Mapping the health outcomes of menstrual inequity: a comprehensive scoping review

Abstract

Introduction

Menstrual inequity refers to the systematic and avoidable differences experienced by women and people who menstruate, based on having a menstrual cycle and menstruating. Given the paucity of prior research examining the impact of menstrual inequity on health, a scoping review was conducted to explore and map out the menstrual inequities and their association with health outcomes in women and people who menstruate within the published academic literature.

Methodology

Two searches were conducted in May 2022 and March 2024 in PubMed and Scopus. Academic literature published until December 2023 was included. Following the screening process, 74 articles published between 1990 and 2023 were included in the review. Results were then synthesised through narrative analysis and organised into nine categories.

Results

A range of both physical and emotional health outcomes were documented to be associated with menstrual inequity. Urinary tract infection, reproductive tract infection, and other genital discomforts (e.g. itching) were linked to certain menstrual discomforts (e.g. dysmenorrhea) as well as a lack of access to menstrual products, menstrual management facilities and/or menstrual information. The emotional health outcomes, especially anxiety, distress and depression, were salient and were shown to be related to menstrual stigma, the lack of menstrual information and the limited access to menstrual-related healthcare.

Conclusions

The majority of the included studies were focused on menstrual management, being one of the most addressed themes concerning menstruation, and the health outcomes were mainly reproductive tract infection and emotional/mental health. Expanding the range of health outcomes studied will strengthen research and inform policy. Further research is needed to better understand the complex association between menstrual inequities and other potential health outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-025-02103-0.

Plain Language summary

Menstruation and the menstrual cycle are connected to the overall health of women and other people who menstruate. Menstrual inequity refers to the unfair situations and barriers that women and people who menstruate face because they menstruate. These include not having access to proper menstrual healthcare, menstrual education and knowledge, menstrual products, lacking services and facilities for menstrual management, experiencing menstrual stigma and discrimination, and the ability to fully participate in social, community, political and economic spheres. All these challenges can have an impact on their overall health. This study had the objective to explore these menstrual inequities and their association with health outcomes in women and people who menstruate in the published academic literature. We included information from 74 articles published until December 2023. The findings showed that menstrual inequity is linked to various health issues. For example, physical healthproblems, like urinary or reproductive tract infections, were often linked to difficulties managing menstruation. Moreover, emotional health issues like anxiety, distress, and depression were connected to experiences of menstrual stigma and discrimination, and having limited access to menstrual healthcare and education. This review also found that more research is needed about the relationship between menstrual inequity and health outcomes to fully understand how menstrual inequity affects women and people who menstruate. By doing so, researchers can provide better information to guide policies and improve health of women and people who menstruate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-025-02103-0.

Introduction

Menstruation, the menstrual cycle and how they are related to the overall health of women and people who menstruate (PWM) is a widely under-prioritized topic in both the academic, social and political field [1, 2]. This corresponds to a well-documented gender bias within health that continues to persist, manifesting itself, among other things, as an underrepresentation of women in health-related studies, misdiagnosis of women’s symptoms, the trivialization of women’s complaints, and discrimination in the awarding of research grants towards female researchers and research on women’s health [3]. This disregard of health conditions that disproportionately affect women is rooted in the all-encompassing tendency for society, its institutions, discourses and norms, to be centred around (white, cis-gendered, heterosexual, able-bodied) men and their needs, values and priorities, consequently prioritizing the male experience and marginalizing any other experience - such as menstruation [4, 5].

We understand menstrual inequities (MI) as a concept grounded in health equity and social inequities frameworks. Medina-Perucha et al., 2023 define MI as “the systematic and avoidable differences in the access to menstrual healthcare, education and knowledge, products, services and facilities for menstrual management, menstrual related experiences of stigma and discrimination, and social, community, political and economic participation based on having a menstrual cycle and menstruating” [6]. This umbrella term encompasses fundamental dimensions of MI, such as menstrual poverty (the struggle to afford menstrual products) [7] and menstrual management [8], menstrual healthcare, experiences of stigma and discrimination, and social, community, political and economic participation. These dimensions often intersect and overlap, maintaining and reinforcing health inequities for women and PWM. Framing these dimensions within the broader concept of MI allows for attending to how such inequities are a structural issue, rather than an individual one. Table 1 illustrates a conceptualisation of the relations between these concepts.

Table 1.

Relationship between menstrual inequity (MI) and its components

Concept	Definition	Relationship with menstrual inequity
Access to menstrual healthcare	The access to timely diagnosis, treatment and care for menstrual cycle-related discomforts and disorders, including access to appropriate health services and resources, pain relief, and strategies for self-care [9].	Menstrual inequity occurs when healthcare systems do not recognise and prioritise menstrual health. This can result in delayed, inaccurate diagnoses, unnecessary medicalisation, dismissal of symptoms, among other issues.  Menstrual inequities do not, however, exist in isolation and also intersect with other types of (health) inequities such as race, class, gender etc. Moreover, there are barriers (e.g., economic, geographic) that limit the access to specialised menstrual healthcare for some women and PWM.
Access to menstrual products and menstrual poverty	The ability to obtain safe, effective, and affordable menstrual materials (e.g., cups, pads, tampons). Limited access to these products is known as “menstrual poverty”. We understand and classify menstrual poverty in three types: (1) not being able to afford menstrual products, (2) not being able to afford preferred products, and (3) having to prioritize menstrual products over other products or activities [1].	Menstrual poverty is a material expression of menstrual inequity. Menstrual poverty not only highlights inequities related to menstruation and the menstrual cycle, but also reveals other inequities such as financial hardship and poverty.
Menstrual related experiences of stigma and discrimination	Menstrual stigma and discrimination are the result of complex social notions manifesting as negative attitudes towards menstruation. Menstrual discrimination refers to marginalization, oppression, harassment or even microaggressions directed at individuals because they menstruate and have a menstrual cycle [10, 11].	Menstrual stigma and discrimination are both an expression of and contributing factors to menstrual inequities. Menstrual stigma and discrimination have a wide range of negative consequences for women and PWM’s health, sexuality, wellbeing and social status. It furthermore upholds social and institutional barriers limiting access to resources, information, healthcare and supportive environments perpetuating social exclusion.
Access to menstrual management	The access to clean menstrual management is defined as access to materials to absorb and collect blood, that can be changed in privacy as often as necessary for the duration of the menstruation, soap and water for washing the body as required and having access to facilities to dispose of used menstrual management materials [12]. Other definitions also specify that menstrual management facilities are clean spaces, where water is available and include a bin and can be locked [1]. Many definitions are based on the use of ‘menstrual hygiene management (MHM)’ although we choose not to use the term ‘hygiene’ because of the connotations associating menstruation with a lack of cleanliness.	The lack of access to menstrual management reflects menstrual inequity, as insufficient possibilities to manage menstruation with dignity, which can affect health and social participation. Barriers that limit access to menstrual management are expressions of systems that reproduce a variety of inequities not limited to menstrual inequity (e.g., gender, class, territoriality). These structural inequities shape the material and social conditions that hinder safe and dignified menstrual management for women and PWM.
Access to menstrual education and knowledge	The access to accurate, timely, age-appropriate information about the menstrual cycle, menstruation, and changes experienced throughout the life-course, as well as related self-care and hygiene practices [9].	A lack of access to menstrual education and knowledge directly contributes to menstrual inequity, as it limits (self-)knowledge about the body and menstruation-related processes. In some contexts, menstrual education has been provided incompletely or predominantly with a biomedical focus, leaving out important information on self-care and socio-cultural aspects of menstruating. This prevents a comprehensive understanding of the menstrual cycle.
Access to social, community, political, and economic participation	Being able to participate in all spheres of life refers to being able to decide whether and how to participate in the civil, cultural, economic, social, and political spheres, during all phases of the menstrual cycle, free from menstrual-related exclusion, restriction, discrimination, and/or violence [9].	The access to social, community, political and economic participation are closely linked to other dimensions of menstrual inequity, such as access to adequate menstrual management, freedom from menstrual stigma and discrimination, and acquisition of menstrual education and information, among others. When women and PWM face barriers through lack of access to resources and education, or the presence of stigma and discrimination, their full participation cannot be realised.

The concept of MI serves to draw attention towards how androcentric social structures (which prioritise cis male experiences and perspectives) systematically stigmatise menstruation [13]. Several frameworks have been applied within research to investigate systemic menstrual-related disparities, such as the menstrual justice framework [14] or the human rights framework [15]. Both approaches emphasize how political and economic structures are shaped by different axes of domination generating disadvantages, oppression and violations of the fundamental rights of women and PWM [14, 16, 17]. They do not, however, directly engage with how these systematic inequities affect the health of women and PWM.

The urgency of examining health outcomes linked to MI is alternatively underscored by the social determinants of health (SDH) framework. This framework highlights how the circumstances in which people are born, grow, work, and live significantly impact their health [18]. SDH thus include (but is not limited to) economic policies and systems, development agendas, cultural norms, social policies and political systems [18, 19]. SDH plays an important role in producing and upholding health inequities and have been argued to be even more determining of an individual’s health than healthcare or lifestyle choices [18, 20]. Reducing (menstrual) inequities thus requires systemic changes to the SDH, addressing social, economic, and environmental conditions.

Previous research on the health outcomes posed by MI have demonstrated the risk of bacterial infections [21], barriers in the access to adequate diagnosis (and treatment) of menstrual health-related conditions (e.g. endometriosis) [22], a negative impact on mental health [2], and misinformation regarding the menstrual cycle generating subsequent negative health outcomes such as psychological stress [23]. Menstrual experiences like endometriosis, menstruations perceived to be irregular, and menstruations characterized by heavy bleeding or pain, have been demonstrated to be associated with lower quality of life and wellbeing and higher rates of mental health diagnoses [2]. In a similar manner, the experience of menstrual poverty has been shown to be associated with depressive symptoms [24], anxiety, and reproductive and urinary tract infections [25]. Additionally, Holmes et al. (2021) have demonstrated how the normalisation of certain menstrual health issues, such as dysmenorrhea, further prevents women and PWM to seek and receive proper healthcare treatment [23]. Much of this investigation focuses on geographical contexts in the Global South1, but is mainly developed, conducted, and funded by researchers and institutions in the Global North¹. The formulation of research questions, the definition of research subjects, and the theoretical frameworks in menstrual studies are thus often permeated by Western cultural notions, reinforcing predominant global power structures [26–28]. Despite largely being studied in the Global South it has been demonstrated that MI transcend geographical, cultural and socioeconomic status, and therefore are equally relevant in the Global North¹ [6, 23, 29].

While previous literature reviews have been looking into how menstrual management, menstrual poverty and menstrual health literacy affect the (menstrual) health of women and PWM [21, 23, 30–32], little inquiry has so far been carried out to explore how MI, as an umbrella term, may impact the health of women and PWM [6]. The aim of this scoping review is to explore and map the components of MI and their association with health outcomes in women and PWM, as reported inthe published academic literature.

Methods

A scoping review of academic literature was carried out to identify original research articles on health outcomes and their association with MI. This study followed the PRISMA guidelines (see Additional file 1) [33] and was registered in Open Science Framework (10.17605/OSF.IO/ZU73X).

Conceptual framework

This study adopts a critical feminist perspective, recognizing that systemic and structural patriarchal powers in society have an impact on health [34–36]. This approach implies using a social equity lens to conduct research that promotes collective freedom, justice, and equity [37]. Moreover, the SDH framework [38] was used to guide the identification of determinants implied in health outcomes related to menstrual experiences and health. This theoretical framework, in conjunction with the feminist perspective of the review, served as the guiding principle throughout the review process, particularly in the inductive identification of themes within the results. While the results will be presented descriptively for the purpose of facilitating comprehensibility, the structure of the analysis was informed by these frameworks.

The research has furthermore incorporated the practice of reflexivity, which included a critical examination of current approaches to MI in the literature [39]. Considering this, the research team conducted the study based on the following definitions:

• Menstrual inequity: the systematic and avoidable differences in the access to menstrual healthcare, education and knowledge, products, services and facilities for menstrual management, menstrual related experiences of stigma and discrimination, and social, community, political and economic participation based on having a menstrual cycle and menstruating [6].

• Health outcomes: any physical, psychological or emotional health-related symptom or condition. This is aligned with the WHO’s concept of health, defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [40]. This broad definition was necessary to reflect the wide variety of health implications related to the menstrual cycle and MI, including not only physical but mental and emotional health outcomes. We define emotional health based on a definition on emotional well-being as “an umbrella term for psychological concepts such as life satisfaction, life purpose, and positive emotions” [41].

• Social determinants of health: the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life (e.g. economic policies and systems). The SDH have an important influence on health inequities [42, 43].

Given that SDH may influence menstrual experiences and related health outcomes [44], it is important to consider how MI are associated with health outcomes. This review is based on the perspective that health is a social issue and that social inequities determine health outcomes, which are distributed unequally across populations [7, 45]. Although the focus of the review is on inequities, the SDH framework is used to first understand how social inequities arise in relation to menstruation and menstrual health.

Searches

The search was conducted in two databases: PubMed and Scopus. The search was performed in May 2022 and updated in March 2024. This second search was conducted to include recently published articles. The search strategy included the following terms: “menstrual health and hygiene”, “menstrual hygiene management”, “menstrual management”, “menstrual health”, “menstrual poverty”, “period poverty”, “menstrual equit*”, “menstrual inequit*”, “menstrual product*”, “menstrual hygiene product*”, “menstrual education”, and “menstrual knowledge” (see Additional file 2). The search was conducted by GPD and LMP.

Study inclusion and exclusion criteria

Studies were eligible if they were [1] original research articles of qualitative, quantitative and mixed-methods methodologies [2], published until December 2023 [3], in English or Spanish [4], considered at least one health outcome associated with one menstrual inequity dimension (e.g., menstrual poverty, menstrual education, etc.), and focused on [5] women and PWM. No restrictions for age or geographical areas were applied.

Reasons for exclusion were: [1] not focused on menstruation-related SDH [2], publications not including primary data and certain study designs (protocols, evaluations, intervention/pilot studies, conference papers, guidelines, case studies, theoretical framework or questionnaire development studies, editorials, commentaries, viewpoints, systematic literature reviews or meta-analyses, and other review designs) [3], not include any mention or exploration of a relation between one menstrual inequity dimension (e.g., menstrual poverty, menstrual education, etc.) and health outcomes [4], unavailable full-text, and [5] studies not published in English or Spanish. Studies focusing solely on menstrual experiences without a reference to health consequences were not included. This allowed us to map a broad range of evidence, including descriptive studies, while staying aligned with the aim.

Screening process

A total of 4,009 articles were included in the screening process. The screening process consisted of three phases: Phase (I) Title and abstract screening, after deleting duplicates (n = 2,863); Phase (II) Full-text screening (n = 465); Phase (III) Review of full-text screening (n = 96). The screening process was conducted between May and December 2022, and between March and April 2024 (once the search was updated). At the end 74 articles were included in the review. GPD and LMP performed the whole screening process; AGE performed the full-text screening and the review of full-text screening; ASH and ABH collaborated in the full-text screening of some studies. In all screening phases, some articles were triangulated by the members of the research team. The researchers met regularly to discuss and triangulate the screening process and to resolve any disagreements in the inclusion and exclusion of articles. When consensus was not reached, a third reviewer was introduced to make the final decision. This collaborative and reflective approach ensured consistency and transparency in decision-making, in line with good practice recommended for exploratory reviews. The Rayyan software [46] was used to facilitate the screening process. See Fig. 1 for more details on the screening process.

Fig. 1.

Flow-chart of study screening process. *Several studies were excluded for multiple reasons, so the sum of these is not equivalent to the total of excluded articles

Data extraction

Data of the 74 articles were extracted and included in an Excel sheet by AGE, GPD, ASH, ABH, and LMP (February-October 2023), and by AGE, GPD, and ABH (April-May 2024). Data extraction included publication and methodological characteristics (authors, title, year of publication, geographical and period context, objective, methods, study population characteristics, sample, area of study), relevant findings (health outcomes, SDH and the association between health outcomes and SDH), and quality evaluations (see Table 2). The studies were classified according to different categories, which were constructed based on the definitions of MI and the SDH framework. These categories comprised: [1] socioeconomic context [2], menstrual patterns and discomforts [3], menstrual knowledge [4], the quality and accessibility of healthcare services [5], menstrual management [6], menstrual poverty [7], menstrual taboo and stigma [8], gender norms and identity, and [9] social and community participation (see Fig. 2). 22 articles were excluded at the data extraction stage, as they did not focus on health outcomes, or they did not include associations between health outcomes and menstruation-related SDH. The results were summarised according to the categories.

Table 2.

Main characteristics of included studies (n = 74)

Reference	Country of data collection	Methodology and design	Study population	Age of participants	Sample size	Area of study	Health outcome(s)	Quality score*
Camas-Castillo et al., 2023	Brazil (Campinas, São Paulo)	Quantitative (cross-sectional)	Young adult and adult women	18-49y	n = 415	Menstrual management	Psychological quality of life	17/22
Ssemata et al., 2023	Uganda (Wakiso and Kalungu districts)	Qualitative (in-depth interviews, focus group discussions)	Adolescents and young adult students (girls and boys)	15-24y	n = 274 (in-depth interviews), n = 600 (26 focus groups)	The quality and accessibility of healthcare services, Menstrual taboo and stigma	Shame, fear, feeling uncomfortable	18/20
Marí-Klose et al., 2023	Spain (Barcelona)	Quantitative (cross-sectional)	Young adult and adult women	15-34y	n = 647	Menstrual poverty	Poor mental health	22/22
Schmitt et al., 2023	United States (all territories)	Qualitative (in-depth interviews)	Young adult women	18-25y	n = 25	Menstrual poverty	Feeling vulnerable, anxiety	17/20
Borg et al., 2023	Uganda (Mukono District)	Quantitative (cross-sectional)	Young adult and adult women	18-45y	n = 499	Menstrual management	Urogenital symptoms	22/22
Babbar et al., 2023	India (not specified)	Qualitative (secondary analysis of qualitative data from an online survey)	Young adult and adult women	18-49y	n = 140	Menstrual poverty	Concern	15/20
Getahun et al., 2023	Ethiopia (Dilla)	Qualitative (in-depth interviews)	Young adult women	Mean age 21.55y (± SD = 1.191)	n = 20	The quality and accessibility of healthcare services	Fears of become addicted to menstrual pain medication, concern	16/20
Mohammed et al., 2023	United States and United Kingdom (not specified)	Qualitative (critical approach to transcribed data)	Adolescent girls	13-19y	n = 15	The quality and accessibility of healthcare services	Uncertainty	17/20
Boden et al., 2023	United States (St. Louis, Missouri)	Qualitative (content analysis)	Adult women	19-65y	n = 32	Menstrual management, Menstrual poverty, Menstrual taboo and stigma, Social and community participation	Discomfort, anxiety, embarrassment, fatigue, moodiness	19/20
ElBanna et al., 2023	United States (St. Louis, Missouri)	Qualitative (semi-structured interviews)	Adult women	18-50y	n = 15	Menstrual management	Pain, embarrassment, feelings of dehumanization, (di)stress	18/20
Choudhary et al., 2023	India (New Delhi)	Qualitative (interviews)	Young adult and adult women	18-40y	n = 20	Menstrual management, Menstrual taboo and stigma	Stress, frustration, anger, embarrassment, humiliation, shame, worry and concern.	11/20
Betsu et al., 2023	Ethiopia (rural Tigray)	Qualitative (interviews, focus groups)	Adolescent girls	13-18y	n = 79	Menstrual taboo and stigma, Social and community participation	Menstrual anxiety, self-confidence, feeling uncomfortable	14/20
Varshney & Kimport, 2023	United States (not specified)	Qualitative (narrative analysis)	Adolescents, young adult and adult women	9-39y	n = 32	The quality and accessibility of healthcare services, Social and community participation	Emotional anxiety, anxiety of feeling alone	12/20
Chan et al., 2023	United States (all territories)	Qualitative (in-depth interviews)	Young adult and adult women	21-50y	n = 32	The quality and accessibility of healthcare services	Health consequences being on the wrong medication, medical trauma	18/20
Sadique et al., 2023	Pakistan (Sindh province)	Qualitative (interviews, discussion groups)	Adolescents and adult women	Not specified	Not specified	Menstrual management, Menstrual taboo and stigma	Feeling uncomfortable, rashes, itching, vaginal infections, urinary tract infections, embarrassment, discomfort, shyness, afraid being teased by men	13/20
Hennegan et al., 2022	Uganda (Mukono District)	Quantitative (cross-sectional)	Young adult and adult women	18-45y	n = 600	Menstrual management, Social and community participation	Urinary tract infections, discomfort	22/22
Winter et al., 2022	Kenya (Mathare informal settlement, Nairobi)	Qualitative (in-depth interviews)	Young adult and adult women	18-55y	n = 55	Menstrual management, Menstrual taboo and stigma	Embarrassment, concern, shame, fears of harassment, fears of contracting infections, frustration	18/20
Adib-Rad et al., 2022	Iran (not specified)	Quantitative (cross-sectional)	Young adult women	18-20y	n = 340	Socioeconomic context	Psychological distress	17/22
Cherenack & Sikkema, 2022	Tanzania (not specified)	Quantitative (cross-sectional)	Adolescents and young adult women	13-21y	n = 701	Menstrual patterns and discomforts, Menstrual knowledge	Reproductive tract infections	21/22
Alshdaifat et al., 2022	Jordan (all territories)	Quantitative (cross-sectional)	Young adult women	Mean age 21.6y (± SD = 2.2)	n = 594	Menstrual patterns and discomforts	Stress	17/22
Mariappen et al., 2022	Malaysia (Klang Valley)	Quantitative (cross-sectional)	Adolescent girls	13-18y	n = 1,050	Menstrual patterns and discomforts, Menstrual management	Quality of life	16/22
Buitrago-García et al., 2022	Burkina Faso (Kossi Province)	Qualitative** (photo-elicitation)	Adolescents and young adult women	12-28y	n = 56 (focus groups), n = 30 individual interviews	Menstrual management, Menstrual taboo and stigma	Discomfort, concern, shame, feeling unsafe, fear, humiliation.	15/20
Deriba et al., 2022	Ethiopia (North Shewa Zone)	Qualitative** (in-depths interviews)	Adolescent girls	13-19y	n = 12	Menstrual knowledge, Menstrual management	Concern, fear	16/20
Ní Chéileachair et al., 2022	Ireland (all provinces and Northern Ireland)	Qualitative (semi-structured interviews)	Adult women	≥ 18y	n = 21	Social and community participation	Feeling guilty, fears of discrimination	19/20
Boyers et al., 2022	United Kingdom (England)	Qualitative (in-depth interviews, focus group discussions)	Adult women	≥ 18y	n = 32	Menstrual taboo and stigma	Shame, anxiety	18/20
Daniels et al., 2022	Cambodia (2 rural provinces)	Mixed-methods (quantitative: cross-sectional; qualitative: structured interviews, focus group discussions)	Adolescent girls	≥ 14y	n = 75 (structured interviews), n = 55 (focus group)	Menstrual knowledge, Menstrual management, Menstrual taboo and stigma, Social and community participation	Fear, shyness, discomfort, social anxiety	18/20
Swe et al., 2022	Myanmar (Magway Region)	Mixed-methods (quantitative: cross-sectional; qualitative: structured interviews, focus group discussions)	Adolescent girls	11-16y	n = 421 (quantitative study); n = 10 interviews, n = 10 focus groups (qualitative study)	Menstrual taboo and stigma	Shyness, embarrassment, fear, distress	16/20
McGregor & Unsworth, 2022	Australia (urban areas, not specified)	Qualitative (semi-structured interviews)	Young adult and adult women	16-70y	n = 6	Menstrual management, Menstrual taboo and stigma	Confidence issues, concerns, embarrassment, awkwardness, frustration, comfortability	15/20
Schmitt et al., 2022	United States (Chicago, Los Angeles, and New York City)	Qualitative (in-depth interviews)	Adolescent girls	15-19y	n = 12	Menstrual knowledge	Distress	17/20
Ames & Yon, 2022	Peru (Huancavelica, Lima, Loreto, and Ucayli regions)	Qualitative (in-depth interviews)	Adolescent girls	10-17y	n = 277	Menstrual taboo and stigma	Fear of being ridiculed, discomfort, shame	14/20
Asumah et al., 2022	Ghana (West Gonja, Savannah Region)	Qualitative (exploratory study)	Adolescent girls	13-19y	n = 18	Menstrual management	Discomfort and illness	9/20
Wilbur et al., 2022	Vanuatu (Torba and Sanma Provinces)	Mixed-methods (quantitative: case-control; qualitative: in-depth interviews, focus group discussions, Photovoice)	Adolescents, young adult and adult menstruators	10-45y	n = 164 (menstruators with disabilities), n = 169 (menstruators without disabilities)	Menstrual management, Menstrual taboo and stigma	Pain, fear, shame	18/20
Gouvernet et al., 2022	France (not specified)	Quantitative (cross-sectional)	Adult women	18-50y	n = 890	Menstrual poverty	Depression and anxiety	22/22
Sommer et al., 2022	United States (not specified)	Quantitative (cohort)	Adult women	> 18y	n = 1,496	Menstrual poverty, Menstrual taboo and stigma	Stress	19/22
Shah et al., 2022	Gambia (rural Kiang districts)	Mixed-methods (two cross-sectional surveys; focus group discussions, in-depth interviews, menstrual diaries, and school WASH facility observations)	Adolescents and young adult women	11-25y (quantitative study); mean age 15.7–17.5 (qualitative study)	n = 561 (quantitative study); n = 155 (qualitative study)	Menstrual taboo and stigma, Social and community participation	Embarrassment, shame, urinary tract infection symptoms	22/22 (quantitative) 19/20 (qualitative)
Trant et al., 2022	United States (not specified)	Qualitative** (semi-structured interviews)	Adolescents and young adult women	13-24y	n = 10	Menstrual knowledge, Menstrual taboo and stigma	Feeling overwhelmed and scared with menstruation, fear, worry, shame.	15/20
Sharma et al., 2022	India (Punjab)	Quantitative (cross-sectional)	Adolescents and young adult women	15-25y	n = 2673	Menstrual patterns and discomforts	Stress	20/22
Fernández-Martínez et al., 2022	Spain (Andalusia region)	Qualitative (focus group discussions)	Young adult women	Mean age 22.72y (± SD = 3,46)	n = 33	The quality and accessibility of healthcare services	Fear of medication side-effects, fear of developing dependence and tolerance of pain medication, fear of downplaying the severity of pain	18/20
Tanton et al., 2021	Uganda (Entebbe sub-district)	Quantitative (cohort)	Adolescents and young adult women	12-20y	n = 232	Socioeconomic context, Menstrual knowledge, Menstrual taboo and stigma	Anxiety	16/22
Lane et al., 2021	United States (New York City)	Qualitative (in-depth interviews)	NB/trans, young adult, adult population	17-32y	n = 10	Gender norms and identity	Anxiety, unsafety	17/20
Bali et al., 2021	India (urban slum of Madhya Pradesh)	Quantitative (cross-sectional)	Adolescents and young adult women	10-19y	n = 393	Menstrual management	Anaemia	18/22
Gruer et al., 2021	United States (New York City)	Qualitative (in-depth interviews)	Homeless adult women	18-62y	n = 22	Menstrual poverty	Shame, humiliation, experiences of sexual harassment	18/20
Wilbur et al., 2021	Nepal (Kavrepalanchok district)	Qualitative (in-depth interviews, observation, PhotoVoice and ranking)	Adolescents and young people with disability	15-24y	n = 20	Menstrual knowledge, Menstrual management	Feeling uncomfortable, stress, worry, humiliation, concern	18/20
Cardoso et al., 2021	United States (not specified)	Quantitative (cross-sectional)	Young adult women	18-24y	n = 471	Menstrual poverty	Depression	20/22
Nabwera et al., 2021	The Gambia (rural Kiang districts)	Quantitative (cross-sectional)	Adolescents and young adult women	15-21y	n = 358	Menstrual patterns and discomforts, Menstrual management	Depression, urinary tract infections, reproductive tract infections	21/22
Briggs, 2021	United Kingdom (Stoke-on-Trent)	Qualitative (in-depth interviews, focus group discussions)	Adolescent girls	≥ 16y	Not specified	Menstrual poverty, Menstrual taboo and stigma	Worry, anxiety, unhappiness, embarrassment	10/20
Li et al., 2020	Australia (Melbourne)	Qualitative (in-depth semi-structured interviews)	Adolescent girls	Mean age 14.8y, range 12–18	n = 30	Menstrual patterns and discomforts, Menstrual taboo and stigma, Social and community participation	Embarrassment, distress, frustration, self-consciousness, school stress.	19/20
Kim & Choi, 2020	South Korea (Seoul and Incheon)	Quantitative (cross-sectional)	Young adult and adult women	Mean age 21y, range 17–32	n = 383	Menstrual management	Genitourinary infections	22/22
Hennegan & Sol, 2020	Bangladesh (Northern Bangladesh)	Quantitative (cross-sectional data from a cluster randomised controlled trial)	Adolescent girls	Mean age 11.84y, range 10–16	n = 1,359	Menstrual patterns and discomforts, Menstrual management, Menstrual taboo and stigma, Gender norms and identity	Confidence to manage menstruation	20/22
Frank, 2020	United States (Midwest, not specified)	Qualitative (virtual ethnographic approach)	NB/trans, young adult population	Mean age 22y, range 18–29	n = 19	The quality and accessibility of healthcare services	Dysphoric feelings, feeling unsafe	16/20
Ademas et al., 2020	Ethiopia (Dessie City)	Quantitative (cross-sectional)	Adolescents, young adult and adult women	16-49y	n = 602	Menstrual management	Reproductive tract infections	20/22
Borjigen et al., 2019	China (Changsha city)	Quantitative (cross-sectional)	Adolescent girls	11-14y	n = 1,349	Menstrual patterns and discomforts, Menstrual knowledge, Menstrual management	Psychological stress	15/22
Gundi & Subramanyam, 2019	India (Nashik district)	Mixed-methods (qualitative: semi-structured interviews, focus group discussions; quantitative: cross-sectional survey)	Adolescents (girls and boys)	13-19y	n = 1,421 (quantitative study); n = 56 (qualitative study)	Menstrual management, Menstrual taboo and stigma	Menstrual illnesses (itching, dryness, excess discharge), feeling lonely, feeling uncomfortable	17/22 (quantitative) 18/20 (qualitative)
Muralidharan, 2019	India (RG Nagar, Dharavi, central Mumbai)	Qualitative (focus group discussions, in-depth interviews)	Adolescents and young adult women	15-24y	n = 26	Menstrual patterns and discomforts, Menstrual knowledge, The quality and accessibility of healthcare services, Menstrual management, Menstrual taboo and stigma, Social and community participation	Stress, concern, discomfort, embarrassment, security, comfort, genital discomfort, uncomfortable	15/20
Torondel et al., 2018	India (Odisha)	Quantitative (cross-sectional)	Young adult and adult women	18-45y	n = 588	Menstrual management	Reproductive tract infections	21/22
Lahme et al., 2018	Zambia (Mongu District, Western Province)	Qualitative (focus group discussions)	Adolescents and young adult women	13-20y	n = 51	Menstrual knowledge, Menstrual poverty, Menstrual taboo and stigma	Humiliation, (di)stress	16/20
Amatya et al., 2018	Nepal (Far-Western)	Qualitative** (interviews, focus group discussion, observation)	Adolescents and young adult women	10-19y	n = 7	Social and community participation	Psychological problems (loneliness, lack of interest, sleep difficulties, etc.), general problems (headache, diarrhea, etc.), environmental problems (snake bite, insect bite). These are problems related to Chhaupadi	15/22
Van Leeuwen & Torondel, 2018	Greece (Ritsona)	Qualitative (semi-structured interviews, focus group discussions)	Young adult and adult women	18-50y	n = 30	Menstrual management, Menstrual poverty	Genital discomforts (itching), heavy bleeding, irregular periods, shame, concerns, anxiety, social exclusion	16/20
Girod et al., 2017	Kenya (Nairobi)	Qualitative (focus group discussions)	Girl students (not specified)	Not specified, scholar age	6–11 girls for each of 6 focus groups	Menstrual knowledge, Menstrual taboo and stigma, Gender norms and identity	Fear of urogenital tract infections, gonorrhoea, infertility, fear and anxiety of being raped and harassed, stress	15/20
Mathiyalagen et al., 2017	India (Puducherry)	Quantitative (cross-sectional)	Adolescent girls	12-18y	n = 242	Menstrual management	Itching and pustules over genitalia	13/22
Schmitt et al., 2017	Myanmar (Rakhine State) and Lebanon (Tripoli, Beirut and the Bekaa Valley)	Qualitative (focus group discussions)	Displaced (in humanitarian settings) adolescents, young adult and adult women	14-49y	n = 39 (participatory mapping); n = 117 (women aged 19-49y), n = 39 (girls aged 14-18y)	Menstrual knowledge, Menstrual management	Genital discomforts, anxiety, feeling uncomfortable, feeling unsafe	15/20
Hennegan et al., 2017	Uganda (Kamuli district)	Qualitative (semi-structured interviews)	Adolescent girls	12-17y	n = 27	Menstrual knowledge, Menstrual management, Menstrual taboo and stigma, Social and community participation	Genital discomfort (itching, irritation, abnormal discharge, burning sensation), fear, anxiety, stress, abdominal pain, embarrassment, feel confident	17/20
Hennegan et al., 2016	Uganda (Kamuli district)	Quantitative (cross-sectional)	Adolescents and young adult women	10-19y	n = 435	Menstrual management	Genital discomfort (skin irritation/rashes in pelvic area, itching or burning sensation, white or green discharge, concerns about odour), fear of soiling, menstrual pain, embarrassment, shame, insecurity, difficulties to concentrate in school	17/22
Mishra et al., 2016	India (West Bengal)	Quantitative (cross-sectional)	Adolescents and young adult women	10-19y	n = 715 (325 rural and 390 urban areas)	Menstrual management	Gynaecological problems (burning sensation during urination, increased frequency of urination, difficulty in controlling urine, leakage of urine and itching around genitalia)	16/22
Malhotra et al., 2016	India (Uttar Pradesh)	Quantitative (cross-sectional)	Adolescents and young adult women	10-19y	n = 1,800	Socioeconomic context	Attitudes or feelings of impurity during menstruation	16/22
Anand et al., 2015	India (28 states and 6 union territories, not specified)	Quantitative (cross-sectional)	Adolescents and young adult women	15-49y	n = 577,758	Menstrual management	Reproductive tract infections, vaginal discharge	17/22
Ranabhat et al., 2015	Nepal (Kailali and Bardiya districts)	Quantitative (cross-sectional)	Adolescents and young adult women	15-49y	n = 672	Menstrual management, Social and community participation	Reproductive health problems (reproductive tract infections, burning micturition, abnormal discharge, itching in genitalia, pain and foul-smelling menstruation)	20/22
Das et al., 2015	India (Odisha)	Quantitative (case-control)	Young adult and adult women	18-45y	n = 486 (228 symptomatic cases and 258 asymptomatic controls)	Menstrual management	Inflammation, reproductive tract infections, urinary tract infections, genital discomforts (e.g. vaginal discharge).	20/22
Parker et al., 2014	Uganda (Katakwi district)	Qualitative (interviews, focus group discussions)	Adolescents and young adult women	9-20y	n = 765 (focus groups); n = 17 (interviews)	Menstrual management, Menstrual taboo and stigma	Shame, embarrassment	17/20
Crichton et al., 2013	Kenya (Nairobi)	Qualitative (in-depth interviews, focus group discussions)	Adolescents and adult women	12-17y, adult women not specified	n = 87 (girls) and n = 69 (women)	Menstrual management, Menstrual poverty, Menstrual taboo and stigma, Social and community participation	Discomfort, genital discomforts (e.g. dampness, itching, irritation, rashes), concern, anxiety, embarrassment, fear of being stigmatized, low mood, emotional distress, physical discomfort	18/20
Yamamoto et al., 2009	Japan (Fukoka)	Quantitative (cross-sectional)	Young adult women	18-25y	n = 221	Menstrual patterns and discomforts	Stress	19/22
Chen & Chen, 2005	Taiwan (Tainan County)	Quantitative (cross-sectional)	Adolescents and young adult women	15-20y	n = 198	Socioeconomic context	Menstrual distress	14/22
Khanna et al., 2005	India (Rajasthan)	Mixed-methods (qualitative: focus group discussion, interviews; quantitative: survey)	Adolescents and young adult women	13-19y	n = 730	Menstrual management, Menstrual taboo and stigma, Social and community participation	Reproductive tract infections, embarrassment, social exclusion	13/22
Warner & Bancroft, 1990	United Kingdom (not specified)	Quantitative (cross-sectional)	Not specified, assumed adult women	Not specified	n = 5,457	Menstrual patterns and discomforts	Premenstrual syndrome, stress	11/22

*: quality score was assessed using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields [14]. 22 items were scored for quantitative studies and 20 for qualitative studies. **: Buitrago-García et al., 2022, Deriba et al., 2022, Trant et al., 2022 and Amatya et al., 2018 used a mixed-methods design, although the cross-sectional analyses were not included for this review. Other studies’ methods may only reflect the techniques that were analysed for this review

Fig. 2.

Categories of menstrual inequities that guided the analysis

Study quality assessment

The Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields [47] was used to assess the quality of the included studies. Quantitative and qualitative studies were assessed separately, following the guide’s checklists. Mixed-methods studies were evaluated using both quantitative and qualitative checklists, if both quantitative and qualitative data were extracted. Each item was scored as follows (yes: 2; partially: 1; no: 0; not applicable) and calculated over the maximum number of points (22 for quantitative studies and 20 for qualitative studies). Table 2 displays the final score for each article.

Data synthesis and narrative analysis

The data from the 74 included articles were synthesised and organised into the identified categories. AGE, GPD, ABH, and LMP conducted the synthesis and narrative analysis; ASH and CJA collaborated in the narrative analysis. Narrative analysis is suitable to investigate the similarities and differences of findings of different studies, as well as to explore patterns in the data [48, 49]. Data are collected and presented using a textual approach to ‘tell the story’ of the findings from included studies [50], which in our study were grouped into the previously mentioned categories. The analysis process included reviewing, integrating and summarising the data extracted from articles in each category. This process was triangulated by all researchers in regular meetings, by reading the synthesis and narrative analysis of each category, making comments and resolving any doubts or disagreements between the researchers. The final analysis was unified by AGE and GPD.

Results

Study and sample characteristics

A total of 74 articles were included (see Table 2). 51 (69%) were published between 2023 − 2020 [51–101], 16 (22%) between 2019 − 2015 [102–118], three (4%) between 2014 − 2010 [119, 120], three (4%) between 2009 − 2005 [121–123], and lastly one (1%) in 1990 [124]. 35 (47%) used qualitative methods [52–57, 59, 65, 67, 68, 71, 73–75, 78, 82, 84, 87, 88, 91, 92, 95, 96, 98–101, 104, 111, 113, 115, 116, 118–120]; 30 (41%) quantitative methods [51, 60–64, 77, 78, 81, 83, 85, 86, 89, 90, 93, 94, 97, 102, 105–110, 112, 117, 121, 122, 124], and nine (12%) were mixed-methods studies [66, 69, 70, 76, 79, 80, 103, 114, 123]. Most studies included girls and women from menarche to before menopause. Other studies focused on non-binary and trans individuals [84, 95], refugees [115, 118], people with disabilities [71, 76, 88], and people experiencing homelessness [87, 100].

Articles were classified in nine categories (one article could be classified in more than one category). Six (8%) articles were included in the “socioeconomic context” category [60, 62, 81, 83, 107, 122]; 9 (12%) on “menstrual patterns and discomforts” category [61, 62, 64, 90, 92, 102, 111, 121, 124]; 13 (18%) on ”menstrual knowledge” category [61, 66, 69, 72, 76, 80, 83, 102, 104, 111, 113, 116, 118]; eight (11%) on “the quality and accessibility of healthcare services” category [52, 55, 56, 82, 95, 98, 99, 111]; 36 (49%) on “menstrual management” category [51, 53, 57–59, 64–66, 69, 71, 75, 76, 85, 86, 88, 90, 93, 94, 97, 100–102, 104–106, 108–112, 115, 117–120, 123]; 12 (16%) on ”menstrual poverty” category [63, 74, 77, 78, 87, 89, 91, 96, 100, 113, 115, 120]; 26 (35%) on ”menstrual taboo and stigma” category [52–54, 57, 59, 65, 68–71, 73, 78–80, 83, 91, 92, 94, 100, 103, 104, 111, 116, 119, 120, 123]; four (5%) on ”gender norms and identity” category [84, 94, 95, 116]; and 15 (20%) on “social and community participation” category [54, 55, 58, 67, 69, 79, 92, 100, 104, 109, 111, 113, 114, 120, 123].

20 (27%) studies were conducted in Sub-Saharan Africa [52, 54, 58, 59, 61, 65, 66, 75, 79, 83, 85, 90, 97, 98, 104, 105, 113, 116, 119]; 18 (24%) in South Asia [53, 57, 81, 86, 88, 94, 96, 103, 106–112, 114, 117, 123]; 12 (16%) in North America (all of them in the United States (US)) [55, 56, 72, 74, 78, 80, 84, 87, 89, 95, 100, 101]; 10 (14%) in the East Asia–Pacific Region [64, 69–71, 76, 92, 93, 102, 121, 122]; eight (11%) in Europe [63, 67, 68, 77, 82, 91, 115, 124]; two (3%) in North Africa–Middle East Region [60, 62]; and two (3%) in Latin America–Caribbean Region [51, 73]. Two studies (3%) were carried out across different regions [99, 118].

More than half of the studies were conducted in the Global South (48 studies, 65%), while 26 were carried out in the Global North (35%). The affiliations of the first, corresponding and last authors were from institutions in the Global North in 44 publications (59%) [53, 55, 56, 59, 61, 63, 65, 67–69, 71, 72, 74, 76–80, 82–85, 87–95, 99–101, 104, 105, 109, 115, 116, 118, 119, 121, 122, 124], in 20 (42%) cases by institutions in the Global South [51, 57, 60, 62, 66, 73, 81, 86, 96–98, 102, 103, 106–108, 111, 113, 117, 123], and in 10 (38%) cases institutions from both The Global South and Global North [52, 54, 58, 64, 70, 75, 110, 112, 114, 120]. Of the studies conducted in the Global South, 27 (56%) were affiliated with at least one institution in the Global North [52–54, 58, 59, 61, 65, 69, 70, 75, 76, 79, 83, 85, 88, 90, 94, 104, 105, 109, 110, 112, 114, 116, 118, 120], whereas none of the studies conducted in the Global North were affiliated with an institution in the Global South. The three countries that were mostly affiliated with the studies were the US (21 studies, 28%) [53–56, 59, 61, 65, 69, 72, 78, 80, 84, 87, 89, 94, 95, 100, 101, 114, 116], England (17 studies, 23%) [52, 68, 75, 76, 79, 83, 88, 90, 91, 104, 105, 110, 112, 115, 118–120] and India (12 studies, 16%) [81, 86, 96, 103, 106–108, 110–112, 117, 123]. Of the funding institutions, 36 (49%) were located in the Global North [52–56, 58, 59, 61, 65, 68–70, 72, 74, 76, 78–80, 83–85, 87–90, 92, 94, 104, 105, 107, 110, 112, 116, 118, 120, 121], eight (11%) in the Global South [51, 66, 73, 81, 97, 98, 102, 106], and only one (1%) study was funded by institutions in both the Global North and Global South [109]. 15 (20%) publications declared not having received any financial support [57, 60, 63, 64, 67, 77, 86, 91, 96, 99, 103, 111, 113, 114, 117] and in 14 (20%) cases it was not possible to determine whether there had been any funding for the study [62, 71, 75, 82, 93, 95, 100, 101, 108, 115, 119, 122–124]. The funding institutions were mainly placed in the US (16 studies, 21%) [53–55, 58, 59, 61, 69, 72, 78, 85, 87–89, 94, 116], England (12 studies, 16%) [52, 68, 79, 83, 84, 90, 104, 105, 110, 112, 118, 120] and Australia (4 studies, 5%) [70, 76, 85, 92]. 17 studies (23%) were financed by public institutions, organizations or foundations [51, 55, 65, 66, 68, 76, 79, 81, 90, 92, 97, 98, 102, 104–106, 120], 10 (14%) by private ones [56, 58, 61, 69, 72, 80, 84, 87, 88, 107], while four studies (5%) received funding from both private and public institutions [74, 78, 85, 116]. 24 studies (50%) conducted in the Global South were funded by institutions in the Global North [52–54, 58, 59, 61, 65, 69, 70, 76, 79, 83, 85, 88, 90, 94, 104, 105, 109, 110, 112, 116, 118, 120], while none of the studies in the Global North were funded by institutions in the Global South. See Table 3 for further details.

Table 3.

Main characteristics of authorship, affiliations and funding of included studies (n = 74)

1st author, year of publication	Data collection country	Affiliation (1st author)	Affiliation (Corresponding author)	Affiliation (last author)	Affiliation Country	Funding	Funding country
Camas-Castillo et al., 2023	Brazil (Campinas, São Paulo)	Public university	Public university	Public university	Brazil	A public institution and a public foundation	Brazil
Ssemata et al., 2023	Uganda	Public university research institute.	Public university research institute.	Public university	Uganda & Engand	Three public institutions and an independent foundation	United Kingdom
Marí-Klose et al., 2023	Spain (Barcelona)	Public university	Public university	Public university	Spain	The author(s) reported no funding	-
Schmitt et al., 2023	United States	Private university	Private university	Private university	United States	Two private foundations and a public institution	United States
Borg et al., 2023	Uganda (Mukono District)	Private non-university research institute	Private non-university research institute	Private non-university research institute	Australia	Private foundation. One of the authors is furthermore financed by a public institution and a private foundation	United states & Australia
Babbar et al., 2023	India	Private university	Private university	Private university	India	The author(s) reported no funding	-
Getahun et al., 2023	Ethiopia	Public university	Public university	Public university	Ethiopia	Public university	Ethiopia
Mohammed et al., 2023	United States, United Kingdom	Public university	Public university	Public University	Canada	The author(s) reported no funding	-
Boden et al., 2023	United States	Private university	Private university	Private university	United States	This information could not be found	-
ElBanna et al., 2023	United States	Non-profit healthcare organisation	Non-profit healthcare organisation	Private university	United States	This information could not be found	-
Choudhary et al., 2023	India (New Delhi)	Public university	Public university	Public university	United States	Independent federal agency	United States
Betsu et al., 2023	Ethiopia (rural Tigray)	Public university	Public university	Private university	Ethiopia & United States	Not-for-profit organization	United States
Varshney et al., 2023	Not specified	Private university	Private university	Public university	United States	Public university	United States
Chan et al., 2023	United States	Private university	Private university	Private university	United States	Funded in part by the Center for Reproductive Health Research in the Southeast (RISE) through support from an anonymous foundation	United States
Sadique et al., 2023	Pakistan	Public university	Public university	Unspecified	Pakistan	The author(s) reported no funding.	-
Hennegan et al., 2022	Uganda	Private non-university research institute	Private non-university research institute	Public university	Australia & Uganda	Two private foundations	United States & Sweden
Winter et al., 2022	Kenya (Mathare informal settlement, Nairobi)	Private university	Private university	Private university	United States	The first author is funded by a non-profit organization	United States
Adib-Rad et al., 2022	Iran	Public university	Public university	Public university	Iran	The author(s) reported no funding.	-
Cherenack & Sikkema 2022	Tanzania	Private university	Private university	Private university	United States	Private university	United States
Alshdaifat et al., 2022	Jordan	Public university	Public university	Private university	Jordan	This information could not be found	-
Mariappen et al., 2022	Malaysia	Public university	Public university	Public university affiliated hopistal	Malaysia & Australia	The author(s) reported no funding.	-
Buitrago-García et al., 2022	Burkina Faso	Public university hospital	Public university hospital	Private university	Germany & United States	Public institution	Germany
Deriba et al., 2022	Ethiopia	Public university	Public university	Public university	Ethiopia	Public university	Ethiopia
Ní Chéileachair et al., 2022	Ireland	Public university	Public university	Public university	Ireland	The author(s) reported no funding	-
Boyers et al., 2022	United Kingdom (England)	Public university	Public university	Public university	England	Public institution	United Kingdom
Daniels et al., 2022	Cambodia (2 rural provinces)	Private university	Private university	Private university	United States	Private Christian organisation	United States
Swe et al., 2022	Myanmar (Magway Region)	Private non-university research institute	Private non-university research institute	Private non-university research institute	Myanmar & Australia	Two public institutions and two non-governmental organizations	Australia
McGregor & Unsworth, 2022	Australia	Non-profit organisation	Public university	Public university	Australia	This information could not be found	-
Schmitt et al., 2022	United States	Private university	Private university	Private university	United States	Two private foundations	United States
Ames & Yon, 2022	Peru	Private university	Private university	Private university	Peru	Inter-governmental organisation	Peru (UNICEF, Peru office)
Asumah et al., 2022	Ghana	Public university	Public university	Private university hospital	Ghana & United Kingdom	This information could not be found	-
Wilbur et al., 2022	Vanuatu	Public university	Public university	Public university	England	Public institution	Australia
Gouvernet et al., 2022	France	Public university	Public university	Public university	France	The author(s) reported no funding	-
Sommer et al., 2022	United States	Private university	Private university	Public university	United States	Private foundation, public institution and a public university	United States
Shah et al., 2022	Gambia	Public university	Public university	Public university	England	Public institution	United Kingdom
Trant et al., 2022	United States	Private university	Private university	Private university	United States	Private company	Italy
Sharma et al., 2022	India (Punjab)	Public university	Public university	Public university	India	Public institution	India
Fernández-Martínez et al., 2022	Spain	Public university	Public university	Public university	Spain	This information could not be found	-
Tanton et al., 2021	Uganda	Public university	Public university	Public university	England	Three public institutions and an independent charitable organization	United Kingdom
Lane et al., 2021	United States	Private university	Private university	Private university	United States	Private foundation	United Kingdom
Bali et al., 2021	India	Public university	Public university	Public university	India	The author(s) reported no funding	-
Gruer et al., 2021	United States (New York City)	Private university	Private university	Private university	United States	Two private foundations	United States
Wilbur et al., 2021	Nepal	Public university	Public university	Public university	England	Private foundation	United States
Cardoso et al., 2021	United States	Private university	Public university	Public university	United States	Non-profit organization	United States
Nabwera et al., 2021	Gambia	Public university	Public university	Public university	England	Public institution	United Kingdom
Briggs, 2021	United Kingdom	Public university	Public university	Public university	England	The author(s) reported no funding	-
Li et al., 2020	Australia	Public university affiliated hospital	Public university affiliated hospital	Public university affiliated hospital	Australia	Two authors are funded by a public university, one author is funded by a public institution	Australia
Kim & Choi, 2020	South Korea	Public university	Private university	Private university	South Korea	This information could not be found	-
Hennegan & Sol, 2020	Bangladesh	Private university	Private university	Public university	United States & Netherlands	One public institution and a non-governmental organization. One author is furthermore funded by two private foundations	Sweden, United States, The Netherlands
Frank, 2020	United States	Public university	Public university	Public university	United States	This information could not be found	-
Ademas et al., 2020	Ethiopia (Dessie City)	Public university	Public university	Public university	Ethiopia	Public university	Ethiopoia
Borjigen et al., 2019	China (Changsha city)	Public university	Public university hospital	Public university hospital	China	Two public institutions and a public university	China
Gundi & Subramanyam, 2019	India (Nashik district)	Public university	Public university	Public university	India	The author(s) reported no funding	-
Muralidharan et al., 2019	India (RG Nagar, Dharavi, central Mumbai)	Non-governmental organization	Non-governmental organization	Non-governmental organization	India	The author(s) reported no funding	-
Torondel et al., 2018	India (Odisha)	Public university	Private university hospital	Private university hospital	India & England	A public institution and an inter-governmental organization	United Kingdom & Switzerland
Lahme et al., 2018	Zambia (Mongu District, Western Province)	Unspecified	Unspecified	Public university	Zambia & South Africa	The author(s) reported no funding	-
Amatya et al., 2018	Nepal (Far-Western)	Public university	Public university	Public university	Nepal & United States	The author(s) reported no funding	-
Van Leeuwen & Torondel, 2018	Greece (Ritsona)	Public university	Public university	Public university	England	This information could not be found	-
Girod et al., 2017	Kenya (Nairobi)	Private university	Private university	Private university	United States	A private university, a private foundation and a public institution	United States
Mathiyalagen et al., 2017	India	Public university affiliated research institute	Public university affiliated research institute	Public university affiliated research institute	India	The author(s) reported no funding	-
Schmitt et al., 2017	Myanmar (Rakhine State) and Lebanon (Tripoli, Beirut and the Bekaa Valley)	Private university	Private university	Private university	England	A non-profit organization, one independent charitable organization and a public institution	United Kingdom
Hennegan et al., 2017	Uganda	Public university	Public university	Public university	England	Public institution	United Kingdom
Hennegan et al., 2016	Uganda (Kamuli discrict)	Public university	Public university	Public university	England	Public institution	United Kingdom
Mishra et al., 2016	India (West Bengal)	Public university	Public university	Public university	India	Public institution	India
Malhotra et al., 2016	India (Uttar Pradesh)	Inter-governmental organisation	Inter-governmental organisation	Inter-governmental organisation	India	Private company	-
Anand et al., 2015	India	Public university	Public university	Public university	India	This information could not be found	-
Ranabhat et al., 2015	Nepal	Private university	Private university	Public organisation	South Korea	A non-governmental organization and a public institution	Nepal & South Korea
Das et al., 2015	India (Odisha)	Private university	Public university	Public university	India & England	A public institution and an inter-governmental organization	United Kingdom
Parker et al., 2014	Uganda	Public university	Public university	Non-governmental organisation	England	This information could not be found	-
Crichton et al., 2013	Kenya (Nairobi)	Public university	Public university	Non-governmental organisation	England & Kenya	Public institution	United Kingdom
Yamamoto et al., 2009	Japan	Public university	Public university	Private university	Japan	Independent institution	Japan
Chen & Chen, 2005	Taiwan	Private university	Private university	Private university	Taiwan	This information could not be found	-
Khanna et al., 2005	India (Rajasthan)	Public university	Public university	Public university	India	This information could not be found	-
Warner & Bancroft, 1990	United Kingdom	Public university	Public university	Public university	Scotland	This information could not be found	-

Moreover, quotes illustrating some qualitative findings are presented in Table 4. The definition of terms and concepts used in included articles are available in Table 5. The relevant terms and concepts are indicated in italics throughout the Results section.

Table 4.

Quotes for qualitative studies classified by categories

Categories	References	Quotes
Menstrual patterns and discomforts	Li et al., 2020	“I have trouble sleeping when I’m on my period, ‘cause that’s just constantly there and constantly waking me up, so I have to go off to the toilet again”
	Muralidharan, 2019	“I think everyone is worried about their periods. But I think that those who do not get their periods at all are the most stressed… People are quick to misinterpret why a girl is not menstruating… they think she is pregnant”
Menstrual knowledge	Deriba et al., 2022	“I will never forget what I experienced during my first menses; while sitting and learning in class, I noticed that blood flowed from my organ. I was terrified, confused, and fell from the bench to the ground, where my friends carried me out of the class while other students teased me and older girls told me that it was normal even if I did not believe them”
	Trant et al., 2022	“I was in the bathroom doing my business and I saw blood and I was scared.” She said, “I was crying because I didn’t know if I was dying or not” “I guess I was just nervous because I didn’t know like what it was going to do like if it was going to like bleed through my pants or anything, and I was asking my friends about it, and they weren’t that experienced either, so they were kind of telling me false information making me more scared, so”
	Lahme et al., 2018	”I was scared and terrified as I did not know what was happening to me”
	Schmitt et al., 2022	“I told my auntie that there was something wrong, I explained…my severe stomach-ache and the blood on the sheets and she asked me the question: ‘Didn’t nobody ever talk to you about your period?’ And my response was ‘no, I didn’t know what that was’… I was only in third grade at the time…”
The quality and the accessibility to healthcare services	Ssemata et al., 2023	“The nurse is always rude and tough on the girls. Even when you experience severe cramps and need medical attention, the nurse will always say you are pretending and in the end, you struggle with your pain and are not helped”
	Getahun et al., 2023	“When I wanted to go and consult my friends, they always told me that if I use treatment, I might become addicted, so I gave up going. I mean, I live in a rural area where there is no medical treatment, so I did not go”
	Mohammed et al., 2023	“I went to the doctor and I said […] ‘I’m in agony’ so the doctors recommended that I go onto birth control […], so that I wasn’t going through agony all the time, but they still just condensed that down to being just heavy periods so it was never like a label’. They just sort of shoved me off, so I didn’t come back to the doctors”
	Chan et al., 2023	“It’s a woman’s issue which already gets tossed aside and it’s a mental health issue which also gets tossed aside. It’s just- it’s a double whammy of bad luck and they just don’t want to take it seriously for whatever reason.… They just wanna think it’s either brain issue or it’s a reproductive system issue and they can’t seem to connect that it’s- they’re both. They’re tied into each other. And that the body is making the brain feel this way.”
	Fernández-Martínez et al., 2021	“I think they won’t consider it important, if they ask me about my cycle, my pain, if I’m not in extreme pain they’ll ask me why I want an analysis or cytology test”
	Frank, 2020	“You know even when you go to the doctors now it’s, like, the first thing they ask you is when was the first day of your last period always. And I’m always like, “Why do you need to know?” [..] Like, one time I didn’t take a shit for like two weeks I was just severely constipated and I went to the doctors and they were like, “Oh you’re PMS-ing,” and I’m like, “Okay, like, that doesn’t make me feel better. Can you just like give me something to, like, get this waste out of my body?”
	Muralidharan, 2019	“I like lady doctors. I can talk to them openly about my body and not be embarrassed. I can talk about my chest area or my genitals and not be embarrassed. They can understand what the problem is because they are women, too.”
Menstrual management – Use of menstrual products for menstrual management	Sadique et al., 2023	“I used homemade pads but because of the flood all our houses got destroyed, and we didn’t have anything left. We were living beside the road, all clothes were soaked and floated away. I was forced to use leaves, which was very uncomfortable, and I even got rashes and itching on my vaginal and anal area. It’s after that I had a vaginal infection”
	Daniels et al., 2022	“The pads turn over for [the] sticker isn’t good. The pads are thin and short, [and there is] too much blood. Accidents happen especially when sleeping and playing”
	Wilbur et al., 2021	“When I sit in the wheelchair the pads may fold or something like that might happen which makes me feel uneasy […]. It becomes very uncomfortable to sit. Unlike my sisters who keep moving around, I have to sit in a place continuously. I get angry then and it gets difficult”
	Van Leeuwen & Torondel, 2018	“When I use cloth, when you walk you have a problem in the groin and it is very moist and you have problems and itching”
	Parker et al., 2014	“We are embarrassed to transport rags to and from school. We have no bags to put them in”
Menstrual management – Menstrual care and management practices	Asumah et al., 2022	“When it enters the vagina, you would feel some unusual pain. I just use water to wash my vagina”
Menstrual management – Menstrual care and management spaces	ElBanna et al., 2023	“I was in an alley. I was by a dumpster.… I had soiled my clothes, and uh I was changing, and I see this person walking down… I was trying to hurry up before they got close to me, and it was a guy, and he kept trying to come close and thank God I did have a knife. You know, and once he saw that knife, he kinda went about his business but it made me think if I didn’t have that knife, what would a happened, you know. I remember him calling me, ‘Oh you bloody mess’” “I feel miserable. I don’t even feel like a person anymore, I just feel like I’m existing and I just keep trying to improve my life and trying to find a job and trying to find this and trying to find that and it’s just when you get your period, it’s hot outside and you’re dirty and you can’t take care of yourself, it’s dehumanizing you know”
	Choudhary et al., 2023	“I feel bad. We have to think and plan even for bathing and drinking…It’s not a good feeling. I feel bad, at least during periods. In such a water situation, you can’t work freely” “When water is not there, dishes are not washed and when someone visits and asks me why I am not cleaning them, I feel ashamed. How will I clean the dishes when water is not there!”
	Sadique et al., 2023	“I use old clothes on my period. I have no access to a washroom; therefore I use flood water to clean the vagina and wash the menstrual clothes. I don’t have the place to make it dry due to rainy weather. I have to use the wet one again and again. I experience urinary tract infection and itching”
	Winter et al., 2022	“There are gaps in the door. Sometimes you will find I am standing here and somebody is in the toilet. You feel like he or she is seeing what I am doing inside there”
	Buitrago-García et al., 2022	“You already feel disgusting on your period and you come into a toilet that is again dirty, you feel even more disgusted” “I’m on my period at school, I’m not safe to change, there is no kettle to put water in (…) and it is often dirty” “It’s a little hard to manage (your period) in the bathroom, you’re not safe there because someone can open the door at any time”
	Deriba et al., 2022	“Because the school property and the latrine area are unclean and there is no water, the toilet is always dirty and unpleasant, making it unsafe to use or change modes”
	Daniels et al., 2022	“At school, I feel shy, lack clean water, toilet, soap, and sanitary pad during menstruation”
	Van Leeuwen & Torondel, 2018	“In the tent, if it’s very cold and you have your period, you’re going to feel bad and it’s not comfortable. If it’s hot, you are not going to feel comfortable” “There was a girl of 16 years who lived behind my tent. She was going to the toilet to change her pad. Just when she arrived, there were a lot of young men and she dropped her pad in front of them. She came back crying. I asked her what happened, and she told me the story. For many days, she did not leave her tent”
	Crichton et al., 2013	“If you go to the toilet and see it on the floor or the toilet basin, it is not good. It messes your day when you see it. It is a private thing and not for all to see” “It is a problem because these houses are single rooms and the whole family is there including the father. It becomes hard for them to go and change [sanitary products] and then they also don’t have toilet facilities…Maybe they will wait until night when their family are asleep]”
Menstrual poverty	Schmitt et al., 2023	“Sometimes I would have to buy the way cheaper brand of pads that were no good at all and didn’t really work for me and I was always messing up my clothes. And I didn’t feel good at all, and it was uncomfortable…”
	Gruer et al., 2021	“The humiliation is that you have to keep going back to them and asking them, and when you’re asking for, because they have police and security, so it’s not private. So you’re asking for it in front of NYPD and DHS security, and most of those are male staff”
	Briggs, 2021	“They’re asking friends to bring them in for them. If you ask the girls, that’s what they’ll say, that they do bring sanitary products in for their friends as well, which is also very demeaning isn’t it? Having to ask your friend to bring in sanitary products for you?” “Yeah, it does affect you mentally. I think when it’s affecting your everyday life and you can’t do what you want, it does bring you down”
Menstrual taboo and stigma	Ssemata et al., 2023	“Witches use menstrual blood to cast spells on a person and one way to get this blood is from the menstrual materials. My mum told me never to dispose my pads at school or anywhere” “Some girls say they hate menstruation because it makes them feel uncomfortable sitting with boys at school especially those with the heavy flow because they are worried about bloodstains on their skirts. Some girls are really shy, they fear and will never ask a colleague for help during their menstrual periods, so they suffer in silence”
	Betsu et al., 2023	“Even though I am physically present in class during menstruation, I don’t follow things well and I don’t understand it [the education] well because I’m only thinking about my period, not about the class. So it affects my education. We are really afraid to stand up and do classroom activities [such as writing on the board] because we worry about being soaked with menstrual blood”
	Sadique et al., 2023	“The hygiene (menstruation kit) in our area is distributed by male social workers and as it is strictly prohibited to hide it from others, especially men and now they are distributing it. It’s quite an embarrassing situation and we are afraid of being teased by men during distribution. But I had nothing to manage my periods, so I sent my little daughter to take it” “It is convenient for the woman if menstrual products should be distributed with other items so we wouldn’t feel awkward or embarrassed. The items should be packed separately and then put in a box, so food items or other necessities have hygienic space between them. We would not feel any embarrassment if menstrual kits should be distributed privately by female workers because in our culture it is prohibited to talk to the man about menstruation” “When a heavy flood occurred, we were all wet from head to toe and it was my second day of period and in our culture it is prohibited to take a bath or wash your body during menstruation. My clothes became wet and the scrap of cloth that I used as pad for period blood leaked and stained my kamiz (shirt). I was embarrassed that I covered it with my dupatta (shawl)”
	Boyers et al., 2022	“Don’t want it leaking into your pants and then it’s on show. The embarrassment of walking round constantly checking yourself all the time”
	Daniels et al., 2022	“[I feel] shy at them [boys] because [of] blood stain during menstruation. However, I am not shy if there is no blood stain” “[I] tell teachers and ask them to go home. It helps me not to feel scared” “Teachers are not helpful because they are busy to teach and [have] no spare time” “Teachers are not helpful because students don’t tell teachers, and they [girls] feel shy.”
	Swe et al., 2022	“At first, I dare not buy. Now I buy it from a shop outside the school. Last year, I brought a pad in my school bag. But I thought it can send me to hell, and so I don’t bring it this year. I also worry that boys may see it if I keeps it in the pouch beside my bag”
	Ames & Yon, 2022	“We were in physical education class. We were running, and [a girl] sat down because she was in pain. And then, she asked the teacher for permission to go to the bathroom, and when she stood up, she was all stained. My classmates began to make fun of her (…). She felt ashamed and crouched”
	Li et al., 2020	“A lot of boys notice how constantly I go to the toilet for that little bit of my period… it also gets them to look at you in a different way… I don’t think anybody takes it– unless you’re on it– nobody takes it seriously as you do. And I feel like people need to take it a little bit more seriously”
	Muralidharan, 2019	“I don’t want to make a mountain of a molehill, so I think to myself, let the pain continue. I just sit quietly. Crying will not make the pain go away, telling my mother will not make the pain go away. I just have to go through it”
	Lahme et al., 2018	“The boys… will be laughing… wherever you pass, they will be… mocking and talking about you (being)… careless and dirty. Therefore… we are affected psychologically and become stressed and always live in fear leading to low self-esteem, hence our school performances go down. Some even stop coming to school”
	Parker et al., 2014	“In the village we were able to wash and hang the rags anywhere without shame, in the camp that is very difficult”
	Crichton et al., 2013	“If you don’t have pads, and maybe that day there is water shortage, you will definitely start smelling and if your parent or the people living with you smell that bad odor, they will complain and you will feel embarrassed to say you are the cause”
Gender norms and identity	Frank, 2020	“For me, that week or so of bleeding is when my gender dysphoria is at its peak. It is a continual reminder of body parts that are alien to me. It’s a reminder of all the barriers in front of me as I try to medically transition. I panic about being outed as trans whenever I get sup- plies at the drugstore. And not only that, but I am forced to directly interact with a part of my body that horrifies me — multiple times throughout the day”
	Amatya et al., 2018	“I don’t like to stay at the shed. There is a constant fear of the animals, snakes, and scorpions. We hear about women being raped and abused while staying in the shed”
Social and community participation	Varshney & Kimport, 2023	“This is so scary for women and you feel like you’re the only one in the world going through this […] There wasn’t anything out there about this when I was experiencing it [primary dysmenorrhea]”
	Ní Chéileachair et al., 2022	“You don’t want people in the workplace treated differently. If you say a period is a problem, then they won’t hire you”
	Li et al., 2020	“I couldn’t leave my house, I couldn’t do anything… I didn’t really have an output to make [the menstrual pain] better. I have some mental health problems as well and I find that sport really helps… when I’m not doing sport and then I’m on my period as well, I struggle with that because I don’t have anything to put me in a positive frame of mind about it”
	Muralidharan, 2019	“When we grow up, our parents tell us to stay away from boys. Things really change after we start menstruating—we are not allowed to go out much; we are expected to stay at home; we are not allowed to spend much time with friends. Parents want to know where we are at all times” “I tolerate the pain. What else can I do? If I stay home from school, they mark me absent… this is not a good enough reason to take leave…. I get very stressed. Because I have bad cramps, I have to go to the toilet repeatedly. And the teacher in school doesn’t let you go to the toilet in the middle of class, and this is very difficult for us girls who need to go to the toilet when we have our periods. This really stresses me out”
	Hennegan et al., 2017	That sometimes, this begins when the teacher has entered in class. You need to finish the lesson, if you go out you will not get what the teacher has told, it will keep on burning until the teacher goes out
	Crichton et al., 2013	“When she [mother] is under pressure it is not easy for her to listen to you. She can easily start abusing you instead.… I worry who to tell because there are some mothers who when told about periods don’t care and you are forced to go and tell someone else about it to assist you [with sanitary pads]”

Table 5.

Table of specific terms and definitions from selected articles

Reference	Terms and definitions
Camas-Castillo et al., 2023	Adequate conditions to perform menstrual hygiene outside the home: Having a private place for hygiene, soap, clean water, and disposable bins. Psychological quality of life: Measures self-image, negative thoughts, positive attitudes, self-esteem, mentality, learning ability, memory concentration, religion, and mental status.
Marí-Klose et al., 2023	Period poverty: Not being able to afford menstrual products. Poor mental health: No definition.
Borg et al., 2023	Improvised materials, clean and not reused: Those that were used only once (that is, where participants had reported that they did not wash and reuse any materials) or were cleaned appropriately, were grouped as ‘improvised materials clean or not reused’. Unclean reused materials: Any reused materials (commercially produced or improvised) that were not cleaned appropriately.
Boden et al., 2023	Homelessness: The authors critique the definition of homelessness presented by The United States Department of Housing and Urban Development: “as individuals or families living without stable or adequate housing”. They argue that this definition is too narrow and overlooks hidden forms of homelessness such as “doubling-up” (e.g. shared living arrangements). The authors rely on the study’s participants’ self-identification to validate their unique and varied experiences with homelessness. ​​Menstrual hygiene management (MHM): Obtaining menstrual products, changing products, and controlling associated pain and increased hygiene needs (e.g. bathing and washing clothing more frequently). The authors highlight how MHM requires access to clean absorbents (e.g. tampons, pads), soap, clean water, and shelter to clean and change products safely and privately. Poor MHM then occurs when any of these needs are unmet.
Choudhary et al., 2023	Dignity: The felt experience and signal to the self that one has worth and value.
Varshney & Kimport, 2023	Primary dysmenorrhea: Painful menstruation in the absence of pelvic pathology.
Chan et al., 2023	Premenstrual dysphoric disorder: Cyclical recurrence of distressing or impairing affective symptoms, which must appear 3–4 days before menstrual bleeding.
Hennegan et al., 2022	Unmet menstrual needs: The extent to which women have access to resources and environments to care for their body which supports their preferences, comfort, privacy and safety during their last period.
Cherenack & Sikkema et al., 2022	Menstrual symptoms: Physical and psychological experiences associated with the pre-menstrual and menstrual phase, such as bloating, cramps, fatigue, and irritability Menstrual deficits: Difficulties getting menstrual supplies, a lack of education and social support, and difficulties getting money for absorbent materials or difficulties finding someone to get help or talk to about menstruation.
Alshdaifat et al., 2022	Perceived stress: The degree to which situations in a person’s life are perceived as stressful because it taps into unpredictable and uncontrollable situations in one’s life. Dysmenorrhea: Chronic pain spasmodic in nature that occurs right before or during menstruation.
Mariappen et al., 2022	Quality of life: No definition. Heavy menstrual bleeding: No definition. Dysmenorrhoea: Recurrent cramping abdominal pain associated with nausea. Amenorrhea: No definition. Oligomenorrhea: No definition. Physical and psychosocial health: No definition.
Daniels et al., 2022	Menstrual knowledge: As examples of menstrual knowledge the authors mention knowing to shower and clean with soap, use pads to prevent staining, change pads multiple times per day, dietary knowledge and the correct way to wear disposable pads, such as knowing how to properly position pads or keep them in place. Reliable menstrual products: Whether menstrual products were reliable were not defined, however the authors defined unreliable products as products with poor adhesive, inappropriate sizing, limited absorbent capacity, and failure to prevent odours.
McGregor & Unsworth, 2022	Visual impairments: Having an eye condition that caused low vision or blindness.
Gouvernet et al., 2022	Menstrual poverty: The authors asked participants to indicate whether they encountered difficulties in acquiring menstrual protection during lockdown. Depression: No definition. Anxiety: No definition.
Sommer et al., 2022	Income loss: Having experienced a personal loss of income in the past month as a result of the coronavirus. Increased stress: Assessed by asking the participants whether they agreed with the following statement: “Compared to before the pandemic, getting my sanitary product is more stressful”.
Sharma et al., 2022	Amenorrhea: The absence of bleeding phase for two/three months continuously. Stress: No definition.
Tanton et al., 2021	Anxiety: Operationalised as ‘anxiety about next menstrual period’ and defined according to participants stating that they agreed or strongly agreed with the following statement: “I feel anxious about having my next period”.
Bali et al., 2021	Menstrual hygiene management: Adolescent girls using a clean menstrual management material to absorb or collect blood that can be changed in privacy as often as necessary for the duration of the menstruation period, using soap and water for washing the body as required, and having access to facilities to dispose of used menstrual management material.
Cardoso et al., 2021	Period poverty: Not being able to afford menstrual products. Depression: No definition.
Nabwera et al., 2021	Heavy menstrual bleeding (HMB): No definition. Depression: No definition.
Li et al., 2020	Heavy menstrual bleeding (HMB): No definition. Dysmenorrhea: No definition.
Hennegan & Sol, 2020	Confidence to manage menstruation: Girls’ level of assurance in undertaking tasks associated with managing menstrual bleeding, including collecting, washing, drying and changing menstrual materials. Gender norms: Attitudes towards gender equity and gender norms covered topics such as discrimination, social image, dominance and female education.
Frank, 2020	Gender dysphoria: No definition. Anxiety: No definition.
Borjigen et al., 2019	Psychological stress: No definition. Dysmenorrhea: No definition. Menstrual restrictions: No cold drinks, no strenuous exercise such as running and no bathing during menstruation.
Gundi & Subramanyam, 2019	Menstrual illness: Extreme pain during menstruation, itching near the genitalia, foul smell near the groyne, excess white discharge, periods multiple times in a month, periods missed or general weakness. Severe/moderate/mild taboos: Whether participants were told to follow religious restrictions, keep menstruation a secret from males in the family, sit away from the rest of the family, not touching or talking to boys during menstruation. Menstrual complaints: No clear definition, but examples of itching, dryness, excess white discharge are mentioned.
Muralidharan, 2019	Stress: No definition. Irregular menstruation: A period that occurred much earlier than expected or twice in a month, a period that was delayed by a couple of months or the absence of periods for ≥ months.
Torondel et al., 2018	Menstrual hygiene management practices: The type of absorbent material used, the frequency it is changed, associated body washing, the methods of washing, drying and storing reusable pads as well as other contextual factors, such as the location of menstruation-related changing and washing practices. Frequency of menstrual product change: The authors divide the frequency of menstrual product change into “more frequent” which is defined as 2 changes or more per day, or “less frequent”, defined as changing once per day.
Lahme et al., 2018	Lozi tradition: An initiation process that girls are required to conform to at the beginning of menarche. It includes various rituals, one entailing being kept in isolation from family and friends for between 3 weeks and 6 months.
Amatya et al., 2018	Chhaupadi: A tradition in far-western Nepal that entails a menstrual exile and is characterised by the “untouchability” of menstruating women and girls. It is forbidden for them to touch other people and certain objects, and they are required to live away from the community, typically in a livestock shed, during menstruation.
Van Leeuwen & Torondel, 2018	Heavy bleeding: No definition. Irregular periods: No definition.
Girod et al., 2017	Menstrual management: Access to toilets, water, disposal, ablution spaces, and pads are mentioned as part of menstrual management. Furtherrmore, WASH facilities were observed to be adequate for menstrual management by assessing cleanliness, function, lighting, and privacy.
Mathiyalagen et al., 2017	Satisfactory menstrual hygiene practices: Washing genitalia more than twice a day during menstruation.
Hennegan et al., 2017	Anxiety: No definition. Stress: No definition.
Hennegan et al., 2016	Adequate privacy: Whether privacy for changing menstrual absorbents were adequate were understood by asking participants if they worried about being observed when washing their menstrual absorbents. When they answered “no”, privacy was considered adequate.
Mishra et al., 2016	Menstrual hygiene practices: Use of absorbent materials, cleaning and drying practices if the product was reused, frequency of change of menstrual products and cleaning practices of genitals during menstruation. Practices such as use of sanitary pads, use of detergent for cleaning of clothes/rags if reused, regular cleaning of genitals and use of pipe water for cleaning genitals were considered by the authors to be more hygienic than the use of clothes/rags, washing clothes/rags only by water for reuse, irregular cleaning of genitals and use of pond water for cleaning of genitals, respectively. Gynaecological problems: Any burning sensation during urination, increased frequency of urination, difficulty in controlling urine, leakage of urine and itching around genitalia.
Malhotra et al., 2016	​​Attitudes or feelings of impurity during menstruation: The authors do not provide a clear definition but mention that attitudes about menstruation are measured in questions related to girs’ feelings of impurity, isolation, depression, and irritation.
Ranabhat et al., 2015	Reproductive health problems: Assessed based on the comprehensive cervical cancer control manual 2006 from WHO, and guidelines for the management of sexually transmitted infections 2003 from WHO, especially with focus on reproductive tract infection. The participants were asked whether they experienced a burning sensation during urination, severe pain and/or foul-smelling discharge during menstruation etc. Chhaupadi: Traditional practice in Nepal where menstruating women are imposed certain restrictions, such as restrictions to consume milk products; restricted access to public water sources; not being allowed to touch men, children, cattle, living plants, or fruit bearing trees; and having to live outside the home such as in an animal shed.
Yamamoto et al., 2009	Premenstrual symptoms: A constellation of physical, emotional, and behavioural symptoms which occur premenstrually and remit after the onset of bleeding. Physical symptoms included abdominal pain, headache, nausea, skin disorders, abdominal bloating, painful breast, and swelling of extremities. Emotional symptoms included irritability, anger, depression, and tension. Behavioural symptoms included increased food intake, decreased food intake, hypersomnia, lethargy, and marked lack of energy. Stress: The accumulation of somatic, psychological, and behavioural changes occurring in a person as a result of exposure to psychosocial stress. Heavy menstrual flow: No definition. Irregular menstrual cycle: Amenorrhea (menses occurring less often than every three months), long cycles (≥ 39 days) for two consecutive periods or more, short cycles (≤ 24 days) for two consecutive periods or more, and menstrual cycles too irregular to determine the cycle length.
Chen & Chen, 2005	Menstrual distress: Symptoms of pain, water retention, autonomic reactions, mental distress, impaired concentration, behaviour change, and arousal.
Khanna et al., 2005	Safe menstrual practices: The use of either readymade sanitary napkins or new cloths.
Warner & Bancroft, 1990	Stress: No definition. Premenstrual syndrome: No definition. Natural menstrual cycle: A menstrual cycle unmodified by oral contraceptives and uninterrupted by pregnancy.

* It should be noted that not all the articles included in the scoping review are represented in Table 5. The table highlights terms and definitions from selected articles where the authors’ definitions were necessary to understand the review's findings.

Socioeconomic context

A study among adolescent and young adult women in India links living in a deprived district (OR = 0.29, ± 95% CI 0.23) and living in a middle economic status household (OR = 0.61, ± 95% CI 0.42) with attitudes or feelings of impurity during menstruation (Table 5) [107]. Anxiety (Table 5) about menstruation is associated with participants not living with their mother (aOR = 1.91, 95% CI 1.01–3.60) in adolescent and young adult women in Uganda [83]. Another study conducted in Iran states that one predictor for Global Severity Index (understood as equivalent to psychological distress by the authors) is mother’s education. It was also found that the severity of dysmenorrhea is associated with mother’s education (p = 0.037) in young adult women [60]. A study in Taiwan shows positive correlations between menstrual distress (Table 5) and age (b = 0.205, p < 0.001), as well as mother’s occupation (b = 0.179, p < 0.001) in adolescents and young adult women [122].

Menstrual patterns and discomforts

In Gambia, heavy menstrual bleeding (HMB) (Table 5) in adolescents and young adult women is associated with increased prevalence of depression (Table 5) (aPR = 1.4, 95% CI 1.0–1.9) and reproductive tract infections (RTIs) (aPR = 1.4, 95% CI 1.1–1.8) [90]. Similarly, a study in Malaysia report that adolescent girls with HMB, dysmenorrhea, or amenorrhea/oligomenorrhea have lower quality of life (Table 5) (70.23 ± 13.53, p = 0.001), compared to those who do not have these menstrual patterns (76.36 ± 14.93, p = 0.001). Concretely, physical health (74.10 ± 16.83 vs. 79.00 ± 15.86, p < 0.001) and psychosocial health (68.05 ± 14.27 vs. 73.21 ± 13.09, p = 0.001) (Table 5) are lower among those with HMB, dysmenorrhea, or amenorrhea/oligomenorrhea, compared to those without these menstrual patterns [64]. Amenorrhea (Table 5) is likewise shown to be associated with stress (Table 5) in adolescents and young adult women in India (OR = 1.24, 95% CI 1.06–1.44) [81]. In an Australian qualitative study, adolescents link HMB and dysmenorrhea with poorer emotional health (e.g. anxiety, worry) [92]. In another qualitative study, adolescents and young women in India report that the presence of irregular menstruations (Table 5) are associated with feelings of fear and stress (Table 5), as this might be related to premarital sex and potentially being pregnant [111]. In Japan, young adult women with premenstrual symptoms, HMB, and irregular menstrual cycles (Table 5) show higher scores of stress (Table 5). The same study shows that stress score, HMB, and menstrual pain are significant predictors for premenstrual symptoms (Table 5) (aOR_{stress score}=1.03, 95% CI 1.01–1.06; aOR_{heavy menstrual flow}=2.34, 95% CI 1.11–4.91; aOR_{menstrual pain}=3.43, 95% CI 1.52–7.72), whereas higher stress scores (aOR_{stress score}=1.03, 95% CI 1.01–1.05) and lower body mass index (BMI) (aOR_BMI=0.86, 95% CI 0.77–0.97) are related to experience irregular menstrual cycles (Table 5) [121].

Dysmenorrhea (Table 5) is associated with higher psychological stress (Table 5) in adolescent girls in China, compared to those without dysmenorrhea (x̄ and SD dysmenorrhea: 21.38 ± 4.94, x̄ and SD no dysmenorrhea: 20.27 ± 4.81, p = 0.000) (102). Similar results are provided by a study in Jordan, where higher stress (Table 5) scores are correlated with the presence of dysmenorrhea (Table 5) in young adult women (rpb = 0.185, ≤ 0.001) (62). A family history of dysmenorrhea (Table 5) (OR = 2.33, 95% CI 1.43–4.15) is a predictor of the Global Severity Index (understood as equivalent to psychological distress by the authors) in young adult women in Iran (60). Besides, adolescents and young adult women from a study in Gambia report an increased prevalence of urinary tract infections (UTIs) symptoms with extreme pain during menstruation (aPR = 1.3, 95% CI 1.2–1.4) (90).

In the United Kingdom (UK), women experiencing long natural menstrual cycles (Table 5) are more likely to experience premenstrual syndrome (Table 5), and among younger women who have never given birth, those who previously used oral contraception report more PMS (premenstrual syndrome) (current users, 37%; never users; 39%, ex-users 50%; p = 0.0003). PMS is shown to be less frequent among women who recently discontinued using oral contraception. In the same study, an association between PMS and stress (Table 5) is observed (x² = 23.3, p = 0.019) [124]. In a study in Tanzania, menstrual symptoms (e.g. irritability, cramps) (Table 5) are associated with RTIs (aOR = 1.69, 95% CI 1.21–2.36) among adolescents and young adult women [61].

Longer time since menarche (> 1 year) is associated with higher level of confidence to manage menstruation (Table 5) at home, compared to less than one year since menarche (aOR = 1.39, 95% CI 1.39–1.78) among adolescent girls in Bangladesh [94]. Another study among adolescents in China, state a correlation between higher psychological stress (Table 5) regarding menstruation and reaching menarche at a lower age (< 13 years) (x̄ and SD menarche < 13y: 20.97 ± 4.93; x̄ and SD menarche ≥ 13y: 19.92 ± 4.83, p = 0.019) (102).

Menstrual knowledge

Several studies report that misinformation about menstruation affects emotional health (e.g. fear, anxiety) at menarche [69, 72, 80, 88, 113, 118] and before menarche [66, 111]. A qualitative study in the US reveals that late and limited menstrual education from parents or at school poses consequences on mental health [80]. Similarly, another qualitative study states that adolescent girls in Cambodia with menstrual knowledge (Table 5) at the onset of menarche feel more confident about menstruation [69]. In contrast, adolescents in Uganda with lower menstrual biology knowledge are less likely to report anxiety (Table 5) about their next menstrual period (aOR = 0.44, 95% CI 0.23–0.84), compared to those with greater knowledge [83]. Similarly, another study from China states that psychological stress (Table 5) increases with menstrual knowledge in adolescent girls (b = 0.324, 95% CI 0.114–0.534) [102].

A qualitative study shows that the disparities between information provided by family and peers, compared to the information received in an educational intervention is a source of stress (Table 5) for adolescent girls in Uganda [104]. Concretely, some girls are told by their families to restrict activities during menstruation, while in the educational intervention they are recommended the contrary [104]. In a qualitative study in Kenya, girls express fear about getting infections due to poor menstrual management (Table 5), as they believe that urine splattering onto the vulva can cause UTIs, gonorrhoea, or infertility [116]. A study in Tanzania, finds that the risk of RTIs is higher among adolescents and young adult women with menstrual deficits (including the lack of menstrual education) (Table 5) (aOR = 1.91, 95% CI 1.24–2.95) [61].

The quality and accessibility of healthcare services

The (lack of) attention in healthcare systems and professionals for menstrual-related consultations results in emotional impacts (e.g. frustration, isolation) in participants of several qualitative studies [55, 56, 82, 99]. For example, the dismissal of symptoms, misdiagnosis, and other negative experiences may lead to “medical trauma” (not defined by the authors) and mistrust of doctors among young and adult women [56]. In the same study, participants elucidated the adverse health effects resulting from the administration of inappropriate medications due to the inability to obtain an accurate diagnosis (e.g. for premenstrual dysphoric disorder (Table 5)) [56]. Based on adolescents and young women narratives in India, the medical treatment is only undertaken in cases where menstrual discomfort and pain disrupt daily routines [111]. Additionally, adolescent and young girls in Uganda fear unfriendly attitudes from teachers and school nurses when they need menstrual consultations [52]. In a similar manner, menstrual healthcare services are often avoided by trans and non-binary menstruators in the US because of feeling uncomfortable and having negative encounters with healthcare providers [95].

Participants from a qualitative study in India experience barriers to healthcare access (e.g. distance from healthcare facilities and associated travel costs) which affect their emotional health (e.g. being uncomfortable, self-conscious). Furthermore, they prefer talking to women doctors to avoid embarrassment [111]. Other barriers to healthcare access are identified in Ethiopia, where young adult women avoid healthcare services because of fears of becoming addict to menstrual pain medication. These fears are especially salient in rural areas, where healthcare facilities are not generally accessible [98]. Participants with primary dysmenorrhea from a study with self-published narratives online in the US, report feeling isolated due to the lack of access to insurance for possible therapies. Moreover, according to their narratives, other extra-medical factors such as “finances, politics, education, and logistics” (not specified) complicate relief from primary dysmenorrhea [55].

Menstrual management

Use of menstrual products for menstrual management

Poor menstrual hygiene management practices (Table 5) are associated with higher prevalence of lower RTIs in young and adult women in India. Concretely, those diagnosed with Candida infection are more likely to use reusable cloths (aPRR = 1.54, 95% CI 1.2–2.0) [112]. Another study with adolescents and young adult women in India reveals that not using sanitary pads is associated with RTIs (aOR = 1.04, 95% CI 1.021–1.071) and vaginal discharge (aOR = 1.30, 95% CI 1.266–1.341) [108]. Similarly, reusable cloths are associated with inflammation (OR = 2.03, 95% CI 1.4–2.9), RTIs (aOR = 2.3, 95% CI 1.5–3.4) or having either bacterial vaginosis (BV) or UTIs (aOR = 2.8, 95% CI 1.7–4.5) in young and adult women in India [110]. A study from Uganda states that using clean/not reused materials (aPR = 1.33, 95% CI: 1.04–1.71) or unclean reused materials (Table 5) (aPR = 1.84, 95% CI: 1.46–3.42) is related to higher prevalence of self-reported urogenital symptoms, compared to using disposable pads only among young and adult women [85].

Women in a Greek refugee settlement participating in a qualitative study link having genital discomforts (e.g. itching) to using cloths made by themselves [115]. Similarly, participants from a qualitative study in Pakistan explain their sensations of genital discomforts (e.g. rashes) by the use of leaves or cloths for collecting menstrual blood that have already been used by other women [57]. Besides, participants from two different qualitative studies in Cambodia and Uganda reveal that using sanitary pads for a prolonged time increases genital discomforts [69, 104]. Moreover, adolescent girls from a qualitative study in Cambodia express that having reliable menstrual products (Table 5) available reduces emotional health impacts (e.g. shyness) about staining [69]. In a similar manner, based on the narratives of a few adolescent girls in Uganda, those whose parents regularly provide disposable pads and pain relievers express lower levels of anxiety (Table 5) [104]. Some women living in slums in India express feeling more secure using branded sanitary pads, while others preferred cloths because of greater comfort and less genital discomfort [111].

A study with adolescent girls in Bangladesh finds that using sanitary pads poses higher odds of reporting confidence to manage menstruation at home (Table 5) (aOR = 3.41, 95% CI 1.64–7.07) and at school (aOR = 2.41, 95% CI 1.54–3.87), compared to using old cloths. Girls who always/often access menstrual products at school have higher odds of confidence to manage menstruation (Table 5) at school (aOR = 4.71, 95% CI 2.11–10.49), compared to those that only occasionally have access [94]. However, in another study in Uganda, having access to sanitary pads at school was associated with an increased prevalence of UTIs (aPR = 1.4, 95% CI 1.2–1.5) [58]. Using unclean menstrual absorbents is associated with increased concerns about odour among adolescent and young adult women [105], and the absence of menstrual materials is linked to staying at home due to emotional and physical impacts (e.g. abdominal pain) in adolescent girls [104].

Psychological stress increases with a higher frequency of sanitary pads changes in adolescent girls in China (b = 0.855, 95% CI 0.243–1.468). However, the results from this study do not exhibit a clear relation between these variables [102]. Another study finds that changing menstrual products only once per day is associated with RTIs (aOR = 8.99, 95% CI 4.51–17.92) [97]. Moreover, the transportation and changing of menstrual products to school generate emotional health impacts (e.g. embarrassment) on women from a qualitative study in Uganda [119]. In a study in India, young and adult women changing menstrual products less frequently (Table 5) are more likely to have BV. Higher frequencies of menstrual products change (Table 5) are shown to be protective against infection in women with BV (aPRR = 0.56, 95% CI 0.4–0.75) [112].

The emotional impacts of menstrual management are expressed by people with disabilities in several qualitative studies [71, 76, 88]. People with mobility impairments express feeling uncomfortable regarding specific types or wrong positioning (not specified) of menstrual products [88]. Moreover, people with visual impairments explain experiencing emotional repercussions (e.g. worry) because of their difficulties with seeing potential blood stains and disposing of menstrual products discreetly [88]. A study from Australia describes how some women with visual impairments (Table 5) order menstrual products online or ask family/friends to buy them, to avoid embarrassment. However, a few participants mention feeling confident about asking supermarket staff members for assistance [71]. Participants from two studies in Vanuatu and Nepal, express feeling ashamed of relying on others to manage their menstruation [76, 88].

Menstrual care and management practices

Gynaecological problems (Table 5) are shown to be less prevalent if menstrual hygiene practices are better (Table 5) in adolescent girls in India. Those with higher levels of education (b = 0.23), age (b = 0.12), mother’s level of education (b = 0.17), father’s level of education (b = 0.28), and a monthly household income (b = 0.14), have better menstrual hygiene practices (Table 4) and less prevalence of gynaecological problems (Table 5) (b=-0.13) [106]. Moreover, unsatisfactory menstrual hygiene management (Table 5) is associated with itching in genitalia (x² = 6.909, p = 0.009) and pustules over genitalia (x² = 7.871, p = 0.005) in adolescent girls in India [117]. Another study among adolescent girls in urban slums in India found that poor menstrual hygiene management (Table 5) is associated with anaemia (aOR = 2.66, 95% CI 1.1–5.7) [86]. A study from India shows that the odds of RTIs increase when adolescents and young women do not engage in safe menstrual practices (Table 5) (OR = 3.07, p = 0.0000) [123]. Besides, psychological stress is demonstrated to increase when engaging in menstrual restrictions (e.g. not bathing while menstruating) (Table 5) in China (b = 0.073, 95% CI 0.032–0.114) [102]. In another study, quality of life (Table 5) is correlated with taking oral contraceptive pills for menstrual problems (Table 5) among adolescent girls (b = 7.976, 95% CI 2.691–13.260) [64].

Not washing hands with soap before touching the genital area (aOR = 3.94, 95% CI 1.49–10.45) and washing the genital area only once per day during menstruation (aOR = 5.76, 95% CI 2.07–16.05) is associated with RTIs in Ethiopia [97]. Bathing or vaginal washing only with water during menstruation is associated with genital discomforts (e.g., vaginal discharge) (OR = 2.4, 95% CI 1.01–5.7) among young and adult women in India [110]. Vaginal douching during menstruation poses a higher odds for genitourinary infections (OR = 4.93, 95% CI 1.29–18.84), and using a bidet during menstruation shows a positive association with genitourinary infections (p = 0.015) in young and adult women in South Korea [93]. Whereas, adolescent girls from a qualitative study in Ghana associate the use of soap to was the vagina with discomfort and illness [75].

Drying reusable menstrual products inside the home and keeping cloths hidden is shown to be associated with having Candida infections, compared to drying them in the sun/open space (aPRR = 1.78, 95% CI 1.34–2.38), or keeping them stored within cupboards (aPRR = 1.96, 95% CI 1.49–2.57) [112]. Similarly, one qualitative study states that participants in refugee settlements in Myanmar and Lebanon experience genital discomforts related to hiding and wearing damp cloths [118]. However, adolescent and young women in Uganda express feelings of shame associated with drying cloths outside [119]. Women from a qualitative study in Pakistan suggest that the lack of access to washrooms, clean water to clean the vagina and wash the menstrual cloths, and not having a place to dry menstrual products could be related to UTIs and itching [57]. In contrast, drying menstrual products inside the home or hiding them is associated with less white/green discharge and feeling less ashamed in a study from Uganda (OR = 0.44, 95% CI 0.21–0.91) [105].

Menstrual care and management spaces

The lack of access to inadequate facilities for changing menstrual products has an impact on the emotional health of the participants in several studies [51, 57, 58, 65, 66, 100, 101]. Young and adult women without adequate conditions to perform menstrual hygiene outside their homes (Table 5) are at higher risk to report lower psychological quality of life (Table 5) (OR = 1.01, 95%CI 1.00–1.02) in Brazil [51]. Two qualitative studies reveal that using shared public toilets or inadequate sanitation facilities (Table 5) is linked to fear of victimisation, harassment, and crime [59, 101]. Long waiting times and distances in community toilets are a concern for young and adult women because they link it to heavy bleeding, irregular periods (Table 5) and infections [115]. Based on women’s narratives in a study from Kenya, the condition of the bathroom structure (e.g. lack of privacy, lack of gender separation, inadequate access to water) has an impact on women’s emotional health (e.g. shame). Women are also concerned and anxious about the lack of gender segregated bathrooms [115, 118], as the absence of gender-segregated bathrooms is associated with shame and social exclusion [115]. Given the lack of privacy, most women express their preference to manage menstruation at home [59]. Also, changing menstrual products inside shelters/home is reported to be extremely discomforting because of the lack of privacy in other qualitative studies [57, 118, 120]. In one study, adolescents and adult women prefer public toilets, despite considering them inadequate [57].

In India, changing pads indoors (aOR = 0.56, 95% CI 0.3–0.9) decreases the likelihood to have BV [110]. In fact, UTI symptoms are shown to decrease when there is privacy in school toilets (aPR = 0.6, 95% CI 0.5–0.7) in Gambia [90]. Contrarily, adequate privacy (Table 5) for washing absorbents is associated with shame (aOR = 3.18 95% CI 1.54–6.57), insecurity (aOR = 2.16 95% CI 1.09–4.28), and difficulties to concentrate in school in Uganda (aOR = 3.03 95% CI 1.54–5.99) [105]. Lacking places to manage menstruation was related to adolescent girls feeling concerned, and sometimes leads them to skip school in Ethiopia [66]. Similarly, young and adult women with unmet menstrual needs (Table 5) are more likely to report work absenteeism and discomfort in a study in Uganda (aPR = 1.45, 95% CI 1.17–1.79) [58].

Using unclean latrines is associated with having RTIs among adolescent, young and adult women in Ethiopia (aOR = 4.20, 95% CI 2.00–8.80) [97]. Similarly, socioeconomically deprived girls experience menstrual illnesses (Table 5) due to unclean toilets in India [103]. Using dirty, shared latrines is also linked to feeling unsafe and uncomfortable, as well as to fear of kidnapping when using them at night among girls and women in refugee settlements [118]. Cleanliness at home (aOR = 2.64, 95% CI 2.04–3.42) and the presence of a bin (aOR = 1.57, 95% CI 1.01–2.44) are associated with confidence to manage menstruation among adolescent girls [94]. In the same study, the confidence to manage menstruation increases when participants feel comfortable using the toilet at school (aOR = 2.06, 95% CI 1.55–2.72) and when there is a light in the sanitation facility (aOR = 2.83, 95% CI 1.51–5.32) in Bangladesh [94]. One qualitative study in Burkina-Faso report that schoolgirls feel discomfort due to the unclean toilets, and are concerned about the availability of clean water, preferring menstrual management at home for more privacy [65]. Similar findings are reported in other studies [66, 69].

Women whose water source is outside the home are more likely to have RTIs (OR = 1.46 95% CI 1.0–2.2) [110], and more likely to have reproductive health problems (Table 5) if water is lacking during menstruation (aOR = 2.78, 95% CI 1.32–5.88) [109]. Similarly, reproductive health problems (Table 5) are associated with having no access to water during menstruation (OR = 2.78, 95% CI 1.32–5.88) in Nepal [109]. Women in India participating in a qualitative study express that the persistent lack of water in households generates emotional impacts (e.g. anger, stress) related to a perceived loss of dignity (Table 5) for not being “clean” during menstruation [53]. In a study in Gambia, girls attending schools with a water source that is only functional two-four per week (aPR = 1.4, 95% CI 1.3–1.6) have an increased prevalence of UTIs. An increase of RTIs is found when the duration to collect water at home is less than 30 min (aPR = 1.2, 95% CI 1.0–1.5), and a decrease of RTI symptoms when soap to wash hands is available in the school toilets (aPR = 0.6, 95% CI 0.5–0.8) [90].

Menstrual poverty

Period poverty (Table 5) is associated with moderate (aOR = 1.83, 95% CI 0.99–3.38) and severe depression (Table 5) (aOR = 2.34, 95% CI 1.09–4.99) among college women in the US. These associations remain significant considering the variable “previous mental health diagnosis” [89]. Period poverty is furthermore associated with poor mental health (Table 5) (aOR = 1.85, 95% CI 1.12–3.05) among young and adult women in Spain [63]. Menstrual poverty is also affecting the emotional health (e.g. fear, low mood, shame) of women in several contexts in the Global North and South [87, 91, 100, 115, 120]. Based on young women’s narratives from the UK, their social relationships are affected when asking for menstrual products, or when asking for a loan to be able to purchase them. Also, not being able to afford pain medication affect how women relate to others while in pain [91]. In two studies from the US, participants who experience homelessness (Table 5) report emotional impacts of menstrual poverty [87, 100]. Concretely, in one of the studies, women express shame, humiliation, and in some cases (sexual) harassment, when accessing menstrual products in shelters [87]. Other qualitative research highlights the genital discomforts (e.g. dampness, itching) experienced by adolescents in Kenya and Zambia when they struggle to access menstrual products and when using rags due to financial constraints [113, 120].

Additionally, menstrual poverty (Table 5) was associated with depression (Table 5) (aOR = 2.27, 95% CI 1.43 − 3.17) and anxiety (Table 5) (aOR = 1.89, 95% CI 1.18 − 3.03) in adult women during the COVID-19 lockdown in France [77]. In a study from the US, income loss (Table 5) during the COVID-19 pandemic was associated with higher odds of not being able to afford menstrual products (aOR = 3.64, 95% CI 2.14–6.19), and of experiencing increased stress (Table 5) when acquiring menstrual products (aOR = 2.2, 95% CI 1.66–2.77) in adult women. Moreover, higher odds of stress when acquiring menstrual products is related to lower educational attainment (aOR = 1.74, 95% CI 1.12–2.71) [78]. Qualitative studies also highlight the impact of menstrual poverty on emotional health during the COVID-19 pandemic [74, 96]. The emotional health of young women in the US is shown to be affected when lacking sufficient menstrual products and therefore having to rely on makeshift menstrual products due to shortages, whereas anxiety is lessened when buying menstrual products in bulk. On the other hand, many participants indicate complications in their daily routines. For instance, a few women in this study experience anxiety when using poor quality menstrual products in the workplace. In the same study, women reveal the emotional impacts (e.g. feeling vulnerable) of possible leaks caused by low quality and cheap menstrual products. Some of them shower more frequently to avoid feelings of dirtiness and fear of emitting bad odours [74]. In a study from India, one participant mentioned being concerned about requesting a male to purchase menstrual products during the lockdown [96].

Menstrual taboo and stigma

Many studies show how adolescent, young and adult women [54, 71, 73, 78, 80, 100, 111, 116, 119, 120] and PWM [76] are emotionally affected (e.g. fear, discomfort) if their menstrual status is revealed - especially to men [53, 65, 70, 123]. Based on one qualitative study, the onset of menstruation introduces gender inequities (not defined by authors) that impact the emotional health and safety of girls at school. Based on the narratives of participants of several qualitative studies, the teasing, bullying, judgement, aggression and lack of understanding by men pose an emotional impact on adolescent girls at school (e.g. stress, shame) [52, 69, 73, 92, 104], sometimes resulting in them avoiding social settings [70]. In a study in Pakistan, participants feel embarrassed to receive hygienic kits from male workers [57]. A quantitative study from Uganda shows that girls either being teased during their menstruation (aOR = 2.89, 95% CI 1.28– 6.54), or being worried about being teased during their periods pose higher odds of anxiety (aOR = 2.27, 95% CI 1.21–4.27) [83].

Other studies suggest an internalization of menstrual stigma. In Uganda, participants expressing anxiety about getting their menstruation is associated with believing it is not healthy to run, dance or cycle during menstruation (aOR = 1.83, 95% CI 0.95–3.50), and with beliefs of uncleanliness when a girl is on her period (aOR = 1.97, 95% CI 1.04–3.73) [83]. Participants from another study in Uganda report fear of being bewitched when disposing menstrual products [52].

Research amongst adolescents and young women reveal that the secrecy around menstruation results in feelings of embarrassment and shame in Gambia [79]. Likewise, a few women living in slums in India reveal feeling uncomfortable washing menstrual cloths because they perceive menstrual blood as dirty [111]. Anxiety, embarrassment and stigma is also related to fear of leakage and body odour because of infrequent change of menstrual products in Pakistan [57], the UK [68], and Kenya [120]. Women acknowledge feeling self-conscious when menstruating in public spaces, which amplifies emotional health impacts (e.g. worry) during menstruation in the UK [91]. A participant from a study in Australia expresses how menstrual taboo increased the sense of self-consciousness among adolescents with HMB and dysmenorrhea (Table 5) [92].

In India, few adolescent girls feel comfortable discussing their menstruation with school teachers. Boys seem more comfortable asking questions to a schoolteacher regarding menstruation, compared to girls (IRR = 2.38 95% CI: 1.80–3.15). Moreover, being comfortable asking questions to schoolteachers is associated with menstrual knowledge (IRR = 1.41 95% CI 1.06–1.88), and positive beliefs about menstruation (PR = 1.72 95% CI 1.19–2.49). In the same study, girls from low socioeconomic urban settings prefer to keep their menstrual complaints (Table 5) hidden, or to use home-based remedies. Feeling unable to communicate menstrual-related complaints seem to create fear, stress and body-shame amongst the girls. Higher stress about menstrual staining is present in the participants who are communicated severe menstrual taboos (Table 5) (IRR = 1.31 95% CI 1.10–1.57), compared to those who are communicated mild or no taboos (Table 5). Additionally, newly married adolescent girls share how they feel uncomfortable discussing anything related to menstruation with their husbands, which leave them feeling lonely during their menstruation [103]. Adolescents who are comfortable discussing menstruation experience higher confidence to manage menstruation at home (aOR = 2.13, 95% CI 1.61–2.82) [94]. Interestingly and contradictorily, the same study finds that discussing menstruation with a parent or guardian in the past three months is associated with lower odds of confidence to manage menstruation at home (aOR = 0.60, 95% CI 0.47–0.77), whereas having discussed it with friends in the past three months is associated with increased odds of confidence to manage menstruation at school (aOR = 1.59, 95% CI 1.21–2.09) [94]. Additionally, a qualitative study from India finds that young adults are uncomfortable discussing menstruation with their mothers [111].

Gender norms and identity

The gender norms tied to women and how they affect menstrual experiences are explored in some articles. Adolescent girls with internalised gender norms (e.g. agreeing values favouring males over females) (Table 5) predict lower confidence to manage menstruation at school (aOR = 0.96, 95% CI 0.93–0.98) and at home (aOR = 0.95, 95% CI 0.92–0.97) in Bangladesh [94]. Adolescents from a qualitative study in informal settlements in Kenya express fear of being raped and harassed from males; a fear that becomes especially triggered during menarche. Some participants disclose that they have been raped and feel unsafe in their communities [116].

Based on trans and non-binary menstrual experiences in the US, the social links of menstruation to womanhood and the gendering of menstrual products can be related to gender dysphoria (Table 5) [95]. Moreover, public toilets are considered unsafe [84] and become a source of anxiety (Table 5) [95]. A few younger trans and non-binary participants using menstrual products fear harassment if they are heard using menstrual products in bathrooms aimed for men, with some waiting to use menstrual products until they are alone [84]. Using men’s bathrooms when menstruating is considered unsafe by one participant when menstruating [95] but are still preferred due to their gender affirming nature [84, 95]. Moreover, trans and non-binary participants express feeling self-conscious using gender-segregated toilets, as they consider their bodies are being policed to ensure their gender matches with the bathroom [84].

Social and community participation

Adolescent and young girls from two studies in India reveal the emotional impacts of menstruation (e.g., stress, tension, embarrassment) due to the sociocultural implications of their communities (e.g. menstruation linked to marriage, supervised interactions) [111], and the exclusion from social activities and spaces during menstruation [123]. Another study from Nepal shows that reproductive health problems (Table 5) are associated with practising Chhaupadi (Table 5), a tradition that requires that women and girls live away from the community during menstruation (aOR = 14.6, 95% CI 6.99–30.5) [109]. In another qualitative study from Nepal, participants report mental and emotional health implications (e.g. boredom, unhappiness) when staying at a shed during Chhaupadi (Table 5) [114]. In a study from Zambia, adolescent girls report experiencing the Lozi tradition (a ritual at the onset of menarche) (Table 5) as traumatic [113].

Based on adolescent girls’ narratives in Australia, the lack of support systems at school (e.g. available medication for menstrual pain, understanding from teachers) is linked to suffering from school stress (not defined by authors) [92]. Similarly, girls from a study in Kenya report emotional health impacts (e.g. emotional distress) in school environments [120]. Moreover, self-confidence is sometimes lost during menstruation because of paying attention to menstrual blood during class [54]. This fear becomes a barrier to both concentration and participating in games [104]. In a study from Gambia, missing school during the most recent menstrual period was associated with having at least one UTIs symptom (aOR = 1.71, 95% CI 1.16–2.52) or RTIs (aOR = 1.99, 95% CI 1.34–2.94) [79]. A study in Uganda shows that young and adult women who think that women should avoid working during menstruation (aPR = 1.94, 95%CI 1.50–2.51) and should stay at home during menstruation (aPR = 1.49, 95%CI 1.02–2.18) are more likely to miss work and report discomfort [58]. Moreover, based on adult women narratives in Ireland, fears of discrimination and feelings of guilt for not remaining productive while experiencing menstrual pain are reported [67].

In a qualitative study from the US, women experiencing homelessness (Table 5) describe not socialising with friends due to fatigue and embarrassment of inadequate menstrual hygiene (Table 5) [100]. Adolescent girls from a study in Cambodia express feeling more comfortable socialising with females during menstruation, because they consider them mutually caring in contrast to males [69]. Moreover, some adolescent girls in a qualitative study in Kenya report concerns about the lack of support from their mothers [120]. Based on adolescent girls narratives’ in Australia, social and day-to-day activities during menstruation are affected due to HMB and dysmenorrhea, and often result in fatigue, low mood and feelings of isolation [92]. One participant of another qualitative study fears primary dysmenorrhea (Table 5) due to the lack of discourse and the sense that others cannot understand their pain, contributing to a sense of isolation and anxiety of feeling alone [55].

Discussion

This scoping review encompasses data from 74 original research articles that examine the relationship between MI and health outcomes in women and PWM from diverse age groups, geographical locations, and sociocultural contexts, among other characteristics. Emotional and mental health along with genitourinary tract infections were the most researched and reported health outcomes related to MI among the included studies. The preponderance of research findings indicating that mental and emotional health is one of the most frequently reported outcomes in relation to MI highlights the necessity for research that does not reduce women’s and PWM’s experiences to an emotional vulnerability inherent to the menstrual cycle. A narrow focus on biological factors alone may contribute to the perpetuation of gender stereotypes that obscure the structural factors that shape these experiences, thereby reinforcing the stigma surrounding the processes women and PWM experience. Besides, it is important to consider that MI may not be exclusively associated with the aforementioned health outcomes, but that they could also be linked to a broader range of health-related outcomes. It is important to notice that the androcentrism [125], and the hegemonic biomedical approach within academic research [36, 126, 127] have significantly hindered the development of comprehensive studies on MI from a SDH framework.

The field of menstrual research employs a multitude of terminological approaches that are not standardised. For example, the terms “menstrual hygiene” and “menstrual management” are at times used as synonyms, despite the fact that the term “hygiene” carry connotations that may be perceived as stigmatising [128]. As illustrated in Table 5, several studies included in this review showed differences in the use and understanding of menstrual research-related concepts. Given the increase of menstrual research in recent years, it is crucial that future research prioritise the refinement of conceptual frameworks and terminology employed in this field. One area that needs further attention is the conceptualisation of menstrual health [9]. In addition, this review identified deficiencies in the quality of several included articles. These included studies that failed to conceptualise menstrual health and its emotional or mental aspects. This may stem from the limited availability of validated instruments in menstrual research which can affect the way data are collected and interpreted. Addressing these gaps is fundamental for improving the quality of menstrual research and ensuring that menstrual health is comprehensively understood and effectively addressed.

One of the most notable findings from this review is the significant similarities in the relationship between MI and health outcomes across different sociocultural and geographical contexts. Although this review identifies countries where studies have been conducted, it does not provide a detailed analysis of the specific cultures within each of these countries. Moreover, it is important to challenge the culturalist perspective– the attribution of menstrual beliefs and practices solely pertaining to certain cultural, social or geographic contexts [129]. On the contrary, this continuous finding demonstrate that social conceptions of menstruation and menstrual practices cut across such contexts. A culturalist perspective may oversimplify complex phenomena by neglecting broader structural factors, which could in turn reinforce stereotypes and ethnocentric narratives. Furthermore, research that does not incorporate a critical examination of coloniality2 may be problematic, as it has the potential to misinterpret and decontextualise the findings [130]. As this scoping review demonstrates, 56% of the included studies conducted in the Global South were affiliated with at least one institution in the Global North, whereas none of the studies conducted in the Global North were affiliated with an institution in the Global South. The preponderance of institutions from the Global North studying menstruation in the Global South raises important concerns about the balance of power and agency within academic research. This means that research institutions from the Global North define the research agenda, control the funding and interpret the results. This can potentially result in imposing specific cultural worldviews and values that may not fully reflect the specific nuances of each context, inflicting a culturalist and even discriminatory perspective. The predominance of Western institutions and epistemologies in menstrual research exemplifies an epistemic injustice (systemic discrimination relating to the creation of knowledge), as the knowledge and lived experiences of women and menstruating people in the Global South are often reframed through other interpretative frameworks, limiting the reflection of diverse realities. Research initiatives led by Global North institutions may prioritise the interests of international funders. Consequently, certain studies may present Global South communities primarily through a lens of vulnerability, rather than acknowledging their agency. Even well-meaning research may inadvertently repeat power imbalances—for example, by not including local voices, keeping control of knowledge in the hands of Global North institutions, or not involving communities in deciding what to study and how to interpret it. Recognizing these imbalances is crucial for advancing a truly research agenda within menstrual research. Future research -and research teams- should critically reflect upon their positionality, promote equitable research collaborations (e.g., research led by Global South institutions and researchers), and ensure the presence of Global South epistemologies in research.

Although the majority of the findings from the included studies pertain to what could be considered “negative” experiences associated with menstruation, a few articles do highlight some more “positive” aspects, such as feelings of confidence or comfort when discussing menstruation. The paucity of research on “positive” menstrual experiences can be attributed to the negative and stigmatising connotations that menstruation entails [131] and that menstruation is often perceived as a burden rather than a health indicator [132]. This may result in the omission of positive menstrual experiences reported by some women and PWM, overlooking how SDH—such as education, social support systems, and others—can also foster positive experiences. Adopting a salutogenic perspective [133] in menstrual research and policies, which emphasises the factors that promote health and well-being, would enable the exploration of how different SDH can generate health and well-being during menstruation. Several findings on the relationship between menstrual patterns, discomforts and health outcomes are reported in this review [60–62, 64, 81, 90, 92, 94, 102, 111, 121, 124]. Some studies have reported that HMB is associated with psychological impacts (e.g. higher stress, depression), diminished quality of life, and an increased risk of RTIs. In addition, dysmenorrhoea is associated with poorer emotional/mental health (e.g. stress, worry), a reduction in quality of life, and UTI symptoms. Moreover, these relationships can be exacerbated by structural determinants of health (e.g. socioeconomic status) and other determinants like limited access to healthcare, limited access to menstrual products, social stigma surrounding menstruation, and inadequate social support [134, 135]. These findings underscore the importance of addressing MI in the broader context of SDH. They also highlight the need for comprehensive approaches that enhance both physical and emotional/mental health outcomes, while tackling the underlying structural inequities shaping menstrual experiences. Future studies should address the intersections of different dimensions of MI (e.g. menstrual patterns and access to menstrual healthcare) to better inform effective policies and interventions.

Education is a pivotal SDH, as it enables individuals to both make informed choices and reduce health inequities. Prior research has indicated that the provision of educational resources to the population can lead to enhanced health literacy, which is linked to better health outcomes [136]. Data from this review suggest that the lack of menstrual knowledge before menarche has impact on emotional/mental health [66, 111], findings that are consistent with previous evidence [23, 44, 137]. Interestingly, two studies [83, 102] in our review indicate the opposite relationship: adolescent girls with more menstrual knowledge experience higher levels of anxiety/stress. This finding raises an important question regarding the role of information, as it may suggest that excessive information, contradictory messages, or inappropriate methods and formats for conveying information could contribute to a more overwhelming experience and a detrimental impact. As other research has pointed out, menstrual education should be integrated into the school curriculum before menarche and consider the diversity of menstrual experiences of women and PWM students [45, 138]. Menstrual education should be adapted to the context and needs of individuals and should extend beyond the adolescent/school population to include the adult population, and also men and people who do not menstruate [139].

Access to healthcare is determined by several factors, all of which have an impact on health equity: socioeconomic status, education, health literacy, the availability of healthcare professionals and facilities, geographic location, government regulations and healthcare funding [140]. It is worth empathising that the structure and access to healthcare systems differs across countries (e.g. in the services offered, the cost of healthcare to users, etc.). This has an inevitable impact on increasing health inequities, through the differential access to health care systems depending on factors such as gender, race, ethnicity, administrative status, or social class of individuals and communities [141–143]. In this review, the inadequate access to healthcare and assistance for menstrual-related conditions (e.g. primary dysmenorrhea) among women and PWM is described as having an impact in emotional health [55, 56, 82, 99]. Other articles have also identified this issue amongst women living with endometriosis, which is linked to a long process of diagnosis that exacerbates discomfort and contribute to anxiety or depression [144, 145]. Many of these conditions lack specific treatments, in part because of androcentrism in health sciences [125], leading to the reliance on painkillers and hormonal contraceptives [45, 146, 147]. However, it is important to highlight the pathologisation of some menstrual experiences guided by a hegemonic biomedical approach [36, 126, 127], leading to an over-medicalisation of some women and PWM. Both the dismissal from healthcare providers– downplaying the severity of symptoms– and the scarcity of solutions offered may foster the avoidance of healthcare facilities [56, 148]. It is also important to emphasise the lack of training for healthcare professionals beyond the hegemonic biomedical model, which also has an impact on their ability to respond to these menstrual needs. In order to improve both menstrual health and the emotional/mental health of women and PWM, it is essential that healthcare services become more sensitive, accessible and depathologising.

More than half of the included studies are focused on menstrual management, revealing that this is one of the most addressed themes concerning menstruation. Consistent with the findings presented in this review, numerous studies have shown that inadequate menstrual management practices (e.g. using unclean menstrual products, prolonged use of menstrual products, inadequate access to sanitation facilities, etc.) are associated with an increased prevalence of RTIs [108]. In addition, the lack of adequate spaces for menstrual management can have a significant emotional impact on women and PWM. Although menstrual management studies approach a wide variety of aspects (access, type and frequency of change of menstrual products, or access and status of menstrual management facilities) in relation to health outcomes (e.g. RTIs), some of them largely fail to address the deeper structural factors that underlie these relationships. These structural determinants may include socioeconomic status and political instability and violence in some contexts (e.g. studies centred in menstrual management in refugee settlements). Furthermore, poverty and economic instability do not only restrict access to menstrual products but also exacerbate other health disparities. Similarly, political instability can hinder the development of sustainable menstrual management facilities, disproportionately affecting vulnerable populations by limiting their access to the essential resources for safe and healthy menstrual management [149].

Some studies have highlighted the impact of menstrual poverty on mental health (e.g. depression) [63, 77, 78, 89]. In addition, the impact of menstrual poverty on emotional health has been recognised, particularly during the COVID-19 pandemic. It is important to mention that menstrual poverty encompasses not only the access to menstrual products, but also broader issues like economic challenges and social vulnerability [150]. It is imperative that efforts to address menstrual poverty extend beyond merely providing access to menstrual products, taking into account the underlying socioeconomic vulnerabilities that significantly affect emotional health [150]. For instance, the decrease in emotional and mental well-being is often linked to inadequate living conditions and housing insecurity. Furthermore, it is crucial to acknowledge that menstrual poverty is a gendered issue, with women and PWM bearing a disproportionate burden due to systemic gender inequities, which in turn intensify their experiences of poverty [151].

Menstrual taboo and stigma, and their impact on emotional health, are widely reported in several studies [53, 54, 65, 70, 71, 73, 76, 78, 80, 100, 111, 116, 119, 120, 123]. Menstrual-related stigma is found across different regions and reveal outcomes such as fear of leakage or body odour, embarrassment to talk about menstruation with male teachers or peers, and fear of being teased or harassed due to menstruation. It is essential to recognise that menstrual taboos and stigma are rooted and maintained by gender inequities [34, 152, 153], and deepened in intersecting inequities based on race, social class and other SDH. Menstruation has generally been socially constructed as an invisible experience, which contributes to maintaining the silence, stigma and discrimination against women and PWM, and disregarding the consequent health impacts [10, 154].

On the other hand, this review’s findings also emphasize the health impacts on social and community participation [54, 55, 58, 67, 69, 92, 100, 104, 109, 111, 113, 114, 120, 123]. The role of cultural and societal values (e.g. Chhaupadi), a structural social determinant, is key in the results of this review, as it appears to have an impact on RTI prevalence and emotional health. This is consistent with previous research that has pointed out that marginalization and social exclusion have an influence on health. For instance, individuals experiencing marginalization often lack the resources needed to engage in community health, which in turn may exacerbate health disparities [155]. Fostering community engagement to build awareness and provide support systems that can improve health outcomes and strengthen social cohesion, thereby preventing social exclusion due to menstruation.

Limitations

Some limitations can be acknowledged from this study. Only two databases (Scopus and PubMed) were used to perform the searches, thus potentially leaving out important and relevant research. However, it is important to note that these two databases are the most widely used in the academic community. Another limitation is that review follows a scoping review methodology rather than a systematic review, which may also have resulted in the omission of some relevant studies. However, the selection of a scoping review is well-suited to the exploratory nature of this subject, as it permits greater flexibility in mapping and synthesising the emerging results. The integration in the review of both qualitative and quantitative studies, with diversity of samples (e.g. in ages, context) may limit the overall generalisability of the review. Nevertheless, the combination of methodologies permits the acquisition of a more comprehensive range of perspectives and evidence of the phenomenon of study. Lastly, the quality of some included articles is relatively weak, which may have an impact on the results presented. Given the relative novelty of the topic, the number of available studies is limited. It is therefore necessary to include these articles to provide an initial overview of the research field. Furthermore, the studies included in this review explicitly linked dimensions of MI with health outcomes. This has led to the exclusion of relevant and critical research in the menstrual field that did not address health outcomes. This underscores the necessity for future research that incorporates the assessment of health impacts.

Implications for research and policy

This scoping review underscores gaps in research on various aspects of MI and the impact on health outcomes. As discussed above, much of the existing literature primarily focuses on menstrual management. Other aspects that impact MI (e.g. menstrual education) are important to study with the lens of SDH and its relationship with outcomes in health. While there is a need for further research on the relationships between MI and emotional/mental health and RTIs, our review also suggests that more research is needed to investigate the relationship between MI and other potential health outcomes. Moreover, future research should delve deeper into the role of SDH, such as socioeconomic status, racism, administrative status, or gender identity, which can all shape MI and intersect with the relationship with health outcomes. It is therefore necessary that future research, policy and practice are approached from an intersectional perspective. In this sense, it is crucial to examine culturalist practices and the impact of coloniality on knowledge production, practice and policy. Furthermore, it is essential for future studies to directly address the health impacts of MI, as this relationship sometimes is not the primary focus of many studies. Indeed, it would be valuable for future research to explore the intersections and interactions among different dimensions of MI and how they can influence health outcomes. Deepening the scope of inquiry will provide a more comprehensive understanding of how menstruation-related inequities influence health. Additionally, future research should assess the effectiveness of interventions aimed at reducing MI and improving health outcomes, as evaluating such interventions can offer evidence-based insights for policymakers and practitioners seeking to address this issue. Future policies should be guided by research and consider the specific contextual factors of the populations they aim to serve. These policies should take a multifaceted approach, addressing various dimensions of MI rather than focusing on a single aspect (e.g. menstrual management). Policies must also integrate menstrual health needs into national health and gender equity agendas, ensuring that healthcare resources are distributed equitably to meet the diverse needs of women and PWM.

Conclusions

This scoping review presents an overview of the evidence available concerning the relationship between MI and health outcomes, based on a SDH framework. Many studies were concentrated on the menstrual management area and health outcomes like RTIs and emotional/mental health. It is imperative to pursue studies that more comprehensively elucidate the relationship between MI and health outcomes, as well as to investigate all potential determinants of MI through an intersectional perspective. Furthermore, this review proposes the challenge of setting aside culturalist views in menstrual research. Besides, it would be beneficial to map out a more exhaustive range of potential health outcomes (beyond emotional/mental health and RTIs) that may be associated with MI. Longitudinal studies could provide insights into the long-term health impacts of menstrual inequity. In addition, future studies should focus on better conceptualising the terminology and instruments used for assessing menstrual health and inequities, to improve the quality of menstrual research production. This research also contributes to our understanding of the impact of MI on the health of women and PWM. It is therefore vital that this relationship is translated into policymaking and healthcare professional practices. Current and future research in the field of menstruation should inform the development of evidence-based policies and community actions. In this sense, policies and community actions need to be implemented at different levels and can be carried out not only in school settings or the healthcare system but also at the community level. Furthermore, future research would benefit from adopting participatory designs and equitable collaborations, particularly when conducting research from the Global North in the Global South.

Electronic supplementary material

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Abbreviations

HMB

Heavy menstrual bleeding

MI

Menstrual inequities

PMS

Premenstrual syndrome

PWM

People who menstruate

RTIs

Reproductive tract infections

SDH

Social determinants of health

UK

United Kingdom

US

United States

UTIs

Urinary tract infections

Author contributions

A.G.E.: Conceptualization, Investigation, Formal analysis, Writing– original draft; G.P.D.: Conceptualization, Investigation, Formal analysis, Writing– original draft; A.B.H.: Conceptualization, Investigation, Formal analysis, Writing– original draft; A.S.H.: Conceptualization, Investigation, Formal analysis, Writing– review & editing; C.J.A.: Conceptualization, Methodology, Formal analysis, Writing– review & editing; L.M.P.: Conceptualization, Methodology, Investigation, Formal analysis, Funding acquisition, Project administration, Supervision, Writing– original draft.

Funding

The project received a research grant from the Carlos III Institute of Health, Ministry of Economy and Competitiveness (Spain), awarded on the call for the creation of Health Outcomes-Oriented Cooperative Research Networks (RICORS), with reference RD21/0016/0029 (Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS)), co-funded with European Union– Next Generation EU funds. The funders had no role in the development of the study and this manuscript.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The study was approved by the ethics committee of the Institut de Recerca en Atenció Primària Jordi Gol i Gurina (IDIAPJGol) (Research Institute in Primary Health Jordi Gol i Gurina). Ethical approvals were obtained on 2nd of June 2022 (REF. 19/178-P). All activities included in the study were carried out according to existing guidance in ethics as indicated in the Universal Declaration on Bioethics and Human Rights adopted by UNESCO (19/10/2005); the Council of Europe Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine (1997) and its additional protocol on biomedical research (2005); the Helsinki Declaration (2013) and relevant EU laws (European Parliament and Council Directive 2001/20/EC); the Spanish Law on Biomedical Research (14/2007) and the LOPD (Spanish Law on Personal Data Protection) (3/2018).

Consent for publication

Not applicable.

Competing interests

The authors declare having recently received funds from DIM Protect to support the team’s research on equity and menstrual health in Spain. DIM Protect was not involved in the conceptualization or development of this study. The authors declare no other conflict of interest.