Gender Diverse Populations and Menstruation

Transgender and gender diverse individuals are at increased risk for depression, anxiety, eating disorders, self-harm and suicide compared to their cis-gendered peers [28]. For transgender and gender diverse individuals who do not identify with being assigned female at birth, menses can be incredibly distressing and contribute to any existing mental health issues [28]. The presence of a menstrual cycle can worsen dysphoria, distress, anxiety, depression, and suicidal ideation [30]. To properly care for patients who desire menstrual suppression due to dysphoria and discomfort with their menstrual cycle, physicians can utilize hormonal medications to impact menses[31]. Most patients use oral contraceptive pills (OCPs), not for contraceptive reasons but to induce amenorrhea. However, OCPs contain estrogen and patients have reported discomfort with the feminizing effects of the medication [28]. Additionally, complete amenorrhea on OCPs can be difficult to achieve and breakthrough bleeding can be distressing to patients [28]. Levonorgestrel intrauterine devices (IUDs) are being used more frequently because of increased amenorrheic effect; however, the intrauterine insertion procedure can increase anxiety among patients [28] [32]. Medical providers may also consider offering progestin-only pills, depot medroxyprogesterone, and testosterone to patients. Providers should work with their patients to create individualized menstrual management plans that are aligned with their patients’ goals.

Menstrual Health Education

The dissemination of menstrual health education is often split among social media, schools, family, and physicians. As aforementioned, social media discourse on menstruation is focused on the stigma associated with menstruation — social media platforms serve as a space for significant education and reframing around the matter. In the section below, we will further delve into the other spaces for education about menstruation.

School Systems

For younger children, an introduction to menstrual health education generally begins within the school system. In the United States, the National Sexuality Education Standards (NSES) serve as a framework for topics to be discussed in the classroom [33]. The NSES outlines broader focus areas such as puberty and adolescent reproductive anatomy; however, the NSES are simply “voluntary guidance and do not ascribe or mandate any particular teaching practice” [33]. This results in much being left up to the discretion of individual states and educators themselves. While some physiological aspects of menstruation are suggested by the NSES, there is little on management of menstruation itself [34]. In fact, Michigan, Oregon, and Utah are currently the only states in which menstruation management is explicitly included in school health standards [34].

Menstrual health education is not only variable, but also limited in implementation. In 2014, the Center for Disease Control (CDC) carried out the School Health Policies and Practices Study to examine components of school health across the country. The report found only 39.5% of U.S. schools required in-school instruction on reproductive anatomy and puberty, [35]. Furthermore, in a 2022 study interviewing students from Midwestern middle and high schools, many reported their menstrual health education to be inadequate. Students felt discussions were primarily centered on the anatomy of menstruation rather than methods for managing their health [36]. Additional surveys reported that 79% of teenagers feel they need a more in-depth education on menstrual health, without which they were more prone to poor menarche experiences and negative attitudes regarding their bodily changes [37,38]. Widespread variability and lack of quality menstrual health education among U.S. schools is poorly received by students, which can have negative implications for managing menstrual distress in the future[37].

Family

The role of the family on menstruation is dependent upon culture and varies extensively across households. Intergenerational discussions on sex and menstrual education are often perceived as taboo. While sexual and menstrual education are different, the two subjects are interconnected and discussed in tandem, especially in the context of the education on reproductive health and pregnancy. Evidence suggests that the socio-cultural background and upbringing of the parents themselves can affect relay of sexual and menstrual health information to their child. Parents often act as a barrier to youth obtaining sexual and menstrual health education, as 87% of American high schools allow parents to opt their child out of sex-ed classes[39]. On the other hand, some teenagers feel the education they receive from mothers and siblings are much more informative than that of schools[36]. Ultimately, while the role of the family is crucial in shaping the child’s perspective on menstrual health, it is extremely variable and dependent on multiple factors.

Clinical Settings

The American Academy of Pediatrics (AAP) recommends sharing anticipatory guidance about menstruation to premenarchal patients and their families to ensure a smooth transition into puberty[40]. There is also emphasis on using menses as a vital sign, meaning providers should regularly ask patients the date of their last period at each visit[41]. While these guidelines are in place for primary care physicians, similar frameworks are reinforced by specialized clinicians. For instance, ACOG is in accordance with the AAP in stating that pubertal development education should begin at 7–8 year visits[42]. In practice, however, adherence to these suggestions in clinic is variable. A 2020 questionnaire surveying pediatric physicians across the country found that 58.2% were “not at all or only slightly” familiar with anticipatory guidelines of menstrual health[42]. The study also found discrepancies within male and female clinicians. On average, only 32% of male pediatricians felt “very or extremely’ knowledgeable about menstruation compared to 68.1% of female pediatricians [42]. Proper provider education on menstrual health as well as adherence to suggested guidelines is crucial in the role of providers, especially regarding their premenarchal patients.

Business and financial aspects of menstruation

Menstrual products industry

The most common menstrual products are disposable sanitary pads, panty liners, tampons, and menstrual cups [43]. The first commercial menstrual napkin appeared at the end of the 19^th century by Johnson & Johnson[44], while the first commercial tampon appeared in 1936[45]. Globally, the menstrual product market has been valued at more than 40 billion dollars, and the related advertising industry can affect individuals’ health and well-being by influencing purchase habits and gender stereotypes[46]. In the United States, an individual spends, on average, $18,000 on menstrual products in their lifetime[47].

Access to menstruation products

Menstrual products are a necessity for every individual who menstruates. However, access to products is affected by economic, cultural, social, and political barriers[48]. Recently, awareness has been raised in the United States regarding limited access to menstrual products for homeless, incarcerated, and low-income individuals [49,50]. It is estimated that 16.9 million menstruators are living in poverty.[51]. More than 210,000 homeless individuals struggle to secure menstrual products[47], and instead, use cloth, rags, tissues, toilet paper or other makeshift materials as an alternative [49,50]. Recently, Sebert Kuhlmann et al. conducted a cross-sectional study of 183 low-income women in St. Louis to understand their menstrual hygiene needs. Kulhmann et al determined that almost two thirds of participants could not afford menstrual products during the past year[49]. Furthermore, in the past several years, COVID-19 has exacerbated period poverty due to economic stagnation, supply chain issues, and the closure of schools and businesses[51,52].

Improving access to menstrual products promotes both financial and physical well-being in vulnerable populations. Currently, several efforts have been initiated to make menstrual products more affordable or free [47]. Some states have also enacted policies to exempt menstrual products from taxation and provide free menstrual products through homeless shelters, correctional facilities, and public schools. However, the disparities have not yet been eliminated[49], and more intersectional collaboration is needed to create safe, cost-effective products that are potentially reusable[49].

Femtech

Femtech encompasses a variety of period and/or fertility tracking technologies and mobile applications, which provide convenient ways to help individuals track their menstrual health, menopause, fertility and more. Companies have made advancements in addressing individual health needs in the past several years. Femtech allows menstruating individuals to take a role in managing their own health data. However, there are still gaps between the needs of menstruators and the functionalities of these technologies[53]. Other challenges in this industry include data sharing practices with individuals’ health data[54]. The Health Insurance Portability and Accountability Act (HIPAA) does not explicitly protect health information stored on personal phones or tablets[55]. Thus, menstrual data is vulnerable to subpoenas or being sold to third parties. For example, in 2021, the Federal Trade Commission (FTC) filed a complaint against the menstrual tracking app Flo, claiming that Flo had allegedly shared millions of user’s data with third parties such as Facebook and Google[56]. Six months after the complaint was filed, the FTC announced their settlement with Flo, stating the app must undergo an independent review of its privacy policy, and must obtain user permission to share any health information[57].

Public Policy, Law, and Menstruation

Recent legislation regarding menstruation

Menstruation has been a topic for recent municipal, state and national legislation. Growing social and political pressure has contributed to the “menstrual equity” movement, with the goal of increasing access to menstrual products for all those who menstruate. In 2016, New York City pioneered the change and became the first locality to pass a package of “menstrual equity” bills, comprising different legislative amendments for schools, correctional facilities, and homeless services[58]. Since then, over 60 menstrual equity laws have been passed, which focus on eliminating the sales tax for menstrual products, increasing accessibility of menstrual products, and requiring ingredient disclosure in menstrual products to address safety concerns[59]. Of these, two federal laws have been enacted, one of which allows menstrual products to be paid with pre-tax dollars, and the other which requires prisons to provide menstrual products[59].

The most extensive piece of federal legislation is that of the Menstrual Equity For All Act of 2021. This bill specifically requires that menstrual products must be provided nation-wide for students at elementary and secondary schools, students at institutions of higher education, incarcerated or detained individuals, homeless individuals, individuals on Medicaid, and federal employees [60]. This bill has been introduced to Congress, yet not voted on or passed[60].

Laws requiring access to menstrual products are not without controversy. New Hampshire attempted to pass HB129, in an attempt to change a 2019 “period poverty law” which mandated public schools supply menstrual products in bathrooms[61]. HB129 required distribution of menstrual products via school nurses and administrators in schools[62], rather than in restrooms, adding an extra level of interaction in the intimate process of menstruation. While this bill was ultimately voted against on April 18^th, 2023, its existence demonstrates the politicized nature of menstruation.

Menstrual leave in the workplace

There are currently no federal or state laws in the US that mandate paid menstrual leave. Menstrual leave, which allows one to take time off work due to menstrual symptoms, is a complex policy that could have myriad intended and unintended effects. Some employers may choose to implement paid menstrual leave; however, others may require menstruators to use their sick or personal days. The concept of federally mandated menstrual leave has risen in popularity. A study examining the U.S. public’s (N=600) perceptions of such a policy found that 45% of participants would support menstrual leave if it were implemented in the U.S.[63] However, there is little research that explores explores the benefits and disadvantages that menstrual leave policies pose. More research is necessary to guide workplace policy to potentially alleviate the burden of menstruation on employees.

Health disparities within Menstruation

Menstrual Disorder Prevalence and Management

As aforementioned, low-income individuals often have limited access to menstrual products due to high costs. Furthermore, these disparities may be exacerbated by decreased access to period-tracking applications and/or smart phones in addition to a lack of education about menstrual health. Research into health technology in other sectors has demonstrated a lag in “diffusion” or “uptake” of technology use through all SES levels, specifically with a slower uptake in low-income individuals[64][65]. This trend observed in other sectors suggests that Femtech is limited in its ability to address inequities in menstrual health[66]. Beyond the question of access, however, there is also the consideration of disparities in prevalence of menstrual disorders. A systematic review found the burden of uterine fibroids to be higher in Black vs. White individuals; whereas, the prevalence of endometriosis for Black individuals is the same as or lower than White individuals[67]. On a public health level in the United States, the higher burden and severity of uterine fibroids in Black individuals are due, in part, to increased exposures on a systemic level across a lifetime[67][68]. Additionally, Black individuals with fibroids or endometriosis experience worse outcomes, such as higher rate of surgical complications, longer surgery times, and increased likelihood of re-admission, reflecting the role of systemic racism in creating health disparities with menstrual disorders[67] [68].

Cultural Aspects of menstruation

Traditions and beliefs about menstruation can be a part of cultural heritage, which vary based on ethnicity, nationality, or religion[69]. This review will look at specific examples of how menstruation interacts with culture.

Stigma surrounding menstruation

There is considerable stigma in the United States surrounding menstruation. Individuals who menstruate often experience embarrassment and fear with regards to discussion or even the occurrence of menstruation[70]. Based on an analysis of research and public media, Johnston-Robledo and Chrisler argue that menstrual blood is a stigmatizing mark[71]. One study found 33 of 44 interviewed individuals experienced or were afraid of experiencing menstrual leaks, and explained how visible signs of menstruation are interpreted at “contamination”[72]. Furthermore, researchers describe the “hidden stigma” of menstruation as menstrual products are designed to be concealed[71]. For example, advertisements for menstrual products use blue liquid instead of red to represent period blood[73]. Ultimately, there exists a cultural taboo surrounding menstruation, despite its regularity and universality. This taboo can have negative consequences to individuals’ health. A study of menstrual shame and sexual decision-making in 199 undergraduate women found individuals who report feeling more comfort about menstruation also reported less sexual risk[74]. In recent years, there has been more awareness and media produced to address this stigma. In 2018, “Period. End of Sentence.” was released and won an Oscar that following year. The documentary follows a group of women in India who learn to manufacture their own pads and distribute them at lower costs, while also tackling the taboo[75]. The international attention on this documentary represented a step forward in bringing awareness to menstrual health.

Menstruation and Religion

Menstruation in religion is closely related to the associated societal stigma. Several religious scholars have described the “impurity” that is prescribed to menstruation in various religious texts, including those of Hinduism, Islam, Christianity, and Judaism [76,77]. For example, the authoritative literature on Dharma (Hindu religious law) outlines codes of conduct for society, and defines menstruating individuals, along with “low-caste” individuals, as undesirable and impure. “High caste” men are instructed to avoid any form of contact with menstruating individuals, including sharing food, physical touch, and conversation. [77]. Similarly, Judaism describes impurity framework surrounding menstruation [69]. Jewish code of law describes the “Niddah period” which encompasses an individual’s beginning of menses to the end of seven clean days, after which the individual is instructed to take a ritual bath[78]. In the Eastern Orthodox Christian Church, participating in sacraments, such as communion, or touching holy items, such as the Bible, is prohibited for menstruating individuals[76]. William E. Phipps argues that throughout Judeo-Christian history, the prescribed impurity of menstruating individuals has allowed religious institutions to exclude women from holding positions of authority, reflecting the concrete effects of stigma on power and access[79]. Studying historical, religious references to menstruation allows scholars to better understand the roots of stigma surrounding menstruation.

Future directions

Menstruation is considered the fifth vital sign by both the American Academy of Pediatricians and ACOG[40,42], due to its importance to the health of menstruators. As highlighted in this review, menstruation extends to several spheres of society, including psychology, education, business, policy, race, and religion. As such, parents, teachers, parents, physicians, and researchers can better educate and empower individuals who menstruate. Given our findings in the variability of menstrual education between families, schools, and clinical settings, education on menstrual health should be more accessible and standardized across the country. Improving education will help to reduce stigma in the United States and allow for a widespread baseline understanding of the components of menstrual health. Furthermore, healthcare research must routinely consider menstruation as a health outcome[80]. Though menstruation is considered a vital sign in Pediatrics and Obstetrics and Gynecology, it is still not a prioritized health marker by researchers. Despite restrictions and setbacks to reproductive health with recent legislation in the United States, municipalities and research institutions must consider and prioritize menstruation as a vital part of public health. Research has the power to guide workplace, educational, and municipal policy. Improving understanding of menstruation and its relationship to various aspects of society will better inform advocacy for menstruators’ rights and generate solutions to address issues such as period poverty and menstrual inequity. Continued research and alignment with public health officials and policy makers can improve menstrual health and improve accessibility to education and period products, bettering the health landscape for menstruating individuals.