Adolescent menstrual health must go beyond pads

Abstract

Marni Sommer and colleagues argue that lack of data on adolescent menstrual health is hindering investment in broader measures to improve long term wellbeing and gender equality

Menstruation and the menstrual cycle affect female health and wellbeing from menarche, the first menstrual period, to menopause.^{1 2 3} Adolescent girls and women worldwide consistently report negative experiences with menstruation, including missed or delayed diagnosis of menstrual disorders. These issues have far reaching consequences for their wellbeing, education, livelihood opportunities, empowerment, and overall health.^{4 5 6} Investment in menstrual health (box 1) during adolescence is increasingly recognised as a pathway to mitigate these consequences and address gender inequality. This was emphasised in 2022 when the World Health Organization declared menstrual health as a health and human rights issue and not solely a hygiene issue.⁸ The emerging concept of menstrual justice highlights how harmful power structures and social norms result in menstrual related discrimination in many spheres of life that impede menstrual health.⁹

Box 1. Main components of menstrual health⁷ .

Menstrual health is a state of complete physical, mental, and social wellbeing, not merely the absence of disease or infirmity, in relation to the menstrual cycle. Achieving menstrual health implies that women, girls, and all other people who experience a menstrual cycle can

• Access accurate, timely, age appropriate information

• Care for their bodies during menstruation, including access to water and sanitation facilities and menstrual materials

• Access timely diagnosis, treatment, and care for menstrual related discomforts and disorders

• Experience a positive and respectful environment

• Decide whether and how to participate in all spheres of life during all phases of the menstrual cycle

Despite increased attention, insufficient data are available on adolescent girls’ menstrual health across countries. The absence of data on girls’ multidimensional requirements for menstrual health renders the challenges they experience invisible. Partly because of this, the media, donors, governments, and implementers have concentrated on providing menstrual pads as a “quick fix,” tangible, and easily measurable solution. Better data from well resourced rigorous research would inform the development of more comprehensive, impactful, and cost effective interventions.¹⁰ Current gaps must be addressed by increasing the visibility of menstrual health in monitoring efforts, research, and the development and implementation of contextually grounded interventions.¹¹ This would enable a move away from a narrow focus on the provision of pads to address the complexity of adolescent girls’ menstrual health needs.

Although this analysis focuses on adolescent girls in low income countries because of their unique needs and critical importance of investing in this age group, women and others who menstruate must also be considered in a broader menstrual health agenda. We also refer to menstrual pads rather than other products (eg, cups, pants) because single use pads are the most commonly provided menstrual material in government, donor, and programmatic initiatives targeting girls.

Competing priorities for research

A major barrier to increasing global and national investment in menstrual health is the argument that limited resources should be prioritised for social challenges and interventions that have stronger evidence for reducing girls’ morbidity and mortality. These include risks such as gender based violence, early and unintended pregnancy, HIV infection, and cervical cancer in the absence of the HPV vaccine. However, all these issues have important fundamental links to menstrual health.

Knowledge about the menstrual cycle is foundational to understanding fertility and sexual and reproductive health, while the identification of abnormal bleeding in the context of cervical cancer requires an understanding of normal bleeding and willingness to engage with healthcare providers about menstrual concerns.³ A 2024 study analysing a cohort of girls in Ghana suggested that the onset of menstruation increased girls’ vulnerability to sexual violence, with menarche seen as indicating sexual or marital readiness.¹² Research in Kenya found that some early adolescent girls engage in transactional sex to afford menstrual pads,¹³ contributing to negative sexual and reproductive health outcomes.

Focused investment on these menstrual health associations,¹⁴ and how to intervene effectively, has been initiated (eg, through UK Research and Innovation^{15 16}), with multiple other funders, such as the Bill and Melinda Gates Foundation, interested in supporting research to build the evidence. For example, studies in Kenya found adolescent girls provided with menstrual cups maintained a healthy vaginal microbiome and had reduced bacterial vaginosis and transmission of sexually transmitted infections.^{15 16 17}

However, little research has been done on the links between menstrual health and health and economic outcomes. Although benefits have been shown from investment in other areas affecting girls, such as education,²⁸ financing of menstrual health research on these links or the development of interventions has been scarce. As a result, resources are narrowly focused on menstrual pad programmes, often with the stated aim of reducing school absenteeism. However, absenteeism is not a priority indicator in the global gender and education agenda and interventions to address absenteeism may also have limited effect unless accompanied by menstrual health education, pain relief, adequate menstrual friendly toilets in schools, and supportive teachers and peers.

Narrow focus offers limited support for adolescent girls

Despite the many components essential for achieving menstrual health, the narrow focus on menstrual pads has persisted, partly because the products are easily measurable and messaging is simple. Data from the menstrual health and hygiene funding tracker indicate that 30 out of 31 investments of at least $1m focused on provision of menstrual products, along with 27 out of 28 government efforts.¹⁸ Yet pad programmes raise numerous issues around sustainable provision over time, supply chain challenges, girls’ right to make informed choices about the products they use, and disposal and waste management.¹⁹

The focus on pads is often reinforced by media and advocacy campaigns and the fact that governments can show “action” when pad programmes are launched. Although these programmes can raise awareness about menstrual health and menstrual stigma, channelling limited resources towards the provision and distribution of pads ignores the potential to achieve greater impact through structural interventions addressing the broader requirements for menstrual health. Such interventions would lead to sustained improvements in quality of life, from menarche to menopause.

Value of improved monitoring and measurement

Inadequate measurement of menstrual health has also limited attention given to a broader array of investments that could improve adolescent girls’ health and wellbeing. To date, most research on menstrual health has been descriptive, providing important insights on the status of menstrual health in terms of levels of awareness, hygiene practices, and attitudes.^{5 20} Much of the intervention and programme reporting has focused on outputs—the number of menstrual pads distributed or the number of girls reached through educational sessions. Although such studies and assessments enhance our understanding of the nature, scale, and complexity of the problem, nationally representative data are lacking on key components of menstrual health such as the effect of providing safe, clean, menstrual friendly toilets in schools or training teachers to be more knowledgeable and supportive. These data are essential to recognise the breadth of menstrual health needs, for tracking of progress over time, and for informing the development and adaptation of relevant policies and programmes.

Governments and donors may perceive that the impact of menstrual health is most easily measured and demonstrated through the tangible provision of menstrual products. This belief feeds into accountability systems that suggest the problem has been resolved once pads are provided, thereby neglecting other essential components of menstrual health. The consequence of this mindset is far reaching, hindering research into the many facets of menstruation, and preventing the development of national, institutional, and individual level data needed to assess impact over time.²¹

A newly launched set of global indicators for national monitoring of menstrual health and hygiene for adolescent girls can promote measurement beyond product access and lead to improved health and education outcomes.²¹ These indicators cover multiple sectors (table 1) and draw from existing data collection efforts, including the joint monitoring programme on water and sanitation in schools and relevant questions from Demographic and Health Surveys (DHS) carried out in over 90 low and middle income countries. A new menstrual health module aligned with the menstrual health and hygiene indicators is now available as part of the Unicef Multiple Indicator Cluster Surveys when countries request its inclusion, and DHS could also incorporate a small number of menstrual health indicators to provide comparable data across countries in the short term, facilitating action while reducing data collection burdens. Future efforts may also explore incorporating menstrual health issues, such as menstrual pain, into assessments of quality adjusted life years.

Table 1.

Priority menstrual health and hygiene indicators²¹

Domain	Data level	Target
Materials	Individual	% of girls who reported having enough menstrual materials during their last period
	School	% of schools with menstrual materials available to girls in case of an emergency
Water, sanitation, and hygiene	Individual	% of girls who reported changing their menstrual materials during their last menstrual period at school
		% of girls who changed their menstrual materials at school in a space that was clean, private, and safe during their last menstrual period
	School	% of schools (primary/secondary) with improved sanitation facilities that are single sex and usable (available, functional, and private) at the time of the survey
		% of (primary/secondary) schools with improved sanitation facilities that are single sex, usable (available, functional, and private), lockable from the inside, have covered disposal bins, and have disposal mechanisms at the time of the survey.
		% of (primary/secondary) schools that have water and soap available in a private space for girls to manage menstruation.
Knowledge	Individual	% of students (male/female) who have received education about menstruation in primary and secondary school
		% of females who know about menstruation prior to menarche
		% of females with correct knowledge of the fertile period during the ovulatory cycle
	School	% of schools where education about menstruation is provided for students from age 9
		Existence of pre-service or in-service teacher training about menstruation at the primary or secondary level
		% of schools that have at least one teacher trained to educate primary/secondary students about menstruation
	National	% of countries where national policy mandates education about menstruation at primary and secondary level
Discomfort/disorders	Individual	% of girls who report that they were able to reduce their menstrual (abdominal/back/cramping) pain when they needed to during their last menstrual period
		% of girls who would feel comfortable seeking help for menstrual problems from a healthcare provider
Supportive social environment	Individual	% of girls who have someone they feel comfortable asking for support (advice, resources, emotional support) regarding menstruation
Menstrual health impacts	Individual	% of girls who report a period does not affect their day
		% of girls whose class participation was not affected by their last period
Policy	National	% of countries with policies or plans that include menstrual health and hygiene
		National budget is allocated to menstrual health and hygiene; funds are dispersed to the schools in a timely and efficient manner

While this initial list of indicators begins to tackle gaps in understanding of the benefits of investing in menstrual health, a broader range of indicators is needed to build a robust evidence base. Linking these measures to evidence of their association with broader health and social outcomes such as menstrual health over the life course or academic success could yield further insight and spur investment. Additionally, it would increase attention to the diverse domains and interventions needed to improve menstrual health related health, education, social and economic outcomes.

Pathways to menstrual health and equity for girls

Despite compelling arguments for the importance of menstrual health,^{8 22} economic and political resources and commitment remain sporadic and limited. Commitment must expand to holistically address menstrual health, integrating it into different sectors as a potential pathway for improved population health outcomes.

In relation to health outcomes, investing in menstrual health programming and research has the potential to alter girls’ sexual and reproductive health trajectories and empowerment. Menarche in early adolescence is a critical developmental window for young people and offers multiple opportunities to intervene—for example, to build foundational knowledge about sexual and reproductive health, enhance body literacy, and improve healthcare seeking behaviours throughout life.^{2 3} Improving the skills of health workers to support the prevention and treatment of menstrual disorders is also critical. For example, early identification and care of heavy menstrual bleeding can alleviate issues such as anaemia and menstrual related disorders, improving quality of life and potentially reducing risks of infertility and certain cancers.²³

Increased investment in menstrual health research could also address associations between menstruation and negative mental health outcomes, such as depression linked to early menarche, and improve long term health and wellbeing.^{14 24} Investment would also contribute to improved vaginal health and lower the risks of reproductive tract and sexually transmitted infections, which limited data suggest are associated with inadequate hygiene and vaginal practices.²⁵

In education settings, it is essential to invest in menstrual friendly water, sanitation, and disposal facilities, train and sensitise teachers and peers, and incorporate menstrual health education into curriculums and community outreach programmes, including providing practical information and options for menstrual products, pain relief, and healthcare support for girls in and out of school. Pain relief should also include connections to healthcare workers to identify symptoms of potential menstrual disorders. Education should include boys and men to raise awareness about menstruation and menstrual stigma and discrimination. For example, a study in Bangladesh demonstrated that providing both sexes with a combined intervention addressing sanitation facilities, menstrual health education, and support reduced school absence and dropout and improved psychosocial wellbeing among girls.²⁹ Well funded research is necessary to identify the most cost effective approaches, including earlier and improved diagnosis and treatment of menstrual disorders.

Investing in menstrual health would also tackle persistent gender inequities by challenging pervasive, harmful social norms that limit girls’ mobility, educational opportunities, future workforce participation, and bodily agency. The benefits of interventions in health, education, and beyond could lead to long term benefits across a wide range of social outcomes in girls’ lives.

Past investments in HIV/AIDS and family planning have shown the value of focusing on broader health outcomes and structural and environmental approaches rather than just product distribution.^{26 27} A comprehensive approach that includes balanced, targeted support across relevant sectors, and the integration of menstrual health into sexual and reproductive health policies to promote access to information, resources, services, and products will yield far reaching benefits, addressing critical health issues for adolescents and women throughout their lives. Designated government leadership is vital to develop domestic financing for menstrual health. Moreover, establishing accountability mechanisms to track progress across sectors using good quality data, including the new menstrual health and hygiene indicators as a starting point, will substantially advance the menstrual health agenda. More consistent and long term political and financial investment will also foster more robust research initiatives to better understand menstruation related health issues and determine comprehensive and cost effective interventions beyond the distribution of menstrual pads.

• Key messages

• Investment in menstrual health in low resource contexts can address gender inequality and social challenges for school aged girls

• Inadequate data on the state of menstrual health across these countries hinder meaningful action

• Instead response focuses on mass provision of menstrual pads as a tangible, easily measurable solution

• Improved evidence, derived from well resourced research and evaluation of interventions, would support budget allocation and expand the design of more comprehensive interventions