Mindsets and menses: decoding young women’s attitudes towards menstrual leave – an observational study from South India

Abstract

Objective

The primary objective of this study is to investigate the perceived need and attitudinal perspectives regarding menstrual leave policies among young women in rural South India. The secondary objective was to determine the socio-demographic, menstrual and workplace-related factors associated with attitudes towards menstrual leave among young women.

Design

An analytical cross-sectional study was performed from May 2023 to August 2023.

Setting

In a rural district of Tamil Nadu, South India.

Participants

The study encompassed 955 young female students above 18 years of age enrolled in educational institutions in a rural district of Tamil Nadu, India. Participants were pursuing diverse professional programmes including medical, dental, allied health sciences, pharmacy and engineering courses.

Outcome measures

The primary outcomes included assessment of basic menstrual characteristics (age of menarche, regularity, product usage and pain experiences), pain evaluation using the WaLIDD scale (which measured working ability, anatomical pain location, pain intensity via Wong Baker scale and pain duration) and attitude assessment through a 10-dimension Likert scale. The attitude assessment explored both supportive factors (pain management, environmental considerations, medical leave allocation, menstruation normalisation and performance impact) and potential concerns (medicalisation, perceptions of fragility, stigma, disclosure issues and abnormal leave usage). Secondary outcome measures encompassed the analysis of factors influencing these attitudes, followed by a multivariable linear regression model to identify significant predictors.

Results

Among 955 female students (mean age 19.56±1.33 years), the majority supported menstrual leave for maintaining hygiene (82.3%) and managing dysmenorrhoea (75.8%). A substantial proportion (64.4%) viewed it as a means of normalising menstruation discourse, while 61.6% believed it could enhance workplace performance. However, concerns existed about medicalising menstruation (47.9%) and reinforcing gender stereotypes (43.4%). Multivariate analysis revealed that medical students (B=0.67, 95% CI: 1.34 to 2.00), those with graduate-educated fathers (B=1.64, 95% CI: 0.31 to 2.97), earlier age at menarche (B=−0.23, 95% CI: −0.45 to –0.01) and participants reporting menstrual interference with daily activities (B=0.96, 95% CI: 0.02 to 0.89) held significantly more positive attitudes.

Conclusion

While young women generally support menstrual leave policies, particularly for hygiene and pain management, there are significant concerns about workplace stigmatisation and gender stereotyping. Educational background, parental education and personal menstrual experiences significantly influence attitudes toward menstrual leave. These findings suggest the need for carefully structured menstrual leave policies that balance biological needs with workplace/student place equality concerns.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Comprehensive assessment approach using validated tools (WaLIDD scale) and a well-structured questionnaire covering multiple dimensions of menstrual attitudes.

• Novel bi-dimensional attitude assessment framework that captures both supportive factors and potential concerns, providing a balanced perspective on menstrual leave policies.

• Diverse study population including students from various professional backgrounds (medical, dental, allied health sciences, pharmacy and engineering), allowing for comparative analysis.

• Study population limited to students (mean age 19.56 years) excludes working women’s perspectives, who might have different experiences and attitudes toward menstrual leave.

• Self-reported data may be subject to social desirability bias, particularly given the sensitive nature of menstruation-related topics.

Introduction

Menstruation is a natural biological process experienced by women, often accompanied by physical discomfort and emotional challenges. While many women can manage their menstrual symptoms without significant disruption, others face dysmenorrhoea, menorrhagia, fatigue, weight gain, headaches, nervousness, irritability, mood swings and stress that affect their personal studies and academic performances.¹ Women face difficulties not only with their menstrual symptoms but also with the lack of proper water, sanitation and hygiene facilities (WASH). Women who have atypical menstruation and are working frequently endure pain to the point that they are unable to execute their tasks.^{2 3} This can be considered as a minor reason for sickness presenteeism, which is defined as ‘when an employee/worker goes to work despite feeling so ill that he or she judges that sick leave would have been proper’.⁴ Even though menstruation cannot be considered as sickness, the poor health and increased demand of attendance requirement among the young population makes them to be available even without their ‘utmost’ health. (And increased demand for rest at the comfort of home is needed for the women, during the initial days of the start of menstruation, especially among younger girls and working women). Achieving good menstrual health or menstrual hygiene management requires individuals to have comprehensive resources including information, supplies, adequate sanitation facilities, supportive environments with sensitised supervisors and educators and accessible healthcare workers trained in menstrual health disorders. The integration of WASH facilities with menstrual health management is particularly crucial, as millions of women and girls worldwide experience period poverty characterised by limited access to period products, menstrual education and adequate WASH facilities.^{5 6}

India’s menstrual health landscape has undergone significant transformation over the past two decades through comprehensive policy initiatives, with government programmes including the integration of menstrual health into Accredited Social Health Activist roles (2005–2010), the Menstrual Hygiene Scheme (2010) and various educational initiatives under Samagra Shiksha Abhiyan collectively increasing menstrual product usage from 15% in 2010 to 78% in 2019–2021. However, analysis of National Family Health Suvey-5 data reveals persistent challenges across affordability, accessibility and sociocultural barriers, with approximately 80% of women with no schooling still using cloth compared with 35% with higher education, and significant educational disruption continuing due to inadequate menstrual health infrastructure in schools.⁷,⁹

Research demonstrates that 40% of girls remain absent from school during menstruation due to inadequate facilities, lack of privacy, cultural restrictions and insufficient maternal education, while physical and emotional symptoms including irritability, headaches and body pain create functional impairments affecting nearly half of students’ academic efficiency. Although premenstrual syndrome affects approximately one-third of young women and dysmenorrhoea impacts working ability in over half of affected individuals, actual absenteeism rates vary significantly, with some studies showing only 12% missing classes while others report 65% experiencing disrupted activities, missed tests and absences due to pain, anxiety, shame and concerns about leakage.¹⁰,¹⁵ This research underscores that menstruation’s impact extends beyond physical discomfort to encompass broader issues of educational access, academic achievement and social participation, highlighting the need for comprehensive approaches addressing both physiological and sociocultural dimensions of menstrual health in educational and workplace contexts.

In response to these documented challenges, menstrual leave as a policy presents a complex duality of benefits and concerns. While its primary goals are to alleviate the physical and psychological discomfort that many women experience during their periods and to help eliminate stigma by recognising menstruation as a valid reason for absence, the policy implementation raises important considerations. Menstrual leave provides women with opportunities to prioritise self-care, manage their symptoms effectively and maintain their overall well-being.^{16 17} However, granting leave during menstruation may disrupt regular academic schedules, leading to missed classes and practical work, potentially reducing productivity in educational institutions and companies. It could create logistical challenges for teachers, institutions and companies in managing absences and scheduling makeup sessions, while potentially causing manpower shortages. Moreover, if not implemented properly, it may inadvertently reinforce gender stereotypes and discrimination, perpetuating the notion that menstruation is a weakness or an obstacle to be overcome. Striking a balance between supporting students’ well-being, work productivity and ensuring academic continuity and completion of work schedules is crucial when considering leave during menstruation.¹⁸

Several states in India, like Kerala, Bihar, Assam and a few Northeastern states, have initiated the menstrual leave policy for their young people either fully or partly in some institutions.¹⁹,²¹ Also, the Indian parliament is trying to enforce a bill which provides paid menstrual leave and access to menstrual hygiene products in a better way.^{22 23} Several nations, including South Korea, Indonesia, Taiwan, Japan and Zambia, permit women and females to take period breaks at work. Japan provides options to take time off during their periods, which is a part of the Labour Standards Law of 1947, where any woman employee can take time off if one of the two circumstances applies: either she is experiencing severe menstrual pain and finds it difficult to work, or the work is harmful to her when she is menstruating. Some nations have begun to create programmes to assist women who are on menstrual leave to address the difficulties. This entails offering menstrual products in the workplace, giving flexible work schedules and enabling menstrual leave to be taken without embarrassment or prejudice.²⁴,²⁷

Despite the absence of comprehensive national legislation on menstrual leave in India, emerging state-level policies and private sector initiatives reflect a growing recognition of the need for menstrual health accommodations in educational and workplace settings. In societies where menstruation remains shrouded in stigma and taboo, young women’s attitudes toward menstrual leave reflect deeply embedded cultural norms that can either perpetuate or challenge existing inequalities. In educational settings, female students face unique menstrual health management challenges that directly impact their educational participation and academic performance. Unlike workplace environments where formal regulations may exist, educational institutions often lack comprehensive policies addressing menstrual needs, creating significant barriers to full participation in academic life. Students encounter multiple interconnected challenges: limited access to appropriate sanitation facilities in educational institutions, inadequate privacy for menstrual management during school hours, lack of supportive environments from teachers and peers, educational disruption due to menstrual-related absences and persistent stigma and taboos surrounding menstruation discussions in academic settings. Understanding these perceptions is essential for developing culturally sensitive policies that women will use rather than avoid due to shame or fear of discrimination, and for crafting policies that promote rather than hinder women’s full participation in educational and professional spheres. So, the study aims to assess the need for menstrual leave policies and prevailing attitudes, among young females in a rural district of South India.

Methodology

Study design and study duration

An analytical cross-sectional study was conducted for a period of 3 months, from May 2023 to August 2023.

Study population

The study population consists of female students enrolled in educational institutions (colleges and universities) in a rural district in South India. The sample included students aged >18 years, different educational levels and those who are providing consent.

Sample size and sampling technique

According to the Jessica L Barnack-Tavlaris et al study,²⁸ the sample size was calculated with the proportion of subjects whose menstrual leave policy benefits the menstruators in the workplace and using the formula n=Z²_1-α/2 pq/d²(Z1-α/2=1.96, p=18, q=72.9, d=absolute precision=3), the final sample size came up to 630. We have collected a total sample size of 955.

The study employed a convenience sampling method to gather data from female students enrolled in various educational institutions affiliated with a tertiary medical college in rural Tamil Nadu, India. The study population comprised young women pursuing diverse professional programmes, including medical, dental, allied health sciences, pharmacy and engineering courses. To ensure comprehensive data collection, the investigators made initial contact with all eligible participants during the designated study period. In cases where participants were unavailable during the primary data collection phase, follow-up sessions were scheduled to maximise participation rates.

Study tool

The objective of the study was met with a semi-structured questionnaire. The questionnaire was self-administered and consisted of four sections.

• The first section is the socio-demographic details, consisting of age, degree, education of the mother, education of the father, occupation of the mother, occupation of the father, type of family and marital status.

• The second section is an assessment of the basic characteristics of the menstrual cycle, consisting of the age of menarche, regularity of menses, types of menstrual products used, pain during menstruation and difficulties faced during menstruation.

• The third section is the assessment of pain during menses, which was assessed using the WaLIDD scale.²⁹ The scale consists of working ability, anatomical pain location, pain intensity (Wong Baker) and days of pain. The score is a 3-point Likert scale. The scores were summed, with a score of 0 (no dysmenorrhoea), 1–4 (mild dysmenorrhoea), 5–7 (moderate dysmenorrhoea) and 8–12 (severe dysmenorrhoea) and habits of taking medication.

• The fourth section of our study focuses on assessing attitudes towards menstrual leave. We employed a multifaceted approach to capture the nuances of these attitudes:

• Attitude assessment: we used a Likert scale to measure attitudes across 10 key dimensions. These dimensions were carefully selected to encompass both supportive and potentially sceptical viewpoints on menstrual leave. Single-item questions were used to gauge opinions on well-being rooms and the perceived necessity of menstrual leave. Key dimensions explored: the 10 dimensions assessed can be categorised into two groups:

  • Supportive factors:

    • Pain management.

    • Environmental and hygiene considerations.

    • Medical leave allocation.

    • Normalisation of menstruation.

    • Performance impact.

  • Potential concerns:

    • Medicalisation of menstruation.

    • Perceptions of fragility.

    • Stigma.

    • Disclosure issues.

    • Concerns about abnormal leave usage.

    • Perceptions of fragility.

    • Stigma.

    • Disclosure issues

    • Concerns about abnormal leave usage.

The study employed a strategic coding system to quantify attitudes: supportive factors were coded positively: strongly agree (5), agree (4), neutral (3), disagree (2), strongly disagree (1). Potential concerns were reverse-coded to maintain consistency in interpretation. Individual scores were aggregated to produce a final attitude score. Higher scores indicate more favourable attitudes towards menstrual leave. To determine the most influential factors shaping attitudes, calculated a weighted score for each question: maximum possible score per question: 4775 (955 respondents×5 maximum points). Actual scores were computed by multiplying response frequencies by their respective weights. Factors were then ranked based on their total weighted scores to identify those contributing most significantly to overall attitudes towards menstrual leave.

The questionnaire underwent rigorous validation through a pilot study conducted among 20 medical students prior to the main data collection phase. This preliminary testing revealed a Cronbach’s alpha coefficient of 0.78, indicating strong internal consistency among the questionnaire items, while also confirming the feasibility of the self-administered format and reproducibility of questions through test–retest reliability measures. The pilot study findings informed refinements to the final questionnaire design, including clarification of ambiguous wording in attitude statements, adjustment of response formats for better comprehension and sequencing of questions to get maximum response. The study is described in line with the Strengthening the Reporting of Observational Studies in Epidemiology checklist (online supplemental file 1).

Statistical analysis

The study used Google Forms for data collection, leveraging its accessibility to maximise response rates. The collected data was initially processed in Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA) before being analysed using SPSS V.26 (IBM, Armonk, New York, USA). The study presented a comprehensive overview of the data through descriptive statistics, including frequencies, proportions, percentages, means and SD. Pearson correlation coefficients assessed linear relationships between continuous variables (age and age at menarche) and attitude scores to understand how these factors correlate with menstrual leave perspectives. Independent t-tests compared mean attitude scores between binary categorical variables (medical vs non-medical students, regular vs irregular cycles) to identify significant differences in attitudes across these characteristics. One-way analysis of variance examined multi-category variables (parental education, occupation, family type, dysmenorrhoea severity) to determine whether attitude scores varied significantly across different levels, with post hoc Tukey tests identifying specific group comparisons when overall significance was detected. To identify the most influential predictors of menstrual leave attitudes while controlling for confounding variables, a multivariable linear regression model was constructed. This model included variables demonstrating associations with p values<0.10 from the univariate analysis, with results expressed using B coefficients and 95% CIs.

Results

The study was done among 955 female subjects. The mean (SD) age was 19.56 (1.33) years, minimum age was 18 and maximum was 25 years. In the study, most of the subjects, 343 (35.9%) belonged to medical/dental courses, 239 (25%) from allied sciences/pharmacy, 163 (17.1%) and 210 (22%) pursuing non-medical courses. The other socio-demographic details are put up as table 1.

Table 1. Socio-demographic characteristics of the study participants.

Variables		n (%)
Father education	Graduate	365 (38.2)
	School	504 (52.8)
	No formal education	86 (9)
Mother education	Graduate	349 (36.5)
	School	511 (53.5)
	No formal education	95 (9.9)
Father occupation	Stable	306 (32)
	Unstable	628 (65.8)
	Unemployed	21 (2.2)
Mother occupation	Stable	215 (22.5)
	Unstable	233 (24.4)
	Unemployed	507 (53.1)
Family type	Nuclear family	701 (73.4)
	Joint family	254 (26.6)
Marital status	Married	17 (1.8)
	Unmarried	931 (97.5)
	Other	7 (0.7)

Figure 1 showed the sanitary products used during menstrual cycle by the subjects. In the study, 92.3% are currently using disposable sanitary pads, 3.2% a piece of clean cloth, 2.1% menstrual cups and 13% tampons.

Figure 1. Sanitary products used during menstrual cycle.

In the study, the mean (SD) age of menarche among subjects was 13.13 (1.21) years, 784 (82.1%) subjects had regular periods and 601 (62.9%) subjects had periods for ≤5 days. In the study, 178 (18.6 %) subjects reported that the menstrual cycle had never affected their daily routine, 630 (66%) reported sometimes and 147 (15.4%) as always. Figure 2 showed the occurrence of pain days experienced by the subjects. In the study, 5.5% reported to always have nil pain on any days, and 52.6% with pain always during the first day of cycle. Figure 3 showed the degrees of dysmenorrhoea based on WaLIDD score. In the study, 470 (49.2%) had severe dysmenorrhoea. Figure 4 showed the intake of medication during the cycle with specific days of cycle.

Figure 2. Pain experienced by the participants on the menstrual cycle.

Figure 3. Degrees of dysmenorrhoea based on WaLIDD score.

Figure 4. Intake of medication during the menstrual cycle.

Table 2 showed the factors with respect to menstrual leave. The study revealed that among the participants, 626 (65.5%) reported never having taken leave during their menstrual cycles. Furthermore, 521 (54.6%) expressed a preference for menstrual leave policies over the provision of well-being rooms. Additionally, 33.2% of respondents advocated for the allocation of two menstrual leave days per month. The mean (SD) attitude score was 32.88 (4.39) with a minimum score of 22 and maximum of 50.

Table 2. Factors regarding menstrual leave.

Variables		N (%)
Leave taken during menses	>5 days	22 (2.3)
	1–2 days	236 (24.7)
	3–5 days	71 (7.4)
	Nil	626 (65.5)
Response towards well-being rooms instead of menstrual leave	Menstrual leave is best option	521 (54.6)
	Clean bathrooms	84 (8.8)
	Clean bathrooms and menstrual leave	240 (25.1)
	Well-being rooms better than menstrual leave	110 (11.5)
Colleagues construct women’s behaviour differently and more negatively	Agree	657 (68.8%)
	Disagree	298 (31.2)
Discussed about menstrual-related problems to male relatives	Yes	555 (58.1)
	No	400 (41.9)
Requirement of menstrual leave	1 day/month	204 (21.4)
	2 days/month	317 (33.2)
	3 days/month	306 (32)
	0 days	128 (13.4)
Requirement of menstrual leave to be paid	Yes	652 (68.3)
	No	303 (31.7)
Awareness of menstrual leave in abroad countries	Yes	674 (70.6)
	No	281 (29.4)
Awareness on ‘The Menstruation Benefits Bill, 2017’	Yes	530 (55.5)
	No	425 (44.5)

Figure 5 showed the various attitude responses towards menstrual leave in the study. The topmost factors influencing participants’ attitudes towards menstrual leave were multifaceted. Foremost among these was the recognition of menstrual leave’s potential to ensure a hygienic environment during menstruation, addressing the practical needs of menstruating individuals. Second, participants valued the policy’s ability to help women cope with dysmenorrhoea, acknowledging the physical discomfort many experience during their menstrual cycles. Lastly, respondents appreciated menstrual leave’s role in normalising discussions about menstruation, viewing it as a step towards destigmatising a natural biological process in societal discourse.

Figure 5. Attitude towards menstrual leave among subjects.

The most agreeable response to have a clean environment for hygiene during initial days (82.3% agree/strongly agree) and to cope with initial day pain (75.8% agree/strongly agree). In the study, 64.4% agree/strongly agree to normalising or neutralising the topic of menstruation. Many respondents (61.6%) believe menstrual leave could increase women’s performance in the workplace or student life. Also, 52.7% agreed that menstrual leave might be used to reserve medical leave for non-menstrual health conditions. The study showed 47.9% agree/strongly agree to the concept that menstrual leave medicalises menstruation as ‘debilitating’, 43.1% that leave projects females as less suitable for prominent positions. And 43.4% that menstrual leave affirms views of female fragility and inferiority. In the study, 44.4% of respondents believed menstrual leave could lead to stigmatisation through disclosure, a slightly higher percentage (49.63%) viewed it to avoid uncomfortable questions about menstruation.

Table 3 showed the various correlates of menstrual leave attitude score and the regression model predicting the adjusted independent factors. The primary analysis was carried out to assess the association of different demographic and menstrual cycle-related variables with attitude towards menstrual leave. Age showed a positive correlation (r=0.36, p=0.03) with more favourable attitudes, suggesting older individuals tend to view menstrual leave more positively. Educational background played a significant role, with medical students demonstrating more positive attitudes compared with non-medical students (p=0.001). Parental education, particularly at the graduation level and above, was strongly associated with more supportive views on menstrual leave (p<0.001 for both father’s and mother’s education) (post hoc Tukey test: father’s education: graduation and above, schooling (mean difference 1.85), no formal education (2.69); mother’s education: graduation and above, schooling (mean difference 2.11), no formal education (2.54)). Both maternal and paternal occupations showed significant associations with attitudes (p<0.001 for both) (post hoc Tukey test: father’s occupation: stable occupation, unstable occupation (1.19), mother’s occupation: stable occupation, unstable (1.85), unemployed (1.38)). Interestingly, earlier age at menarche correlated with more positive attitudes (r=−0.17, p=0.03). Participants who reported that menstruation always affected their daily routine held significantly more favourable views compared with those reporting no impact (p=0.003) (mean difference by post hoc Tukey test: none, always 1.27, none sometimes (1.23)).

Table 3. Linear regression model for predicting independent predictors of attitude towards menstrual leave.

Variables		Attitude towards menstrual leave Mean (SD)	Primary analysis Test value, p value	B coefficient (95% CI)
Age in years mean (SD)		0.36*, 0.03		0.06 (−0.14 to 0.28)
Course pursuing	Medical	33.1 (4.53)	9.97†, 0.001	0.67 (1.34 to 2.00)‡
	Non-medical	31.96 (3.72)
Father’s education	No formal education	31.55 (3.57)	30.46§, <0.001	1
	School	32.13 (3.62)		0.29 (−0.89 to 1.48)
	Graduation and above	34.23 (5.14)		1.64 (0.31 to 2.97)‡
Mother’s education	No formal education	31.58 (3.29)	24.06§, <0.001	1
	School	32.27 (3.91)		0.21 (−0.94 to 1.34)
	Graduation and above	34.12 (4.99)		0.92 (0.36 to 2.21)
Father’s occupation	Unemployed	32.33 (4.48)	7.85§, <0.001	1
	Unstable	32.50 (4.17)		−0.27 (−2.14 to 1.59)
	Stable	33.69 (4.71)		−0.08 (−2.01 to 1.86)
Mother’s occupation	Unemployed	32.68 (4.31)	11.52§, <0.001	1
	Unstable	32.21 (3.99)		−0.05 (−0.73 to 0.63)
	Stable	34.07 (4.78)		0.38 (−0.39 to 1.15)
Family type	Nuclear family	32.87 (4.29)	2.88†, 0.090	1
	Joint family	32.89 (4.67)		−0.05 (−0.66 to 0.57)
Age at menarche mean (SD)		−0.17, 0.03 #		−0.23 (0.45 to 0.01)‡
Regularity of cycles	Irregular	32.83 (4.55)	0.8†, 0.12	–
	Regular	32.89 (4.36)
No. of days/cycle	>5 days	32.77 (4.67)	1.99†, 0.16	–
	≤5 days	32.94 (4.22)
Sanitary products using	Cloth/sanitary pads	32.88 (4.39)	0.49§, 0.60	–
	Tampons	33.26 (4.96)
	Menstrual cup	31.60 (3.13)
Affecting daily routine by menstrual cycle	None	31.87 (3.59)	5.83§, 0.003	–
	Sometimes	33.10 (4.47)		0.77 (0.05 to 0.98)‡
	Always	33.14 (4.76)		0.96 (0.02 to 0.89)‡
Reported leave taking during cycle	Yes	33.06 (4.81)	10.75†, 0.36	–
	No	32.79 (4.15)
Degree of dysmenorrhoea	No dysmenorrhoea	32.47 (4.17)	1.54§, 0.19	–
	Mild dysmenorrhoea	32.87 (4.41)
	Moderate dysmenorrhoea	33.20 (4.54)
	Severe dysmenorrhoea	3212 (3.78)

^*Pearson correlation coefficient.

^†Independent t-test, table value.

^‡Significant p value<0.05.

^§One-way analysis of variance test, table value.

However, factors such as family type (p=0.090), menstrual cycle regularity (p=0.12), duration of menstruation (p=0.16), type of sanitary products used (p=0.60), reported leave-taking during cycle (p=0.36) and the degree of dysmenorrhoea (p=0.19) did not show statistically significant associations with attitudes towards menstrual leave. Independent factors in the primary analyses (ie, those with p<0.10) were then entered into a multivariable linear regression model with a stepwise selection procedure to identify independent risk factors. The menstrual leave attitude score was regressed on predicting variables like age, father/mother education, father/mother occupation, family type, affecting daily routine and age at menarche. The overall regression model was statistically significant, and the independent variables significantly predict menstrual leave attitude score, F(14,940)=6.57, p value<0.001. It showed an R² value of 0.30, which implies that the age, father/mother education, father/mother occupation, family type affecting daily routine and age at menarche accounted for 30% of the variation in menstrual leave attitude score.

Medical students had a significantly more positive attitude towards menstrual leave compared with non-medical students (B=0.67, 95% CI: 1.34 to 2.00). Participants whose fathers had graduation-level education or above showed significantly more positive attitudes compared with those whose fathers had no formal education (B=1.64, 95% CI: 0.31 to 2.97). An earlier age at menarche was associated with more positive attitudes towards menstrual leave (B=−0.23, 95% CI: −0.45 to –0.01). Participants who reported that menstruation sometimes (B=0.77, 95% CI: 0.05, 0.98) or always (B=0.96, 95% CI: 0.02, 0.89) affects their daily routine had significantly more positive attitudes compared with those reporting no impact.

Discussion

This study addresses young women’s attitudes towards menstrual leave policies, revealing both strong support for accommodating menstrual health needs and significant concerns about potential negative consequences.

Menstrual cycle-related findings

The study was conducted among 955 female subjects with a mean age of 19.56 years (SD=1.33). In the study, 99.6% reported to be suffering from dysmenorrhoea, 65.5% of participants reported never having taken leave during their menstrual cycles, yet 54.6% expressed a preference for menstrual leave policies over well-being rooms.

A systematic review showed the prevalence of dysmenorrhoea was 71.1%, regardless of the country’s economic condition and that dysmenorrhoea significantly impacts academic performance in both primary and higher education.³⁰ In the study, with 99.6% reporting dysmenorrhoea, and 65.5% of participants reporting never having taken leave during their menstrual cycles, this likely reflects presenteeism rather than absence of symptoms, as participants still experienced significant functional impairment during menstruation. This finding suggests that many young women continue attending classes or work despite experiencing pain and discomfort, potentially compromising their performance and well-being. The high prevalence of dysmenorrhoea, combined with the fact that participants who reported menstruation affecting their daily routine held significantly more favourable views towards menstrual leave, indicates that symptom severity directly influences policy preferences. In a study done in Australia, 72.41% reported being likely to use paid menstrual leave if it is available.³¹ Also, other reports have shown that more than 75% women supported menstrual leave in the workplace.^{32 33} In our study, 68.3% have suggested the menstrual leave needs to be paid, and 317 (33.2%) suggested at least 2 days leave per month. Another study showed (that those subjects who) advocated for yearly menstrual leave largely wanted 12 days per year, while those favouring a monthly frequency primarily preferred 2–3 days per month.³¹ A study conducted in India revealed that a majority of respondents (59.2%) supported the inclusion of menstrual leave under ‘Basic Human Rights’. This perspective stemmed from the recognition that menstruation is an integral part of women’s lives, suggesting that accommodating this biological process is fundamental to ensuring women’s rights and well-being in the workplace.³⁴

Menstrual leave impacts

In this study, respondents strongly supported menstrual leave for maintaining hygiene (82.3%) and managing pain (75.8%). A majority (64.4%) viewed it to normalise menstruation, and 61.6% believed it could enhance women’s workplace performance. These findings highlight menstrual leave as an essential policy intervention for advancing gender equality in educational and professional environments, providing necessary support that recognises women’s physiological needs while ensuring equitable opportunities for academic and career advancement. In a thematic analysis done in America investigating attitudes towards paid menstrual leave, respondents reported both positive effects and concerns. Positive aspects included allowing women to care for their health and well-being, potentially protecting those who already miss work during menstruation.²⁸ A large-scale survey in the Netherlands, encompassing women workers and students, revealed that 13.8% of all women reported absenteeism during their menstrual periods, underscoring reduced presenteeism as a significant advantage of menstrual leave.³⁵ Subsequent studies have shown that women view menstrual leave to address their health needs and manage menstrual symptoms effectively. Moreover, many women reported that such policies would alleviate concerns about compromised workplace presentation due to visible menstrual staining on clothing or furniture.³⁶ Furthermore, job and financial security, as well as improved leave utilisation, were identified as benefits of menstrual leave policies that could help retain women in the workforce.³¹ This finding aligns with the theme of ‘Supporting Women and Women in the Workplace’, identified in an American thematic analysis of attitudes towards menstrual leave.³

Challenges with regards to menstrual leave

In this study, 47.9% worried it might medicalise menstruation as debilitating, 43.1% feared it could portray women as less suitable for prominent positions, and 43.4% thought it might reinforce notions of female fragility. The tension between disclosure and privacy was evident, with 44.4% concerned about stigmatisation through disclosure, while 49.63% saw it to avoid uncomfortable questioning. In a thematic analysis respondents worried about fairness to men, potential abuse of the leave system and difficulties in tracking and enforcement. Unintended effects were a significant concern, with fears that they could further stigmatise menstruation, violate women’s privacy and lead to discrimination against women. Another study emphasised that menstrual leave and associated ‘special treatment’ might inadvertently reinforce perceptions of female fragility, potentially leading to increased discrimination against women in professional settings.³⁷ A research study conducted in India revealed that over half of the participants (56%) expressed concern that implementing menstrual leave policies in educational settings could potentially lead to gender-based discrimination against male students.³⁴ The negative concerns in a study about menstrual leave showed that 20.7% perceived unfairness to men, potentially leading to hostility and controversy in mixed-gender environments. Also, 16.2% of respondents discussed the potential for inadvertent discrimination against women in hiring and promotion. Another concern was about privacy issues related to disclosing personal health information.²⁸ An Italian report had shed light on potential unintended consequences of implementing menstrual leave policies. The report suggested that enforcing such policies could have several negative impacts on workplace dynamics and gender equality. The employers might become more inclined to hire men, potentially creating an unfair advantage for male job candidates. Moreover, the policy could inadvertently reinforce harmful stereotypes about women, particularly the notion that they are more emotionally volatile or that their work performance is significantly impaired during menstruation.³⁸ Current sick leave policies typically require 3–4 consecutive days of absence to qualify for benefits, misaligning with menstrual health needs that may require 1–2 days monthly. This structural mismatch forces women to either work through debilitating symptoms or misrepresent their condition, highlighting the need for specific policy frameworks rather than relying on general sick leave provisions.^{39 40} To address these concerns, implementing confidential leave systems, remote work arrangements or adjusted schedules during menstruation, educational programmes for all staff and framing menstrual leave as a health equity rather than special treatment could help reduce stigma and privacy issues while ensuring successful policy implementation with minimised discrimination risks.

Factors influencing attitude

The study showed that a positive correlation between age and favourable attitudes towards menstrual leave suggests that as individuals mature, they may develop a more supportive stance on menstrual health policies. Also, it can be attributed to increased life experience, maturity and exposure to diverse perspectives. As individuals age, they may become more empathetic and understanding of women’s experiences, leading to a greater acceptance of menstrual leave as a necessary aspect of women’s health and well-being. Moreover, older individuals may have undergone similar experiences or witnessed the struggles of friends and family members, fostering a deeper appreciation for the importance of menstrual leave. Studies have shown that younger age girls were more supportive of menstrual leave.^{28 31 41} The difference can be attributed to the disparity in sample selection criteria, contextual difference with respect to leave policies and timing of the study.

Educational background emerged as a significant factor, with medical students demonstrating more positive attitudes compared with their non-medical counterparts (p=0.001). This disparity might be explained by medical students’ enhanced understanding of menstrual physiology and its potential impacts on daily functioning. Parental education, particularly at the graduation level and above, was strongly associated with more supportive views on menstrual leave (p<0.001 for both father’s and mother’s education). This finding underscores the potential influence of family, educational background on shaping attitudes towards gender-specific health policies. Interestingly, earlier age at menarche correlated with more positive attitudes (r=−0.17, p=0.03), which could indicate that longer experience with menstruation leads to greater appreciation for menstrual leave policies. Additionally, participants who reported that menstruation affected their daily routine held significantly more favourable views (p=0.003), highlighting the role of personal experience in shaping attitudes.

The limitation of the study is as follows: the focus on students, while providing a crucial perspective, may limit generalisability to other populations such as working professionals or individuals in different cultural contexts. The predominantly student population may not represent the diverse experiences of women across India’s varied socioeconomic and cultural landscape, while the cross-sectional design limits our ability to understand how attitudes evolve as cultural norms shift or as individuals gain more life experience with menstruation. The reliance on self-reported data introduces potential biases, as participants might respond based on social desirability or experience recall inaccuracies. Also, content validity assessment through expert panel review was not conducted during questionnaire development, which may have implications for the comprehensiveness and relevance of the attitude dimensions measured in relation to menstrual leave perspectives. Additionally, the use of Google Forms for data collection, while convenient, may have inadvertently excluded participants with limited digital literacy, potentially skewing our sample.

Despite these limitations, the study boasts several significant strengths. The study adopted a comprehensive approach, examining multiple dimensions of attitudes towards menstrual leave, which provides a nuanced understanding of this complex issue. The statistical analysis, including regression modelling, allowed for in-depth exploration of relationships and predictors. The large sample size of 955 respondents provided sufficient statistical power to detect meaningful relationships and differences. Furthermore, by addressing the emerging issue of menstrual leave, our research contributes timely and valuable insights to an important and evolving area of public health and policy.

Future studies should consider longitudinal designs to track how attitudes towards menstrual leave evolve over time, particularly as policies and societal norms change. Expanding the research to include diverse populations beyond students, such as working professionals across various sectors, would enhance generalisability. Incorporating a mixed-methods approach, with qualitative research methods like in-depth interviews or focus groups, could provide deeper insights into the reasoning behind attitudes towards menstrual leave. It would be better to develop and evaluate educational interventions aimed at addressing misconceptions and promoting positive attitudes towards menstrual leave. Conducting studies in regions where menstrual leave policies have been implemented would allow for assessment of their real-world impact on attitudes, workplace culture and menstruators’ well-being. Also, including perspectives from various stakeholders such as policymakers, employers and healthcare providers would offer a more comprehensive understanding of the challenges and opportunities in implementing menstrual leave policies. Implementing targeted menstrual health education programmes across all academic disciplines and developing family-oriented awareness campaigns could help bridge knowledge gaps and adopt more inclusive attitudes towards menstrual leave policies.

Conclusion

The study revealed a complex multifaceted nature of perceptions surrounding the topic of menstrual leave among young females. Medical students, higher paternal education and personal experiences with menstruation, like earlier age at menarche and the degree to which menstruation affects daily routines, were associated with more favourable views towards menstrual leave. Most participants recognised its potential to ensure a hygienic environment and help cope with dysmenorrhoea. Additionally, many viewed menstrual leave as a step towards normalising discussions about menstruation and potentially improving women’s performance in academic or professional settings. However, concerns about the medicalisation of menstruation and potential stigmatisation through disclosure emerged as negative views. With the world facing rapid expansion of product and service industries, coupled with the advancement in artificial intelligence technologies, the focus of the world is now on recruitment and retention of quality workforce. Providing opportunities for the physical and mental healthcare of the female workforce by providing menstrual leaves is an opportunity to develop a high quality and productive female workforce, and the authors felt this opportunity should not be missed by the rapidly expanding corporate world.

Data availability statement

Data are available upon reasonable request.