Menstrual health under the scientific microscope: Text mining analysis

Abstract

Menstrual health represents an interdisciplinary concern that necessitates a broad, integrated understanding beyond its biological foundations, encompassing social, psychological, and cultural dimensions. This study examines whether the corpus of scientific literature from 1970 to 2023 aligns with this holistic perspective by exploring the evolving paradigms within menstrual health. Grounded in Kuhn’s theoretical framework, the research delves into thematic shifts, author collaborations, and international partnerships that have emerged over the decades. Utilizing advanced text-mining methodologies, we analyzed a dataset of 34,854 documents obtained from Institute for Scientific Information Web of Science and PubMed in September 2023. These documents were processed through deduplication and data cleaning to ensure accuracy. The study employs a combination of univariate analyses, correspondence factor analyses, hierarchical cluster analyses, and network analyses to uncover insights into thematic evolution and collaborative dynamics within menstrual health research. Thematic analysis reveals three distinct periods in menstrual health research, depicting evolving paradigms. In the first period (1970–1996), the focus was on reproductive health, infertility treatments, hormonal regulation, and epidemiology. The second period (1997–2017) witnesses a transition, emphasizing menstrual health and social inequalities, gynecological studies, and contraception. The third period (2018–2023) maintains a focus on contraception and reproductive health but introduces a pronounced psychological dimension, emphasizing menstrual disorders, gynecological surgery, and socioeconomic concerns. Collaboration analysis indicates increased connectivity, consolidation of researcher communities, and a shift toward interdisciplinary approaches. While international collaborations demonstrate global commitment, geographical concentration prompts questions about paradigm universality. The study shows the existence and evolution of the menstrual health paradigm. Findings suggest a trajectory toward paradigmatic inscription, marked by heightened collaboration and global commitment. Acknowledging the pivotal role of biological aspects, the study underscores the need for a balanced, holistic understanding of menstrual health. Continued efforts are essential to tailor interventions, foster inclusivity, and honor diverse cultural and psychological realities related to menstruation.

Plain language summary

Menstrual health isn’t just about biology—it also touches on social, emotional, and cultural aspects. But how have researchers addressed this complex topic over the years?

What did the researchers do?

In this study, the researchers examined research on menstrual health from 1970 to 2023. They used special tools to analyze how this research has changed over time, what themes were explored, and how scientists around the world have worked together.

Why does this matter?

The researchers wanted to see if there’s a clear and consistent way that menstrual health is approached in research. If there is, it can help improve health policies and medical practices. But if not, it could mean that different approaches are scattered, leading to less effective solutions.

What did the researchers find?

After analyzing over 34,000 documents, the researchers identified three main phases in menstrual health research:

• From 1970 to 1996, the focus was mostly on reproductive health.

• Between 1997 and 2017, researchers started to look more at social inequalities and contraception.

• Since 2018, there has been a new focus on the psychological aspects of menstruation.

They also noticed that researchers are collaborating more than before, which is a good sign for a more integrated approach to menstrual health. However, even though interest in this topic is global, certain regions are more active in this research than others. This raises the question: is there a shared vision worldwide?

Why is this important?

This work highlights how menstrual health research has evolved and suggests that a more comprehensive approach is needed to guide future studies and health policies. By better understanding the different dimensions of menstrual health, policymakers, healthcare providers, and researchers can create more inclusive and effective solutions for women everywhere.

Introduction

Context

Menstrual health, involving 1.8 billion individuals, encompasses girls, women, transgender men, and non-binary persons. ¹ Menstrual health, in line with the definitions of sexual health and general health, is defined as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, in relation to the menstrual cycle.” ² This significant issue actively engages contemporary discussions in public health, underscored by practical aspects like menstrual flow management, medical issues such as Premenstrual Syndrome affecting up to 77% of women, ³ and psychological implications. It necessitates a positive, respectful, and comprehensive perspective, essential for effective educational and preventive campaigns. However, creating a positive and understanding discourse on menstrual health, tailored to individual, social, and cultural specifics, faces various obstacles, whether social, cultural, or individual. Menstrual health challenges representations of femininity and raises broader issues about the social position of women, both societally and self-perceived. Understanding this involves recognizing the symbolism of menstruation in the social construction of femininity, marking the transition from childhood to the potential for motherhood. ⁴ It also involves considering persistent negative representations of female sexual anatomy, historically rooted and enduring despite evolving mentalities in the 20th century,^5,6 and being aware of the stigma associated with menstruation. Despite the gradual replacement of religious views that stigmatized menstruation as bodily abominations, imperfections, and markers of marginality and deviance in the 20th century, ⁷ negative perceptions of menstruation persist.^8,9

Moreover, menstrual health significantly influences crucial domains like education, somatic health, and the overall well-being of menstruating individuals. ³ Thus, menstrual health can be seen as a current and far-reaching issue that necessitates multidisciplinary collaboration among numerous experts. In this context, the central question we address in this article is: “Do scientific articles align with the current holistic vision of menstrual health, encompassing not only its biological aspects but also social, psychological, and cultural dimensions?” Our approach involves examining the scientific paradigm of menstrual health from two perspectives: by analyzing its content over time and exploring the modes of collaboration among researchers shaping the scientific discourse on menstrual health. We are thus aligned with the continuity of the work of Critchley et al., ¹⁰ who, following an expert conference on “menstruation: science and society,” demonstrated an evolution in scientific publications on the subject, both quantitatively and qualitatively. Alongside a significant increase in the number of publications from the 1940s until today, particularly after 1971, changes in the investigated themes have also been observed by these authors. Before 2004–2005, the focus was on reproductive health and menstrual hygiene with specificities based on economic contexts. ¹⁰ Between 2005 and 2011, emphasis was placed on the implications of menarche and girls’ education regarding menstruation, revealing persistent taboos and stigmas. After 2012, menstrual health emerged as a public health issue, emphasizing sexual health education and hygienic management of menstruation. ¹⁰

The social inscription of scientific paradigms

Socio-cognitive approaches to the construction of scientific knowledge ¹¹ force us to consider that the objective apprehension of a phenomenon requires not only the methodological rigor necessary for the replicability of results or the interchangeability of sources of evidence but also the need to take into account the subjectivity of those involved in science, ¹² all the more so when it comes to understanding more specifically female issues.^13,14 It is therefore necessary to consider the social and cultural norms that govern and guide the laws of discovery: scientific objectivity can only be achieved by being aware of the subjective dimensions that determine it, and not by vainly trying to evacuate them.

According to Kuhn, ¹⁵ scientific knowledge is not objective but relative, based on the interpretation of facts within a tradition, namely a set of beliefs, practices and methods shared within a scientific community at a given time. Science, as a human activity, is thus framed by normative mechanisms that define what he calls the “scientific paradigm.” Determining the enigmas to be solved and the theoretical and methodological means of solving them, the paradigm represents a set of rules shared by a community of scientists, forming a framework for understanding the world. Within this specific framework, the aim is not to discover objective reality, but to describe a version of the world through this prism. Thus, normal scientific activity consists of solving enigmas by adhering to the principles of the paradigm.

Paradigms do not emerge in isolation but are deeply rooted in social, cultural, and historical contexts. They are shaped by prevalent beliefs, norms, and ideas at a given time. Understanding these contextual influences is essential to appreciate the formation and evolution of paradigms, as well as recognizing how they may reflect broader dynamics of society and culture. In the context of menstrual health, paradigms are embedded in contexts shaping specific representations related to women’s health, reproductive medicine, and, more broadly, within normative frameworks defining femininity. Understanding these influences is crucial for analyzing the evolution of approaches and discourses on menstrual health while acknowledging how these paradigms may reflect and contribute to broader changes in the perception of women’s health.

Is there a scientific paradigm of menstrual health?

The evolution of paradigms often mirrors intellectual progress and the maturation of research domains. The inclusion of an object or phenomenon within a paradigm or its constitution as a paradigm provides a conceptual and methodological framework that guides how this object is understood, studied, and interpreted. This fosters coherence in the development of knowledge, facilitates communication among researchers, and allows more significant advances in a particular field. ¹⁵ If the adoption of menstrual health by science aligns with a defined paradigm, it offers a conceptual structure guiding research, health policies, and clinical practices. Such an approach promotes coherence in exploring menstruation-related issues, encourages collaboration among researchers and healthcare professionals, and contributes to a deeper understanding of women’s specific needs. Conversely, if menstrual health is not clearly defined within a paradigm, it may lead to fragmented knowledge and disparate approaches. This fragmentation could hinder the establishment of coherent health policies and the development of effective medical practices. Furthermore, the absence of a defined paradigm might limit the visibility and priority given to menstrual health issues in the fields of research and health policy.

Menstrual health paradigm and sexual rights

It is acknowledged that menstrual health falls within the realm of sexual and reproductive rights.^{16 –18} However, understanding the full scope of this assertion requires a profound understanding of what sexual rights are and sexual health to promote governmental accountability and their universal accessibility.^19,20 Like all fundamental rights, they are inalienable and confer a citizen’s status within society. ²¹ They require a holistic approach and rest on principles of universality, equity, autonomy, self-determination, dignity, and nondiscrimination. ²⁰ In the context of menstrual health, these rights raise essential questions about the universal recognition of rights related to menstrual health, equity in addressing specific needs, individual autonomy in menstrual health decisions, and dignity in the respectful treatment of everyone, regardless of their gender, age, or social class.

Potential obstacles to a positive approach to menstrual health

In 2019, at the end of a major collaborative reflection process, the “Terminology action group of the global menstrual collective” proposed a consensus definition of the concept of “menstrual health,” inspired by the World Health Organization definition of health. ² Menstrual health thus requires a positive, respectful, and understanding vision, a sine qua non for effective educational and preventive campaigns. ²² However, tackling this subject in a positive way that is adapted to the various individual, social, and cultural specificities may encounter social, cultural, or individual obstacle. This raises questions about representations of femininity and the social position attributed to women, both by society and by themselves. It is crucial to recognize the symbolism of menstruation in the social construction of femininity, representing the transition from childhood to womanhood associated with the ability to procreate.^4,23 Furthermore, it is essential to consider persisting negative representations of female sexual anatomy, which are deeply rooted in history despite changing attitudes in the 20th century.^5,6,24 Additionally, it is important to raise awareness about the stigma surrounding menstruation; although religious considerations stigmatizing menstruation decreased in the 20th century, the negative perception persists and is often internalized by women.^7,9

The current work

This article aims to understand the evolution of the concept of menstrual health by exploring the intentions and choices of researchers. By adopting a socio-constructivist approach to knowledge development, defined as the active participation of individuals in the construction of knowledge, it examines the underlying scientific paradigm in menstrual health research since its inception. Based on this framework, the general expectations guiding our approach are as follows.

Regarding the development of knowledge, the objective is twofold. First, in line with Kuhnian theories of scientific development, we aim to highlight the identification of narrow dominant themes, illustrating the formation of academic knowledge structured around menstrual health. Second, by analyzing scientific production on menstrual health over time, we seek to observe changes in central questions, which may indicate an evolution in the concerns and enigmas addressed by researchers.

Concerning the actors involved in knowledge production, our goal is to understand the temporal modalities of the scientific community’s organization around the issue of menstrual health by examining the collaborations between researchers. In connection with the growing recognition of menstrual health as a fundamental right, we hypothesize that the research conducted is increasingly becoming international. We anticipate an increase in the number of researchers and countries involved, reflecting the changing relevance and importance given to menstrual health within the scientific community. Additionally, we expect to see an increase in the number of collaborations, a more structured organization of these collaborations, and potentially an expansion of the networks of researchers working on menstrual health.

This holistic approach aims to anticipate emerging questions in the field, providing a foundation for guiding future research and menstrual health policies tailored to the needs of the populations concerned. It also seeks to identify persistent challenges and guide the development of more effective interventions and policies in this area.

Method

The analyses conducted in this work are structured around three main stages, which will be detailed below: database compilation, database cleaning, and statistical analyses. The sequential organization of these analyses is presented in the flowchart Figure 1.

Figure 1.

Flow chart.

Database compilation

In September 2023, we initiated a preliminary search phase to gather a sample of articles containing the keywords “menstrual health” or “menstruation” (found in the abstract, title, or keywords). After this initial manual review of the literature, we identified recurring keywords, which were then incorporated into the search query. Subsequently, a refined query was constructed to search the scientific databases Institute for Scientific Information (ISI) Web of Science and PubMed, targeting the title, abstract, and keywords with the terms “period poverty,” “menstrual poverty,” “menstrual health,” “menstrual equity,” “menstrual hygiene,” “menstrual hygiene management,” “menstrual cycle,” and “menstruation.” We used standard methods from the field of scientometrics. Automatic content extraction was carried out using the “PubMed R” package. ²⁵ The textual database was consolidated using the “Bibliometrix” package in R software. ²⁶ Both authors participated in all stages of data processing. The first author regularly uses text-mining methods in scientific research. The time period was not initially restricted to obtain an overview of article distribution. After removing duplicates, that is, references present in both databases or duplicated within the same database (same title and same authors), 45,153 documents were retrieved from 1928 to 2024 (see Figure 2). Of these references, 84.98% (n = 38,373) were articles—that is, papers published in scientific journals, excluding literature reviews—6.04% (n = 2,725) were literature reviews, and 6.89% (n = 3,114) were proceedings of scientific events.

Figure 2.

Distribution of the number of publication from 1929 to 2023.

Database cleaning

Subsequent analyses focused on scientific literature published from 1970 onward, a period identified for an acceleration in the number of publications per year until 2023. References dated before 1970 and those lacking publication date information were excluded from the analyses. This led to the analysis of 34,854 references (77.2% of the initial corpus).

We focused on the keywords used by the authors of the publications as descriptors, representing the fundamental core of scientific knowledge.^27,28 More informative and less biased than catchy titles, keywords are widely used for textual network analysis. Keywords were sequences of characters separated by semicolons, aligned with database registration procedures. Thus, keywords were not only individual words but could also be phrases. For example, in the sequence “adolescent; young women; menstrual health; period poverty; migrant,” expressions such as “young women,” “menstrual health,” and “period poverty” were considered full keywords. This approach generated a matrix of 34,854 documents and 44,206 keywords, totaling 1,540,755,924 cells. Subsequently, terms were filtered based on their frequency of appearance, excluding those with a frequency lower than 2 per 10,000 across the entire corpus and those absent in at least 2 documents per 10,000. After this cleaning, 577 terms were identified.

Statistical analysis

Univariate analysis

Initially, univariate analyses were carried out to observe term frequencies across the entire corpus. These analyses, based on a bag-of-words approach, highlight terms of significance in terms of frequency.

Identification of temporal periods: correspondence factorial analysis

The temporality of publications was considered in line with Kuhn’s conceptualizations ¹⁵ and the work of Critchley et al. ¹⁰ We wanted to identify periods of stability and change in the construction of knowledge. Accordingly, correspondence factorial analyses were conducted using a contingency table combining the 577 main keywords with publication dates in years. These analyses were complemented by hierarchical cluster analyses (Euclidean distance and Ward’s algorithm), strengthened by resampling techniques with replacement to ensure result stability.

Identification of themes

Theme extraction involved network analyses based on chi-squared distance matrices. For each period, matrices crossing keywords were generated, retaining significant co-occurrences (threshold of 3, equivalent to a p-value of approximately 0.001). Residues were used to identify interconnected keyword communities. Modularity analyses ²⁹ with the Louvain algorithm defined community structures. ³⁰ To rank the themes, betweenness centrality, which measures the role of certain concepts as bridges between different communities, was used. ³¹ This centrality provides an overview of the variety of contexts in which a word appears, highlighting the connections that are crucial for the circulation of meaning in concept networks. ³²

Collaboration analysis

Following on from the thematic analysis, the exploration of collaborations was a crucial part of understanding the dynamic structure of the scientific construction around menstrual health. In the context of international collaborations on menstrual health, the idea of a “small-world” network was explored. A “small-world” network leverages the benefits of regular and random networks, combining local regular organization for fast information transmission among close neighbors with a few random connections to reduce distances between distant nodes. ³³ Applied to the researchers’ network, a too regular, closed network would hinder the exploration of new ideas from other parts of the network. A too random network would be particularly vulnerable to communication breakdowns due to the lack of structure. On the other hand, a small-world network can be seen as a combination of local structures, a regular network where specific groups interact intensely within themselves, and inter-community communications, ensuring knowledge propagation throughout the entire network.

A network organized on a “small-world” basis seeks an optimal balance between information propagation speed and resilience. The “small-world” index (Sindex) measures this combined efficiency and was therefore used in our study as a crucial indicator to assess the structure of international collaborations. A high Sindex indicates an optimal configuration that maximizes diffusion speed while maintaining coherent organization. Standard criteria classify networks into three categories: confirmed small-world (Sindex >3), probable small-world (1 < Sindex < 3), and non-small-world networks (Sindex <1). ³⁴ This classification is based on the most significant connected component in the network. However, particular attention has been paid not to overlook interactions between disjointed communities. In a network with disjointed communities, the overall small-world index may underestimate barriers to information transmission between distinct parts of the network. ³⁵ Therefore, in addition to the global small-world index, an aggregate score was introduced. This score represents the average small-world indices of each identified community, offering a finer-grained perspective on collaboration structuring at a local level. The study also quantified, for each period, the number of communities with a probable (>1) and certain (>3) small-world index. This nuanced approach has enabled us to gain a better understanding of the complexity of collaboration dynamics between researchers and countries.

Data processing

The data were analyzed using the R software (version 4.3.2). The quanteda package ³⁶ was used for converting raw material into lexicometric matrices. The igraph ³⁷ and qgraph ³⁸ packages were used for network analyses.

Results

Thematic analyses

Overview of keywords

The results of the overall lexicometric analysis reveal a predominant focus of research on the menstrual cycle, highlighting its biological aspects, such as the endometrium, and its biochemical components, notably hormones. Reproductive health, contraception, and pregnancy emerge as central axes. The perspective on menstrual health primarily focused on pathological aspects. The psychological dimension, while present, occupies a more modest place in researchers’ concerns, as illustrated by the lower ranking of the term “depression” (cf. Figure 3).

Figure 3.

Word cloud of the most represented keywords.

Identification of periods

Correspondence factorial analyses, combined with cluster analyses, lead to the identification of three distinct periods (Figures 4 and 5).

Figure 4.

Correspondence factorial analysis.

Figure 5.

Cluster dendrogram.

They reveal (cf. Table 1) a first temporal period characterized by a low average number of articles (n = 317.97) but a high thematic diversity (n = 24), followed by a period of significant growth in the number of articles per year (period 2: 15,727 articles with an average per year of 748.76) and a decrease in the number of themes (period 2: 9 themes), suggesting thematic concentration. The third, more recent period, shows a marked expansion of knowledge (1,757.33 articles per year) without a proportional increase in thematic diversity (13 themes for an average number of articles per theme = 811.08 versus 1,747.11 in period 2). These results suggest an evolution toward a more elaborate structuring of research on menstrual health over time, with discernible thematic and temporal trends. The three periods differ in terms of the number of years considered, so we chose to construct an aggregated index called the “structuring index” to confirm this hypothesis. This index, calculated by balancing the quantity, thematic diversity, and duration of scientific publications, offers a holistic view of their structuring. Measured over a year, the structuring index captures the organization and focus of scientific research on specific themes. A high index will reflect a large number of articles published on average on a given theme, and therefore a focused interest on the part of researchers. Conversely, a low index may reflect a scattering of the topics studied. Based on this index, it appears that we witness a structuring of thought throughout these three periods. Indeed, for period 1, this index was 13.25, while for the second period, spanning 21 years, it is 83.20. The third period, temporally more restricted, obtains a structuring index 1.6 times larger.

Table 1.

Descriptive data concerning publications and research themes as a function of time period.

Time Period	Number of years	Number of articles	Average number of articles per year	Number of themes	Articles per theme	Structuring index (articles per theme/number of themes/number of years)
1970–1996	27	8,585	317.96	24	357.71	13.25
1997–2017	21	15,724	748.76	9	1,747.11	83.20
2018–2023	6	10,544	1,757.33	13	811.08	135.18

Temporal evolution

During the first period (1970–1996), the 10 most central keywords are: “endometriosis,” “premenstrual.syndrome,” “adolescence,” “endometrium,” “reproductive,” “gnrh.agonist,” “contraceptives,” “risk,” “in.vitro.fertilization,” and “ pharmacokinetics.” Research focused on reproductive health, exploring topics such as treatments and interventions related to infertility, hormonal regulation of the menstrual cycle, epidemiology, and risk factors in reproductive health, as well as inter-individual differences, especially in adolescence. Medically assisted reproduction is also addressed (Figure 6).

Figure 6.

Keywords network for the first period of time (1970–1996).

In the second period (1997–2017), the 10 most central keywords are: “poverty,” “endometriosis,” endometrium,” “humans,” breast.cancer,” “fertility.preservation,” “family.planning,” “screening,” “poverty.dynamics,” and “uterus.” A transition occurs with a strong emphasis on menstrual health and social inequalities, particularly in developing countries (e.g., “ethnicity” and “poverty”). Biological aspects of reproduction, gynecological and hormonal studies, as well as medical research methodologies in gynecological pathology, are explored to a greater extent (e.g., “breast cancer,” “fertility preservation,” pregnancy rate,” “ovarian stimulation”). Researchers also focus on women’s individual experiences regarding their menstrual cycle (e.g., “heavy menstrual bleeding,” “menopause,” “time to pregnancy”), with increased interest in contraception (Figure 7).

Figure 7.

Keywords network for the second period of time (1997–2017).

The third period (2018–2023) most central keywords are: “poverty,” “endometriosis,” “medroxyprogesterone.acetate,” “premenstrual.dysphoric.disorder,” “socioeconomic.status,” “family.planning,” “humans,” “endometrium,” and “abortion,” “breast.” This period maintains a focus on contraception and reproductive health, introducing a more pronounced psychological dimension. Menstrual disorders, gynecological surgery, and pathologies threatening reproduction or pregnancy occupy a significant place (e.g., “endometriosis,” “laparoscopy,” “abortion,” “hypertension,” “breast cancer,” “polycystic ovary syndrome”). Social and economic concerns influencing contraception and reproduction become more apparent (e.g., “poverty,” “socioeconomic status,” “psychological factors”), suggesting a diversification of interests over time (Figure 8).

Figure 8.

Keywords network for the third period of time (2018–2023).

Collaborations between authors

The corpus analysis highlights interesting trends regarding the evolution of collaborations among authors in the field of menstrual health. Within the 86,012 authors identified for the entire corpus, a significant majority (73.4%) contributed to a single document, while 13.5% participated in 2 publications. The average number of authors per publication is 4.57, reflecting the collaborative nature of research in this field. An analysis over time reveals some notable changes. During period 1, the average number of authors per document was 3.8, increasing to 4.49 in period 2 and 4.93 in period 3. Although significant differences can be highlighted (F_(2,34850) = 134.1, p < 0.001), it is important to note that the effect size is negligible (η² = 0.007).

To complete these analyses, we analyzed collaboration networks with statistically significant links. Given the number of authors identified and the computational constraints related to analyzing contingency matrices involving billions of cells, we chose to focus on the top 500 publishing authors per period based on the number of publications.

The exploration of collaboration networks (Table 2) highlights a decrease in the number of researcher communities over time (116, 65, and 32, respectively), suggesting a consolidation of collaborations. This is logically associated with an increasing average number of researchers per community and a decrease in the number of communities involving only a limited number of researchers (period 1: 59.48% of communities with fewer than three researchers, period 2: 56.6%, period 3: 43.7%). The giant component of the network—where points are directly or indirectly connected—increases significantly, going from 28.2% to 95.8% from the first to the third period, indicating greater cohesion in international research on menstrual health.

Table 2.

Communities as a function of time period.

Period	Nb researcher in giant component		Global Sindex (giant component)	Nb of communities	Average nb of researcher by community	Nb communities less than 3		Average small-world index	Average small-world index (only communities >2)	Nb communities with S >1		Nb communities with S >3
	N	%				n	%			n	%	n	%
1	141	28.2	93.68	116	4,310	69	59,483	0.637	1,573	39	33,621	1	0.862
2	448	89.6	20.96	53	9,434	30	56,604	0.761	1,753	19	35,849	2	3.774
3	479	95.8	12.66	32	15,625	14	43,750	1.23	2,187	17	53,125	4	12.500

The number of collaborations alone is not sufficient to demonstrate the optimal organization of collaborations: collaborations could be rigid or, conversely, random, negatively impacting information transmission. Therefore, the consideration of small-world indices adds an important dimension to the analysis. The global small-world index gradually decreases from one period to another, suggesting a robust connectivity of the network. A finer reading based on aggregated indices—necessary considering the many isolated communities—confirms small-world organization of collaborations between researchers for period 3, even if it is probable (index >1) without being certain (index <3). For periods 2 and 3, the small-world index only becomes significant (i.e., >1) when the effect of components involving a limited number of researchers is neutralized (respectively, average small-world index-only communities >2-: 1.573; 1.753; 2.187). The number of communities whose small-world value is greater than 1, while decreasing in terms of frequency over the three periods (39, 19, and 17, respectively), increases in proportion to the total number of communities, suggesting once again a structuring that strengthens over time.

International collaborations

For the 34,854 analyzed publications, we extracted the countries of affiliation of the authors for each publication (Figure 9). Out of the 33,444 references with available information (95.6%), we identified 163 countries investigating menstrual health in indexed scientific publications. However, the distribution of countries is not uniform. The United States, dominant with 10,545 occurrences (31.5%), is three times more prevalent than England (3,091 occurrences; 9.2%), the second most significant country, while China, the third country, records only 2,508 occurrences (7.5%).

Figure 9.

Top 10 main publishing countries and the frequency of publications.

For the entire study period, the number of international collaborations was analyzed. Approximately one in five publications (20.89%, n = 6,986) involved at least two different nationalities, and only 5.38% (1,800 documents) mentioned collaborations with more than two nationalities. Furthermore, for the three periods identified in the thematic analyses, the number of international collaborations was calculated, showing an average of 1.11 for the first period, 1.28 for the second, and 1.38 for the third period. Although these fluctuations are statistically significant (F_(2,33440) = 164.4, p < 0.001; all Tukey HSD comparisons <0.001), the differences remain small, even negligible (η² = 0.001).

The quantitative growth of international collaborations in menstrual health (86 countries for period 1, 147 for period 2, and 156 for period 3) is associated with structural changes in these collaborations (Table 3). We thus observe a transition toward stronger integration, with 78.84% of countries involved in the giant community for period 3 compared to 18.6% for period 1. Moreover, the increase in the number of communities exhibiting small-world characteristics (from two in period 1 to nine in period 3) underscores this evolutionary dynamic within the international collaborative network in menstrual health.

Table 3.

International collaborations as a function of time period.

Period	Nb of countries	Nb countries in giant component		Global Sindex (giant component)	Nb of communities	Average Nb of countries by community	Nb communities less than 3		Average small-world index	Average small-world index (only communities >2)	Nb communities with S >1		Nb communities >3
		n	%				n	%			n	%	n	%
1	86	16	18.60	−259.45	64	1,344	62	96.86	0.049	1,552	2	3.13	0	0
2	147	114	77.55	15.97	41	3,585	32	78.05	0.294	1,338	7	17.07	0	0
3	156	123	78.85	14.29	32	4,875	22	68.75	0.494	1,581	9	28.13	0	0

However, the analysis of aggregated indices calls for a more nuanced interpretation of the evolution of international collaborations. Although the overall index suggests a small-world structure as early as the second period (Sindex = 15.97), the aggregated indices show a less pronounced evolution. The average index, multiplied by 10 between the first and the third period (respectively: 0.049 versus 0.494), remains below 1, challenging the small-world structure. Furthermore, even when focusing on communities with at least three countries, the small-world index exceeds 1 but does not surpass 3, suggesting a probability but not a certainty of small-world structuring. Finally, this index remains relatively stable over the three periods (period 1: 1.552, period 2: 1.338, period 3: 1.581). However, the number of communities with an index >1 varies significantly between periods. In period 1, only two communities exceed the threshold of 1, representing a modest 3.125% of all communities. In contrast, for period 3, 9 communities out of the 32 identified surpass this threshold, constituting a much more substantial share of 28.125%. Thus, the homogeneity of the average index over the three periods results from significant variations in the distribution of communities exhibiting small-world characteristics.

Discussion

Adopting a text-mining methodology, our study aimed to explore the evolution of research paradigms on menstrual health over time. In line with Kuhn’s vision of scientific knowledge construction, ¹⁵ our approach sought to provide an in-depth understanding of menstrual health by considering the evolution of addressed questions—the enigmas in Kuhn’s sense—as well as the modalities of knowledge construction, especially through the analysis of collaborations between researchers and international partnerships. Beyond the strictly scientific framework, our project aimed to identify evolving trends in research, highlighting emerging concerns and gaps in understanding menstrual health. This approach sought to provide researchers with a solid foundation to guide their projects by anticipating future questions.

Discussion of menstrual health paradigm content

Our analysis, based on Kuhn’s conceptualization, reveals that research on menstrual health has undergone three distinct periods characterized by evolving paradigms. The application of correspondence factorial analysis suggests substantial transitions in the conception of menstrual health research. Network analyses highlight specific themes for each period, offering a window into the cardinal concerns that guided successive paradigms. Additionally, hierarchical cluster analyses consolidate temporal groupings, supporting apparent stability in paradigm evolution. These three periods, revealed by our analyses, describe a logical progression in understanding menstrual health, starting with general foundations and gradually expanding to include more psychosocial aspects over time. Some studies have already examined the evolution of scientific discourse in the field of health and medicine, highlighting, for instance, the shift in scientific concerns toward more humanized questions ³⁹ or those considering socioeconomic dimensions ⁴⁰ during the second decade of the 21st century. However, such studies remain rare, especially when it comes to integrating the temporal dimension to highlight the evolution of scientific conceptions. To our knowledge, no work of this kind has specifically focused on menstrual health.

Although keyword-based analysis is powerful, it needs to be interpreted with nuance, as the same keywords used at different times may reflect different realities and definitions. Additionally, researchers’ current publication strategies, aimed at optimizing readability, tend to homogenize keywords. However, the strength of our study lies in analyzing these keywords within networks, which allows for a more precise understanding despite these variations. By examining the relationships and connections between different terms, the analysis of keyword networks provides a comprehensive and coherent view of intellectual discussions and thematic trends, effectively overcoming the limitations of individual keyword evolution.

Overall, these results corroborate Critchley et al.’s findings, ¹⁰ showing a period-wise evolution of concerns related to menstrual health. However, our analysis introduces a third period beginning in 2018, extending previous findings. This phase emphasizes the importance of sexual health education and hygienic menstrual management while exploring more specialized and individualized issues such as contraception, family planning, reproductive-threatening pathologies, pregnancy complications, and gynecological disorders. Moreover, it pays increasing attention to psychological dimensions, illustrating a heightened sensitivity to the individualization of medical interventions, gynecological surgery, and infertility. This evolution aligns with the concept of “menstrual health,” emphasized by Hennegan et al., ² highlighting the need for a holistic and individualized approach for the effectiveness of educational, preventive, or support actions. This evolution may also testify to a growing recognition of women’s fundamental rights to menstrual, sexual, and reproductive health. With the broadening of topics to include issues such as contraception, menstrual disorders, gynecological surgery, or social and economic impacts, menstrual health is no longer considered in isolation. The idea of interconnected rights emerges, ²⁰ emphasizing that menstrual health is intrinsically linked to other rights, such as bodily autonomy, sexual education, and access to comprehensive healthcare, in line with the literature.^{16 –18}

Despite this evolution reflecting increased attention to contextualized experiences of menstrual health, the biological dimension remains transversal to scientific discourse, indicating its significant impact on the construction of scientific discourse on menstrual health. Although the biological aspects of menstrual health are undeniably crucial, their overrepresentation raises questions about a balanced view of this domain. The biomedical approach, while revealing underlying physiological mechanisms and legitimizing the importance of menstrual health issues for public health, risks oversimplifying the complexities related to menstrual health, thereby neglecting crucial social, psychological, and cultural aspects. This simplification may, in turn, limit interest in educational and preventive interventions.

Factorial correspondence analysis, focused on the evolution of keyword frequencies over different periods, reveal an increasing concern with a contextualized approach to menstrual health. In the early third decade of the 2000s, menstrual health issues have become increasingly associated with menstrual hygiene concerns, taking into account socioeconomic contexts (inequality, economic growth, income inequality, poverty), basic needs (food security, vulnerability), and climate issues (sustainable development, climate change) for a holistic approach (quality of life, women’s health, reproductive health, menstrual hygiene, menstrual hygiene management). These results encourage an interdisciplinary and integrated approach in menstrual health research and policies. They highlight the importance of considering social determinants of health and developing interventions that address not only medical aspects but also the living conditions of women. Additionally, they emphasize the need for comprehensive policies that take into account socioeconomic and environmental dimensions to improve menstrual health and the overall well-being of women.

Complementarily, semantic network analyses, which focus not on term frequency over time but on the systemic importance of words within semantic networks, also highlight the central role of socioeconomic concerns (poverty, socioeconomic status). However, they also underscore the persistence of a scientific discourse centered around pathologies associated with menstrual health (premenstrual dysphoric disorder, endometrium, abortion). This duality in our results underscores the value of combining frequency analyses with lexical network analyses. Frequency analysis allows for tracking the evolution of concerns and dominant concepts over time, while lexical network analysis offers a more systemic view of the importance and relationships between concepts within scientific discourse. This combination of approaches enriches our understanding by providing both a diachronic perspective and a structural perspective, thereby enabling a more comprehensive and nuanced analysis of menstrual health.

The observed duality is not necessarily negative. This evolution fits well within the dynamics of “normal science” described by Thomas Kuhn, ¹⁵ where the paradigmatic framework is not rigid but can be enriched by new aspects of reality. Indeed, normal science accepts and assimilates new data and perspectives that do not challenge the fundamental paradigm but complement and refine it. Practically, the persistence of medical concerns ensures that advancements in the diagnosis and treatment of menstrual pathologies continue to receive necessary attention, thereby enabling the continuous improvement of menstrual health care. Additionally, the continued focus on pathologies remains a stimulating factor for medical research and therapeutic innovations, leading to more effective treatments and a better understanding of menstrual conditions such as premenstrual dysphoric disorder, endometriosis, and abortion-related complications. However, this integration can have ambivalent consequences. On one hand, maintaining a focus on pathologies while incorporating new elements risks perpetuating a negative view of menstruation, seen primarily through the lens of illness and disorders. This perception can reinforce the stigmatization and pathologization of menstruation, thereby limiting a more natural and inclusive understanding and approach to this biological phenomenon. Furthermore, it could perpetuate the pathologization of femininity, contributing to societal norms that portray menstruation predominantly as a medical issue rather than embracing it as a natural aspect of women’s health.^{17 –22} The focalization on pathologies can also result in an unequal distribution of resources, favoring areas with already established access to advanced medical care while neglecting vulnerable populations who could benefit more from interventions focused on social determinants of health. On the other hand, the growing inclusion of socioeconomic and environmental factors could accumulate anomalies and tensions within the existing paradigm, leading to a paradigmatic crisis. This crisis, while potentially paving the way for a more holistic and integrated paradigm, also represents a danger. Paradigmatic transition periods can be marked by increased uncertainty, institutional resistance, and fragmentation of scientific and medical approaches. This upheaval could complicate the implementation of coherent policies and interventions, potentially delaying progress in menstrual health.

Discussion of researcher collaborations

In addition to analyzing scientists’ concerns in their study of menstrual health, the originality of our work was to consider the way in which they interact and collaborate, a prerequisite for the paradigmatic integration of a research field. As highlighted by Critchley et al., ¹⁰ the number of publications has increased significantly in recent years. Similarly, at first glance, the analysis of collaborations between authors provides tangible indications of a paradigmatic inclusion of menstrual health, marked by increased collaboration, consolidation of communities of researchers, and strengthened connectivity over time. These results possibly reflect a maturation of the research field and an increasing recognition of the importance of menstrual health in contemporary scientific discourse. Thus, the evolution of the average number of authors per publication over time suggests a transition toward a more collaborative and interdisciplinary approach. The increase in the average number of authors per document, from 3.8 to 4.93, indicates a research dynamic becoming increasingly collective, involving a broader range of contributors. The consolidation of collaborations, illustrated by the decrease in the number of researcher communities over time, supports the idea of closer integration of actors in the field of menstrual health. The decrease in the number of communities involving a limited number of researchers highlights the formation of larger and more coherent groupings, potentially indicating the emergence of common consensus or guidelines. The significant increase in the portion of the network where researchers are directly or indirectly connected, from 28.2% to 95.8% from the first to the third period, emphasizes improved connectivity and increased integration of menstrual health research.

In a similar way, the examination of international collaborations in the field menstrual health also offers indications of a progressive inclusion in a shared paradigm on a global scale. The steady growth in the number of countries engaged in research, from 86 to 156 over the period studied, suggests an increasingly widespread commitment to menstrual health issues. The significant increase in the percentage of countries participating in the giant community, from 18.6% to 78.84% between the first and third periods, attests to a deeper integration of international actors. This trend may indicate a convergence toward common research themes, thus potentially reflecting a paradigmatic inscription shared by an international community of researchers dedicated to menstrual health.

According to Coccia and Wang, ⁴¹ such international collaborations tend to promote convergence between fundamental and applied research. This framework of increasing international engagement could explain why research in menstrual health has shifted toward more clinical and psychosocial concerns. Two hypotheses can be advanced to explain this evolution. The first hypothesis is that the evolution of collaborations among researchers has facilitated a more holistic approach to research questions. In this view, the consolidation of researcher communities and increased interactions have promoted a more integrated and comprehensive approach to menstrual health, enabling the exploration of psychosocial, educational, and medical dimensions in a more coherent and interconnected manner. Likewise, it is likely that the increase in internationalization and international collaborations help to explain the paradigmatic changes in the themes addressed: from a biomedical approach tackled by a limited number of countries, we are moving toward an approach that takes account of social particularities, no doubt under the impetus of research that transcends borders. This has potentially allowed for the emergence of new scientific paradigms. The second hypothesis is that the shift toward a more holistic approach to menstrual health has necessitated increased and structured collaborations among researchers and nationalities. The inherent complexity and interdisciplinarity of a holistic approach require greater cooperation and coordination among different experts and disciplines. This need has driven the increase in the average number of authors per publication and the consolidation of research communities, thereby reinforcing the scientific paradigm surrounding menstrual health.

The evolution of scientific collaborations and the adoption of a holistic approach to menstrual health seem to be interconnected and mutually reinforcing. This dynamic can be a driver of the evolution of scientific paradigms, facilitating a more comprehensive and nuanced approach to menstrual health issues. However, it is crucial to remain vigilant regarding potential pitfalls, such as the homogenization of perspectives and increased dependency on collaboration, to preserve the diversity and resilience of the research field. Indeed, our results invite us to some nuances.

First, considering collaborations between authors: The majority of authors identified (73.4%) contributed to only one document, which could indicate occasional participation rather than continuous adherence to a specific paradigm. Also, while the average number of authors per publication has significantly increased over time, suggesting increased collaboration, the magnitude of the effect remains negligible. Moreover, this trend may also be influenced by the increasing complexity of issues addressed in menstrual health, requiring a diversity of expertise. The decrease in the number of researcher communities may be interpreted as a consolidation of collaborations, but it may also reflect a standardization of methodologies or common methodological approaches rather than a convergence toward a shared paradigm. Increased cohesion in the collaboration network may also result from specific collaborations on specific subtopics without necessarily indicating a global consensus on the vision of menstrual health.

Second, considering international collaborations: Although the total number of countries involved in research has increased over time, the uneven distribution of this participation deserves careful consideration. The United States of America largely dominates, accounting for three times as many occurrences as the second-largest country, England, and China, the third country, records only a fraction of these occurrences. This distribution is found redundantly in several scientometric analyses in the field of health and medicine.^40,42 This geographical concentration may suggest a hierarchy of research actors, challenging the true universality of the paradigmatic inscription. The diversity of experiences related to menstrual health can be profoundly influenced by cultural, social, and economic factors specific to each region of the world. By highlighting this geographical asymmetry, it becomes essential to recognize that menstrual health research cannot be universal if it does not reflect the variety of cultural contexts and realities experienced by individuals worldwide. The emphasis on certain countries at the expense of others risks perpetuating narrow perspectives and neglecting important dimensions of menstrual health that may differ significantly from one community to another. Thus, the question of international paradigmatic inscription must be addressed with particular sensitivity to the diversity of contexts and cultures to ensure a truly inclusive and equitable approach. Furthermore, while we observe an increase in the percentage of countries participating in international collaborations, only one in five publications involves at least two different nationalities. This highlights the fact that the majority of publications still come from unilateral or bilateral collaborations, leaving out more diversified participation. Moreover, the increase in the number of communities with small-world characteristics does not necessarily guarantee a convergence toward a shared paradigm. These communities may form around specific subthemes without reflecting a global consensus on the vision of menstrual health. Thus, although international collaborations in the field are evolving, their complex and sometimes restricted structure challenges the simplification of a clear and unified international paradigmatic inscription.

Thus, our results regarding the idea of a paradigmatic organization in the field of menstrual health, while revealing interesting trends, should be considered with caution and invite us to observe the evolution of this trend over the long term. This question is not trivial. Indeed, according to Kuhn, the absence of a paradigm makes it difficult to anticipate the enigmas to be addressed. This leads researchers to adopt a reactive approach, responding to immediate needs rather than anticipating emerging phenomena and under-represented perspectives. Consequently, the discourse on menstrual health may remain fragmented and focused on immediate issues, lacking a cohesive, forward-looking framework. Therefore, while our results reveal interesting trends, they should be interpreted with caution and warrant long-term observation of these evolving patterns.

The analysis of the small-world index provides valuable insights for understanding the dynamics of both researcher and international collaborations. A small-world network, characterized by clusters of specialized communities that communicate closely, enables the rapid and efficient dissemination of ideas while maintaining specialization. ³³ For researcher collaborations, our results show that despite fluctuations in the global small-world index, a small-world structuring is confirmed for period 3, especially when the effect of small communities is neutralized. Although the number of communities with a small-world index greater than 1 decreases in frequency, it increases proportionally to the total number of communities, suggesting a strengthening of this structuring over time. Thus, the decrease in the number of researcher communities can be interpreted not only as a consolidation of collaborations but also as an indication of structuring into small worlds, at least at an interindividual level. This organization allows for the maintenance of specialized clusters while facilitating better integration and collaboration.

Similarly, regarding international collaboration, the global small-world index, combined with the increase in the number of communities with small-world characteristics from 2 to 9, underscores increased connectivity among involved countries. This structural evolution suggests that at an international level, researchers in the field of menstrual health share increasingly convergent interests and methodologies while maintaining the specificity of their approaches, reinforcing the idea of an international paradigmatic framework. These expanded and structured collaborations could foster continuous exchange of ideas, standardization of methodological approaches, and potentially lead to the emergence of consensus on crucial menstrual health issues globally.

Limitations

This work is not without limitations that need to be considered. Among these, the selection of databases, namely ISI Web of Science and PubMed, though justified by their comprehensiveness and relevance, may have also introduced biases. These databases are primarily anglophone and might under-represent research conducted in other languages or in lesser-known local journals. Additionally, differences in indexing criteria between databases may have affected the comparability and coverage of the studied subjects. However, their use ensured that the analyzed articles came from recognized and peer-reviewed sources, thus guaranteeing data reliability. Furthermore, the study did not account for gray literature, such as reports, theses, and other documents not published in peer-reviewed journals, possibly introducing bias by neglecting potentially rich and relevant information sources. Nevertheless, the focus on peer-reviewed publications ensured the scientific rigor and quality of the analyzed data. Moreover, the initial database compilation required rigorous filtering and cleaning to eliminate duplicates and incomplete references. While necessary for ensuring data quality, this process may have introduced biases by excluding relevant studies or over-representing specific themes. Nonetheless, this rigor ensured that the analyzed data were of high quality and representative of the most pertinent publications. The keyword analysis relied on terms chosen by the authors, potentially limiting the analysis’s scope as keywords might not capture the full content richness. Furthermore, current publication strategies favor keyword homogenization to optimize article visibility, which may obscure significant variations in research themes and concerns. Nevertheless, keyword use remains a widely accepted method for broad and comparative analysis of research themes.

In addition to examining term co-occurrences and existing relationships, the study also considered chi-squared studentized residuals to identify atypical or exceptional term associations. While this approach might have introduced additional complexities in result interpretation, it enriched the analysis by providing a more precise and nuanced view of the dynamics present in the studied domain. By prioritizing the analysis of significant links, this method highlighted specific co-occurrences that were unlikely to be due to chance. This allowed for the detection of important relationships that might have been under-represented in traditional analyses.

Considering the temporality of publications through correspondence factor analysis revealed substantial transitions in menstrual health research conception. However, the identified periods were not uniform in duration and publication volume, potentially affecting the interpretation of long-term trends and paradigm shifts. Despite this variation, this approach highlighted important trends and developments over time.

The analyses primarily aimed to describe the trajectory of menstrual health research. However, despite this ambition, they remained primarily descriptive rather than predictive of future menstrual health paradigms, which depend on a plurality of factors including social and cultural norms, technological advancements, and public health priorities. The descriptive nature of the analyses limited the ability to precisely anticipate future orientations and paradigm shifts in menstrual health. Nonetheless, these descriptions provided an essential foundation for understanding current trends and underlying dynamics, offering a basis for more informed future research and policy-making.

Conclusion

Our research explored the evolution of themes and international collaborations in menstrual health, highlighting the importance of the underlying dynamics driving these changes. In a context where, as noted by Fortunato et al., ⁴³ public policymakers seek to understand the mechanisms that govern the evolution of science, this analysis of collaborative dynamics and thematic orientations becomes essential. By understanding how scientific paradigms and collaboration dynamics influence menstrual health, policymakers can ensure that research and health policies are inclusive and equitable. Moreover, by gaining better insight into the dynamics of international collaborations, they can more effectively coordinate efforts with other countries, strengthen these collaborations, and thus maximize the impact of research.

However, while these structural and dynamic aspects are crucial, research and practice in menstrual health must also evolve toward a more balanced and holistic understanding. This involves moving beyond a focus solely on biology or menstrual hygiene ⁴⁴ to also consider the individual and social contexts that shape menstrual experiences. This evolution is already evident in the current trend of research to systematically integrate social, psychological, and cultural dimensions into an emerging scientific paradigm. These efforts are critical not only for adapting interventions to specific needs but also for ensuring that menstrual health policies address broader global issues of social justice, human rights, and sustainable development. ⁴⁵