{"paper_id":"17782ca6-e8ec-4c52-95d9-59289a35d53d","body_text":"FemTech (female-focused technology designed to aid in women’s health) apps range from\nfertility-based apps for pregnancy planning and contraception, to menstrual cycle\napps for the tracking of periods and symptoms. They are a popular and\never-developing field, with more than 200 million downloads. \n 1 \n  The apps that allow the monitoring of menstrual cycles, commonly known as\nperiod tracker apps, are the fourth most popular health app among adults. \n 2 \n  Since the release of the first-ever period tracker, Glow, in 2013, the\nindustry has continuously expanded, with the FemTech market estimated to be worth\n$50 billion by 2025. \n 3\nFertility-based FemTech apps are marketed towards women wanting to know when they\nshould or should not be having sexual intercourse to achieve or avoid pregnancy. \n 4 \n  They are able to do this through user input of biological markers, described\nas fertility awareness–based methods (FABM), which predict ovulation. These markers\ninclude oral basal body temperature, cervical mucous consistency and urinary LH\nlevels, which all increase at, or prior to, ovulation. \n 4 \n  However, generally, fertility apps use a calendar-based algorithm to predict\novulation, which has been shown by various authors to be ineffective in predicting\novulation. 1 , 5\nToday, the choice of period tracker apps is vast, with 7% of the 90,088 health apps\nin the Apple store focussed on women’s health and pregnancy. \n 2 \n  However, it is important that the app a woman chooses to download provides\naccurate information, is effective in predicting her period and is beneficial to her\nlifestyle. Period tracker apps have a responsibility to users as incorrect\ninformation about the menstrual cycle could cause stress when periods are earlier or\nlater than expected, and giving incorrect information about ovulation could lead to\npregnancy or infertility.\nThere have been several studies examining women’s experience of using period tracker\napps using surveys and interviews done in Austria and Spain, \n 6 \n  the USA, \n 7 \n  Australia \n 8 \n  and New Zealand. \n 9 \n  Women report using the apps to plan and prepare for upcoming periods; verify\nmenstrual cycle experiences; inform healthcare professionals (HCPs) confidently and\nplan pregnancy and contraception. But negative effects of using period tracker apps\nhave been reported in these studies, including reports of strong emotional effects\nwhen the app presented a period start date that differed from the actual start date. \n 6 \n  This is of concern when a report regarding the quality and effectiveness of\nperiod tracker apps found many of the apps which claim to be ‘evidence-based’ were\nnot tested in trials whatsoever. \n 10 \n  This is supported by Zwingerman et al., \n 11 \n  whose appraisal of menstrual tracking apps showed 22.1% of apps to contain\nserious inaccuracies. A study by Worsfold et al. \n 12 \n  analyzed the ability of period tracker apps to accurately predict the length\nand dates of five different cycle profiles representing a range of real-life cycles.\nThey found variation between apps in their prediction of fertile days, day of\novulation and period start dates. They concluded calendar-based apps that predicted\novulation and the fertile window were giving inaccurate information. This highlights\nthe inaccuracies and potentially serious consequences of period tracker apps.\nIn the UK, regulatory efforts are being put in place by bodies with the launch of the\nNational Health Service (NHS) Health Apps Library and the National Institute for\nHealth Care and Excellence (NICE) \n 13 \n  recently releasing an Evidence Standards Framework to which health apps must\ncomply. However, a recent study concluded that most apps did not have sufficient\nevidence to meet the minimum criteria of the NICE’s framework and that apps included\nin the NHS Health Apps Library presented no more evidence than apps only found in\nthe Apple app store. \n 14 \n  This conveys the need, and also the challenges, of regulating and keeping up\nwith a constantly updating field of technology.\nThe aim of this study was to ask women about their real-life experiences of using\nperiod tracker apps, their attitudes towards using their app, the information the\napp provided regarding ovulation and how the accuracy of the app in predicting\nperiod start dates affected their feelings and behaviours. It is hoped that the\nresults of this survey will add to the literature highlighting the benefits and\nrisks of such apps.\n\nThis research was approved by University College London (UCL) Research Ethics\nCommittee ID Number: 9831/004, with no anticipated risks for the participants.\nThe first question of the survey was to agree to informed consent. All data were\ncollected and have been presented anonymously and managed in accordance with the\nData Protection Act of 1998.\nThis observational mixed-methods study distributed an online survey to people who\nuse, or have used, a period tracker app. The inclusion criteria were any woman\nwho had used a period tracker. There were no specific exclusion criteria. There\nwas no age limit on respondents to gain an inclusive and representative insight\nof all users’ experiences. Respondents were asked to confirm if they use, or\nhave ever used, a period tracker app.\nA 50-item survey was developed, guided by preliminary polls and discussions\nlaunched via social media. The questions were designed to address demographics,\nmenstrual cycle characteristics and period tracker app use to ensure the\ncollection of relevant data. The phrasing of the survey was formulated to avoid\nirrelevant and leading questions, and participants were always offered a ‘Prefer\nnot to say’ option. Respondents had to answer each question but it was possible\nfor the respondents to stop answering questions and submit the survey, hence\nsome incomplete responses. The survey was in English, with simple and focussed\nquestions to allow the participation of as many users as possible. Qualtrics\nXM ® , a mass distribution and data analysis tool, was used to\ndesign, promote and collect the results of the survey. The survey is available\nin  supplementary data 1 .\nBefore circulation, validation of the final survey took place through cognitive\ninterviewing sessions. During these pilot responses, participants were\ninterviewed as they went through the survey to ensure its ease of use and the\ncorrect understanding of each question. To further confirm this, the survey was\nfirst distributed among a select group run by Joyce Harper ( www.globalwomenconnected.com  via Facebook), prior to mass online\ndistribution on social media via Joyce Harper and Anna Broad’s Instagram,\nTwitter, LinkedIn and Facebook pages. The survey was live for 19 days, from 30\nJune to 20 July 2021.\nDue to the large data set, this article analyzes the findings of a sub-set of\ndata, with a second paper in preparation. This article focuses on demographics\nand menstrual cycle characteristics, as well as the questions regarding\nrespondents’ use of period trackers, their attitudes to inputting data, the\ninfluence of the apps on sexual intercourse, ovulation prediction and the effect\nof the app’s predicted period start dates on respondents’ feelings and\nbehaviours.\nInductive thematic analysis was used for the qualitative data. \n 15 \n  Two questions were analyzed: how they felt when their period started\nearlier than the app’s predicted start date and how they felt when their period\nstarted later than the app’s predicted start date. The responses were read and\nthen re-read to enable immersion into the text and to identify meaningful and\nrepeated units of text. These units of text were assigned codes, allowing more\ndata to be identified and categorized into these codes. The data were reviewed\nagain to ensure all codes had been identified and exhausted, following which the\ncodes were grouped into themes.\n\nA total of 375 surveys were started and 330 completed the survey giving a completion\nrate of 88.0%.\nAll figures show the percentage of responses to each question. For some questions,\nrespondents were asked to select all that apply or three answers that apply, which\nare detailed in the figures.\nTable 1  shows the\nfull details of the demographics, highlighting 91.5% (302/330) of respondents\nwere from the UK. The average age was 26.0 and the majority of respondents\ndescribed themselves as White British, 73.3% (242/330), and heterosexual, 87.0%\n(287/330). Most of the respondents were in a relationship, 66.0% (218/330),\neither married or in a civil partnership, co-habiting, or not co-habiting.\nDetailed demographics of all respondents.\nThe respondents were highly educated, with 77.1% stating their highest\neducational qualification to be either an undergraduate degree, 42.2% (140/330),\nor postgraduate degree, 34.9% (115/330).\nA large proportion of respondents described themselves as having no religion or\nbelief, 60.0% (198/330), or being Christian, 31.8% (105/330). Respondents mainly\nhad no disabilities, 87.6% (289/330).\nThere were several questions that provided insights into the respondents’\nmenstrual cycle characteristics, one of which 10 of 300 women answered as not\ncurrently having periods. Most respondents described their menstrual cycle to be\nbetween 26 and 32 days, 35.0% (105/300), ( Figure 1(a) ) and that it tended to vary\nby 1–4 days each month, 65.7% (197/300) ( Figure 1(b) ).\nA graph showing the women’s responses regarding the characteristics of\ntheir menstrual cycle (a) Menstrual cycle length and (b) variation in\nrespondents’ cycle length each month. Of 300 women, most showed a 26- to\n32-day cycle with 1–4 days variation in cycle length.\nWhen asked about period length and heaviness of bleeding, most respondents\ndescribed their periods to be medium, 62.0% (186/300), and 4–6 days in length,\n68.5% (204/300) ( Figure\n2(a)  and ( b )). Respondents were also asked about the symptoms they experience in\nthe days before their period is due and could select all that applied.  Figure 2(c)  shows\nrespondents had a wide range of symptoms, with the most common being cramps,\n67.3% (202/300).\nA graph showing the women’s responses to the characteristics of their\nmenstrual cycle bleed (a) heaviness of bleeding (b) length of bleeding\nand (c) the different symptoms experience when their period is due. Of\n300 women, the majority defined their bleeding as medium, lasting for\n4–6 days and reported a variety of symptoms when their period was due.\nFor  Figure\n2(c) , the respondents were able to tick all the answers that\napplied.\nRespondents were asked questions to discover and understand their use of period\ntrackers. The mean age of first downloading a period tracker app was 21.4\n(±7.86), with a minimum age of 11 and a maximum age of 52 ( Figure 3 ).\nThe age at which respondents began using a period tracker app. The graph\nshows that the majority of respondents started using the app when they\nwere teenagers.\nRespondents were also asked about the reasons why they first started using a\nperiod tracker. Most respondents wanted to understand their symptoms, changes\nand concerns about their menstrual cycle, 91.2% (301/330) and to prepare for\ntheir period, 69.4% (229/330) ( Figure 4 ).\nThe reasons why respondents downloaded and started using a period tracker\napp. They were able to tick all the answers that applied. Of 330 women,\nthe major reason was to understand their symptoms, changes and concerns\nabout their menstrual cycle.\nThe respondents were asked what they felt was the best thing about using a period\ntracker ( Figure 5 ). The\nfirst and second most commonly selected statements were ‘To know when my period\nis arriving’, 85.8% (283/330), and ‘Helped me understand my body’, 41.8%\n(138/330). However, 29.7% (98/330) of respondents selected ‘To know when I’m\novulating’.\nA graph showing the women’s responses to the question ‘what is the best\nthing about using a period tracker app?’. They could tick all options\nthat applied. From 330 responses, the majority said ‘to know when my\nperiod is arriving’.\nThe majority of respondents’ sexual activity was not influenced by their app’s\npredicted dates, 65.5% (216/330). However, a total of 17.0% (56/330) of\nrespondents stated that it was, with 10.9% (36/330) of all respondents stating\nthey avoid having sex on the fertile days predicted by the app.\nWhen respondents were asked to select the phrase that best described their\nattitude towards entering data into their app, the two most common statements\nwere ‘Entering my data is part of my routine’, 43.0% (142/330), and ‘I often\nforget to enter my data as it is not a priority’, 37.0% (122/330).\nQuestions regarding privacy concerns when using a period tracker showed an\noverall majority, 83.0% (274/330), of respondents had no privacy concerns. When\nasked to further explain their attitudes towards data privacy, many stated it\neither had not even crossed their mind, or that they feel that as they have\ngrown up with the age of the Internet, access to personal data is expected.\nFigure 6  shows the\nmajority said their app gets their period start date right most of the time,\n62.7% (207/330), while 6.7% (22/330) said their app predicts it correctly all of\nthe time. However, 8.8% (29/330) said the app rarely gets it right.\nA graph showing the women’s responses to being asked the extent to which\nperiod tracker apps accurately predict the start date of their period.\nThe majority of respondents said that their period tracker got it right\nmost of the time.\nRespondents were asked if their period ever started earlier than the app\npredicted; 54.9% (189/330) said it had, 24.9% (82/330) said it never had and\n20.3% (67/330) said sometimes. When asked if their period ever started later\nthan the app predicted; 72.1% (238/330) said it had, 10.6% (35/330) said it\nnever had and 17.3% (57/330) said sometimes.\nThere was an opportunity for respondents to write a free text about how they felt\nwhen their period started earlier than the app’s predicted start date. If\nrespondents had nothing more to say, they could state ‘None’. Overall, there\nwere some contrasting responses, ranging from feeling as though it did not\nreally affect them, to strong feelings of anxiety, frustration and confusion.\nThematic analysis of the 145 detailed responses highlighted four key themes:\nfeeling unaffected, being frustrated and unprepared, feeling anxious and\nstressed, and feeling confused and intrigued.\nA large number of respondents described how their period starting earlier than\nthe app’s predicted start date was not a surprise and it did not bother them.\nSome even stated that this was because they did not trust or believe the\npredictions.\n‘Coming early didn’t worry me’ (Aged 21, in a relationship\nco-habiting) \n \n ‘I don’t mind because I know my period will be around that time\nso I am not fussed’ (Aged 23, in a relationship not\nco-habiting) \n \n ‘Just one of those things’ (Aged 31, in a relationship\nco-habiting) \n \n ‘Don’t believe the predictions anyway so was amused’ (Aged 49,\nmarried/civil partnership)\n‘Coming early didn’t worry me’ (Aged 21, in a relationship\nco-habiting)\n‘I don’t mind because I know my period will be around that time\nso I am not fussed’ (Aged 23, in a relationship not\nco-habiting)\n‘Just one of those things’ (Aged 31, in a relationship\nco-habiting)\n‘Don’t believe the predictions anyway so was amused’ (Aged 49,\nmarried/civil partnership)\nReasons for feeling unaffected by an earlier-than-predicted period tended to fall\nunder two sub-themes. First, respondents explained how they understand their\nbody and know their menstrual cycles are irregular; and that they understand the\nsigns and symptoms of their period.\n‘I can nearly always tell the day I will start my period because\nthere is a significant drop in my basal body temperature’ (Aged 24,\nsingle) \n \n ‘I go by my symptoms as that’s when I know my period is going to\nstart but just use the app as a rough guide’ (Aged 23, in a\nrelationship co-habiting) \n \n ‘I didn’t think much of it as my periods have always been\nirregular and unpredictable due to the PCOS’ (Aged 24, in a\nrelationship not co-habiting) \n \n ‘My periods can be erratic so was not bothered’ (Aged 46,\nmarried/civil partnership)\n‘I can nearly always tell the day I will start my period because\nthere is a significant drop in my basal body temperature’ (Aged 24,\nsingle)\n‘I go by my symptoms as that’s when I know my period is going to\nstart but just use the app as a rough guide’ (Aged 23, in a\nrelationship co-habiting)\n‘I didn’t think much of it as my periods have always been\nirregular and unpredictable due to the PCOS’ (Aged 24, in a\nrelationship not co-habiting)\n‘My periods can be erratic so was not bothered’ (Aged 46,\nmarried/civil partnership)\nOn the other hand, many other respondents felt unaffected because they never\nexpected the app to be 100% accurate.\n‘I felt fine – the app predicts it the best it can but I\nunderstand my body doesn’t run according to an app’ (Aged 25, in a\nrelationship cohabiting) \n \n ‘I generally took the app’s predictions as just that –\npredictions not facts, so it didn’t bother me’ (Aged 22, in a\nrelationship not cohabiting)\n‘I felt fine – the app predicts it the best it can but I\nunderstand my body doesn’t run according to an app’ (Aged 25, in a\nrelationship cohabiting)\n‘I generally took the app’s predictions as just that –\npredictions not facts, so it didn’t bother me’ (Aged 22, in a\nrelationship not cohabiting)\nHowever, in some cases, this lack of expectation of the app’s accuracy led\nrespondents to blame their own body and periods when looking for a reason to\nunderstand what is presented by the app as an early period. This sub-theme\nappeared across varying ages and relationship statuses.\n‘I don’t especially blame the app, it’s more directed at my own\nbody’ (Aged 38, married/civil partnership) \n \n ‘Frustrated at own period and its irregularity’ (Aged 23, in a\nrelationship cohabiting) \n \n ‘I never felt it was the apps fault, more that my period was\njust irregular’ (Aged 18, single)\n‘I don’t especially blame the app, it’s more directed at my own\nbody’ (Aged 38, married/civil partnership)\n‘Frustrated at own period and its irregularity’ (Aged 23, in a\nrelationship cohabiting)\n‘I never felt it was the apps fault, more that my period was\njust irregular’ (Aged 18, single)\nAnother frequently mentioned feeling about having an earlier-than-predicted\nperiod was a sense of being surprised, annoyed and unprepared. Respondents\nmentioned how this inaccuracy meant they did not have access to suitable period\nproducts and that they would have worn different clothing. These feelings of\nfrustration made some respondents feel upset, particularly if individuals\ngreatly suffer while on their period, due to disorders such as\nendometriosis.\n‘I was unprepared with sanitary products which was inconvenient’\n(Aged 42, married/civil partnership) \n \n ‘Annoyed because I didn’t have the right underwear on’ (Aged 23,\nin a relationship cohabiting) \n \n ‘Slightly underprepared – for instance I had no tampons at home\nas I thought I had time to buy them before I started’ (Aged 22, in a\nrelationship cohabiting) \n \n ‘Upset. I get severe pain because of endometriosis so I try to\nplan ahead by not being at work if possible, close to painkillers,\nmy heat belt and peace and quiet’ (Aged 30, single)\n‘I was unprepared with sanitary products which was inconvenient’\n(Aged 42, married/civil partnership)\n‘Annoyed because I didn’t have the right underwear on’ (Aged 23,\nin a relationship cohabiting)\n‘Slightly underprepared – for instance I had no tampons at home\nas I thought I had time to buy them before I started’ (Aged 22, in a\nrelationship cohabiting)\n‘Upset. I get severe pain because of endometriosis so I try to\nplan ahead by not being at work if possible, close to painkillers,\nmy heat belt and peace and quiet’ (Aged 30, single)\nThe feelings of frustration commonly appeared with regards to events such as\nholidays, or other activities including exercise, that respondents had planned\nto take place around their period due dates.\n‘Frustrated-it can mean that I’ve planned specific events to\navoid my period, then my period happens anyway’ (Aged 38,\nmarried/civil partnership) \n \n ‘I just need to know more or less when it will be, but it does\nhelp me to plan my activities (e.g. travel, sports)’ (Aged 33, in a\nrelationship cohabiting)\n‘Frustrated-it can mean that I’ve planned specific events to\navoid my period, then my period happens anyway’ (Aged 38,\nmarried/civil partnership)\n‘I just need to know more or less when it will be, but it does\nhelp me to plan my activities (e.g. travel, sports)’ (Aged 33, in a\nrelationship cohabiting)\nMany respondents wrote how they felt worried, stressed, and even let down when\ntheir period came earlier than their tracker predicted. Respondents that were\nleft feeling anxious described how this was in relation to pregnancy and\novulation dates, either because they were trying to conceive or trying not\nto.\n‘Disappointed as trying to conceive’ (Aged 33, in a relationship\ncohabiting) \n \n ‘Went in to check whether I had noted my ovulation date to be\nearlier than the app had predicted’ (Aged 44, married/civil\npartnership) \n \n ‘Worried ovulation day was also wrong’ (Aged 32,\nsingle)\n‘Disappointed as trying to conceive’ (Aged 33, in a relationship\ncohabiting)\n‘Went in to check whether I had noted my ovulation date to be\nearlier than the app had predicted’ (Aged 44, married/civil\npartnership)\n‘Worried ovulation day was also wrong’ (Aged 32,\nsingle)\nIn certain cases, for those respondents who may have believed they were pregnant,\nan earlier-than-predicted period caused stress surrounding implantation\nbleeds.\n‘Would make me think it was possibly an implantation bleed,\nbecame stressful’ (Aged 35, in a relationship cohabiting)\n‘Would make me think it was possibly an implantation bleed,\nbecame stressful’ (Aged 35, in a relationship cohabiting)\nA final prominent theme in this analysis was that, although respondents may have\nbeen confused as to why their period was early, they were also intrigued and\nwanted to find out why this could have happened. This was particularly mentioned\nwhen the predicted start date was wrong by weeks, rather than days.\n‘Wondered why my cycle was so much shorter than usual’ (Aged 30,\nin a relationship cohabiting) \n \n ‘If it’s a week or more early, I think about what could have\ncaused it’ (Aged 21, single)\n‘Wondered why my cycle was so much shorter than usual’ (Aged 30,\nin a relationship cohabiting)\n‘If it’s a week or more early, I think about what could have\ncaused it’ (Aged 21, single)\nRespondents were asked how it made them feel when their period was later than the\napps predicted start date. This was also an open-ended question and respondents\nhad the opportunity to write ‘None’ if they felt they had nothing more to say.\nAlthough this set of responses still showed some contrasting feelings, a much\ngreater proportion of respondents described a sense of anxiety and panic that\nthey could be pregnant. A late period also appeared to uncover worries over\nother reproductive health anxieties, including menopause, causing respondents to\nseek medical advice. After thematic analysis of the 175 responses given, six\nthemes emerged: anxious and concerned about being pregnant, disappointed about\nnot being pregnant, seeking advice and informing HCPs, thoughts about menopause,\nfeeling unaffected and being better prepared.\nOne of the most frequently cited themes was the worry and fear about an unplanned\npregnancy when respondents’ periods were later than predicted. Some mentioned\nhow even though they knew it was likely to be part of their normal variation in\ncycle length, a late period still made them feel worried about pregnancy.\n‘Anxious that I might be pregnant’ (Aged 28, married/civil\npartnership) \n ‘I’m worried about pregnancy, especially if I’ve had sex\nrecently. Even though I know it’s normal for me to be late, it still\nmakes me worried ’.  (Aged 24, in a relationship not\ncohabiting) ‘panicked because the automatic assumption is then that you’re\npregnant ’.  (Aged 20, in a relationship not\ncohabiting) ‘Slightly panicked as it had always been very reliable. I’ve\ncompleted my family now and have no desire for any more children so\nit was a bit worrying that it hadn’t started ’.\n (Aged 35, married/civil partnership) ‘Anxious because I was just waiting for it to come, and worried\nabout being pregnant ’.  (Aged 20, in a relationship\nnot cohabiting)\n‘Anxious that I might be pregnant’ (Aged 28, married/civil\npartnership)\n‘I’m worried about pregnancy, especially if I’ve had sex\nrecently. Even though I know it’s normal for me to be late, it still\nmakes me worried ’.  (Aged 24, in a relationship not\ncohabiting)\n‘panicked because the automatic assumption is then that you’re\npregnant ’.  (Aged 20, in a relationship not\ncohabiting)\n‘Slightly panicked as it had always been very reliable. I’ve\ncompleted my family now and have no desire for any more children so\nit was a bit worrying that it hadn’t started ’.\n (Aged 35, married/civil partnership)\n‘Anxious because I was just waiting for it to come, and worried\nabout being pregnant ’.  (Aged 20, in a relationship\nnot cohabiting)\nFurther to this, respondents were aware that anxiety can delay periods further.\nThey described how the nerves and stress created by a late period, as classified\nby their period tracker, can cause their period to start even later.\n‘Worried as I stress about it, which can delay it even\nmore ’.  (Aged 22, in a relationship not\ncohabiting) ‘I was very anxious and i think the nerves kept delaying my\nperiod further ’.  (Aged 23, single)\n‘Worried as I stress about it, which can delay it even\nmore ’.  (Aged 22, in a relationship not\ncohabiting)\n‘I was very anxious and i think the nerves kept delaying my\nperiod further ’.  (Aged 23, single)\nHowever, an exception to this theme mentioned by a few respondents was that\nbecause they were not sexually active at the time, they were not worried about\nan unplanned pregnancy. Still, a few highlighted how a later-than-predicted\nperiod made them worried about other aspects of their health, including general\nhealth.\n‘When I used a tracker I wasn’t sexually active so being a couple\ndays late never bothered me, but if I was to be using one now I am\nsexually active it would bother me because of the pregnancy\npanic ’.  (Aged 22, in a relationship not\ncohabiting) \n ‘A bit worried/stressed. . .not worried about pregnancy just\nabout general health’ (Aged 21, single)\n‘When I used a tracker I wasn’t sexually active so being a couple\ndays late never bothered me, but if I was to be using one now I am\nsexually active it would bother me because of the pregnancy\npanic ’.  (Aged 22, in a relationship not\ncohabiting)\n‘A bit worried/stressed. . .not worried about pregnancy just\nabout general health’ (Aged 21, single)\nOn the other hand, if a respondent was trying to conceive and pregnancy was what\nthey were hoping for, respondents’ attitudes towards a late period appeared more\nhopeful and excited. For some, it seemed that they did not want to get their\nhopes up, and if their late period eventually started, respondents described a\nsense of disappointment.\n‘Worried I may be pregnant. Possibly secretly excited.\nhappy ’.  (Aged 37, married/civil\npartnership) ‘Hopeful at the time!! Then upset when it came ’.\n (Aged 32, married/civil partnership)\n‘Worried I may be pregnant. Possibly secretly excited.\nhappy ’.  (Aged 37, married/civil\npartnership)\n‘Hopeful at the time!! Then upset when it came ’.\n (Aged 32, married/civil partnership)\nMany respondents felt the need to speak to their doctor when their period was\nlate. Respondents described how as they became concerned and worried over their\ncycle length or delayed period, they looked for advice from their General\nPractitioner (GP).\n‘I also find it concerning (yet important) to see when my cycles\nabnormally long, and have phoned my GP for medical advice’ (Aged 24,\nin a relationship not cohabiting) \n \n ‘It lets me see I’m still within a non-worrying cycle length and\ngives info for doctor if required (I’m not sexually active so this\nwould likely be evidence of a health issue)’ (Aged 37,\nsingle)\n‘I also find it concerning (yet important) to see when my cycles\nabnormally long, and have phoned my GP for medical advice’ (Aged 24,\nin a relationship not cohabiting)\n‘It lets me see I’m still within a non-worrying cycle length and\ngives info for doctor if required (I’m not sexually active so this\nwould likely be evidence of a health issue)’ (Aged 37,\nsingle)\nDiscussing the apps that predicted period dates with HCP became significant to\nrespondents and HCPs when trying to understand if something was wrong and to\nreach a diagnosis.\n‘Frustrating as doctors overlook my condition due to my age and\nseeing “60 days late” for period is disheartening’ (Aged 21, in a\nrelationship cohabiting) \n ‘The data helped me get diagnosed with PCOS ’.\n (Aged 21, in a relationship not cohabiting)\n‘Frustrating as doctors overlook my condition due to my age and\nseeing “60 days late” for period is disheartening’ (Aged 21, in a\nrelationship cohabiting)\n‘The data helped me get diagnosed with PCOS ’.\n (Aged 21, in a relationship not cohabiting)\nA theme most likely to appear within responses from older respondents was how a\nlate period caused them to begin thinking about whether they were becoming\nperi-menopausal.\n‘Thoughts about the menopause’ (Aged 54, in a relationship not\ncohabiting)\n‘Thoughts about the menopause’ (Aged 54, in a relationship not\ncohabiting)\nIn contrast to the previous theme, those who were already aware that they were\nmenopausal were not that affected by their period trackers prediction.\n‘Not surprised as menopausal – though found it funny that it\nbothered to predict when cycles so clearly unpredictable’ (Aged 49,\nmarried/civil partnership)\n‘Not surprised as menopausal – though found it funny that it\nbothered to predict when cycles so clearly unpredictable’ (Aged 49,\nmarried/civil partnership)\nOthers had similar views and feelings as to when their period was earlier than\npredicted. Many respondents wrote analogous responses, mentioning again how they\nunderstood their body does not run according to an app and that they knew their\ncycle can be irregular, so it was to be expected.\n‘Again, I didn’t really think of it in relation to the app. I’ve\nalways presumed the app works out my average cycle length and goes\nwith that. I find it useful to know vaguely when my period is\nstarting and use it for that only. My cycles aren’t totally regular\nto the day ’.  (Aged 27, in a relationship\ncohabiting) \n ‘I know that I have health factors that impact my period so it\ndoesn’t worry me’ (Aged 21, in a relationship not\ncohabiting) \n \n ‘Again, I know I’m not regular so I wasn’t particularly worried’\n(Aged 22, in a relationship not cohabiting)\n‘Again, I didn’t really think of it in relation to the app. I’ve\nalways presumed the app works out my average cycle length and goes\nwith that. I find it useful to know vaguely when my period is\nstarting and use it for that only. My cycles aren’t totally regular\nto the day ’.  (Aged 27, in a relationship\ncohabiting)\n‘I know that I have health factors that impact my period so it\ndoesn’t worry me’ (Aged 21, in a relationship not\ncohabiting)\n‘Again, I know I’m not regular so I wasn’t particularly worried’\n(Aged 22, in a relationship not cohabiting)\nSome respondents described how their use of contraception allowed them to not\nfeel worried or anxious, and that a late period was more of an\ninconvenience.\n‘I’m on the pill so I wasn’t too worried about it. It was more of\nan inconvenience than stressful ’.  (Aged 25, in a\nrelationship not cohabiting) \n “A bit stressed but otherwise fine because I trusted the\ncontraception I’d used more than the app. It made me less willing to\ntrust the app, however. (Aged 18, in a relationship not\ncohabiting)\n‘I’m on the pill so I wasn’t too worried about it. It was more of\nan inconvenience than stressful ’.  (Aged 25, in a\nrelationship not cohabiting)\n“A bit stressed but otherwise fine because I trusted the\ncontraception I’d used more than the app. It made me less willing to\ntrust the app, however. (Aged 18, in a relationship not\ncohabiting)\nA positive theme that became apparent was that, compared to an\nearlier-than-predicted period, respondents felt that they were better prepared.\nResponses showed how a period later than predicted allowed access to suitable\nperiod products; some described how they even prefer a later than predicted\nperiod to earlier than predicted.\n‘if it’s a couple of days late then that’s fine because I’ve\nprepared for it’ (Aged 25, in a relationship cohabiting) \n ‘Was only by a few days and I was able to prepare ’.\n (Aged 21, single) ‘I find that later is less annoying than earlier as you are still\nprepared for it, so I didn’t mind too much ’.  (Aged\n19, in a relationship not cohabiting)\n‘if it’s a couple of days late then that’s fine because I’ve\nprepared for it’ (Aged 25, in a relationship cohabiting)\n‘Was only by a few days and I was able to prepare ’.\n (Aged 21, single)\n‘I find that later is less annoying than earlier as you are still\nprepared for it, so I didn’t mind too much ’.  (Aged\n19, in a relationship not cohabiting)\nHowever, one individual’s comment on this theme mentioned how having a late\nperiod meant that tampons and period pads were unnecessarily used.\n‘I know my cycle is a little irregular but it’s nice to be\nprepared. I do hate the wasted tampons and pads though ’.\n (Aged 20, in a relationship not cohabiting)\n‘I know my cycle is a little irregular but it’s nice to be\nprepared. I do hate the wasted tampons and pads though ’.\n (Aged 20, in a relationship not cohabiting)\nThe final part of the survey asked respondents to select up to three feelings\nthat describe how using a period tracker makes them feel ( Figure 7 ). Overall, the majority of\nrespondents expressed a positive experience; the top three feelings selected\nwere ‘Prepared’, 53.3% (176/330), ‘In control’, 49.0% (162/330) and ‘Informed’\n36.7% (121/330). ‘Indifferent’ was commonly selected, 16.7% (55/330), while the\nmost common negative feeling selected was ‘Frustrated’, 4.8% (16/330). There was\na range in feelings towards using a period tracker.\nA graph showing the respondents’ overall feelings about using a period\ntracker app. They were able to pick three answers. The majority of\nfeelings chosen were positive.\n\nUsing an online survey, the aim of this study was to ask women about their real-life\nexperiences of using period tracker apps. Specifically, their attitudes towards\nusing their app, ovulation prediction and how the accuracy of the app in predicting\nperiod start dates affects their feelings and behaviours if their period comes\nearlier or later than predicted by the app. This is essential to ensure\napp-facilitated period tracking is fit for purpose. While some studies have been\ndone using interviews and surveys in other countries, this was the first UK-based\nsurvey.\nResults highlighted the range in users’ ages, careers and stages of life, as well as\nthe range in attitudes towards entering data. Further findings showed a proportion\nof respondents would either have or avoid having sexual intercourse on their\npotential fertile days. Interestingly, most respondents had no concerns regarding\ndata privacy when using the apps. Only a small proportion of respondents stated\ntheir app always predict their period correctly, and inaccurate predictions were\nmore likely to result in a period later than predicted. The qualitative analysis\nfurther confirmed the range of the apps’ effects on women’s feelings and behaviours,\nalthough a period later than predicted tended to have a greater negative effect than\nearlier than predicted periods.\nThe most frequently selected cycle length of 26–32 days corresponds with a recent\nstudy that investigated over 600,000 menstrual cycles, which found a mean cycle\nlength of 29.3 days. \n 1 \n  Further consistent findings of cycle length were found by Faust et al., \n 16 \n  who reported a mean cycle length among their 225,596 cycles to be 29.6\ndays. This study found 64.1% of respondents to have a variation of 1–4 days,\nwhile Grieger and Norman, \n 17 \n  who looked into menstrual cycle patterns of users of the app Flo, found\n69% of participants to have <6 days variation. When comparing the heaviness\nof respondents’ periods with previously reported findings, fewer data are\navailable. While a 2004 study measured blood loss in those referred with\npotential menorrhagia, the lack of population-wide studies investigating period\nheaviness makes it difficult to put current findings into context. \n 18 \n  This study found that 61.7% of respondents described the heaviness of\ntheir period to be medium and 67.9% described their period to last 4–6 days. The\nlatter finding is consistent with a study carried out by the World Health\nOrganization (WHO), which found a mean period length of 4.7 days; however, the\ndate and the early post-menarcheal nature of this study’s sample must be considered. \n 19\nResults of the survey showed an age range of 40 years between respondents.\nAlthough the mean age was 26.0, this broad range highlights the role period\ntracker apps play at every stage of a women’s reproductive life. The increase in\ndownloading apps around the age of 14–16 is likely to align with the onset of\nmenses, whereas the increase around the age of 28–30 could align with the desire\nto start a family. The most recent data shows the average maternal age for first\nchildren in the UK to be 28.9 years and could therefore be suggested that there\nis an increase in period tracking at this age as women start to plan to conceive. \n 20\nThe reasons why women downloaded a period tracker varied. ‘Wanting to plan and\nprepare for my period’ was the most frequently selected response and ‘Coming off\ncontraception’ included those trying to become pregnant and those coming off\nhormonal contraception. However, four specific categories about their own\nmenstrual cycle (‘Wanted to know more about my menstrual cycle’, ‘Was worried\nabout my menstrual cycle’, ‘To understand changes in menstrual cycle symptoms\nsuch as mood’ and ‘Suffering from PMS’), contributed to an overall 91.2% of\nusers downloading a period tracker because they wanted to understand more about\ntheir body and menstrual cycle. This idea of women wanting to educate themselves\non their menstrual health is consistent with the key finding of an\nAustralian-based survey that researched menstrual health literacy and management\nstrategies in young women. \n 21 \n  This group found 50% of 4202 participants to engage with self-management\nof menstrual symptoms, including research on the Internet, instead of seeking\nmedical advice, even in severe cases. This huge proportion of young women shows\nthere is a great demand from women to want to understand their menstrual cycle,\nbut they may feel unsupported by medical professionals while lacking the vital\neducation regarding the understanding, management and awareness of menstrual\nhealth, something that is being addressed by the International Fertility\nEducation Initiative. \n 22 \n  Feelings of confusion and being intrigued by variations in their\nmenstrual cycle was also a key theme brought up by respondents in later\nqualitative analysis, further exemplifying the want and need for increased\nmenstrual education.\nAn interesting finding was that when respondents were asked to select the phrase\nthat best describes their attitude towards entering data into their app, while a\nfew selected ‘I set an alarm/reminder to enter data as otherwise I would\nforget’, and ‘I only enter data when I need to know when my period will be (e.g.\nholiday)’, there was an opposing almost 50/50 split between the majority of\nrespondents attitudes. One majority, 43.0%, of respondents described entering\ntheir data to be part of their routine. Meanwhile, the other majority, 37.0%,\nselected ‘I often forget to enter data as it is not a priority’.\nThis study found 83.0% of respondents to state they have no concerns regarding\nthe privacy of their data when using a period tracker. When further questioned,\nmost described how they had either never considered this, did not feel they\nentered data that could be used against them or that companies’ access to\npersonal data is expected these days. This overall relaxed approach to data\nprivacy agrees with findings from a mixed-methods study that aimed to reveal\nconsumers' attitudes towards privacy and security when using health apps. \n 23 \n  This group found that these attitudes are highly contextualized and\ndependent on what the app is designed to be used for. A more recent study also\nfound users are less concerned about privacy if they feel the benefits of the\napp were worth it. \n 24 \n  It could therefore be possible for the users to feel that the benefits of\nusing their period tracker outweigh any data privacy concerns and they are not\nworried about the use of any data they do enter. The contextualized nature of\nprivacy concerns is consistent with the findings from Proudfoot et al., \n 25 \n  who found privacy concerns were more likely to be associated with the use\nof mental health apps. This is of particular importance given the results of a\nrecent study that found 88% of 158 mental health apps collect users’ data and\n49% of these share users’ data with third parties. \n 26 \n  Although specific to mental health apps, this could suggest that health\napps as a whole may not be clear enough as to what they use users’ data for. The\nlack of privacy concerns in this present study could therefore be due to a lack\nof user concern regarding the data they are entering, combined with a lack of\nhonesty from tracking apps regarding their data protection policies. An area for\nfurther research could investigate the period tracker’s privacy notices, to\nconfirm users are not being falsely reassured through a lack of\ntransparency.\nAs we have shown, ovulation prediction from a period tracker that only uses dates\nis highly inaccurate and to predict ovulation, an FABM needs to be\nmeasured; 1 , 4 , 9  29.7% stated the best thing about using a period tracker is\n‘To know when I’m ovulating’ and 10.9% said they avoid having sex on the fertile\ndays predicted by the app. These results highlight the trust women have in their\nperiod trackers and illustrate the potential responsibility these apps could\nhave regarding unplanned pregnancies.\nIt is therefore recommended that period tracker apps stop predicting ovulation\ndates without physiological evidence inputted by the individual. In parallel,\nwomen should be made aware of other ovulation tracking methods, such as urinary\novulation detection kits, which work by measuring the luteinizing hormone surge\nwhich happens about 40 h before ovulation, to increase knowledge, and\nconsequently empowerment, of individuals’ own menstrual cycles.\nThe qualitative analysis of this survey provided an in-depth analysis of women’s\nexperiences of using period tracker apps. This portrayed a sense of\nvulnerability as respondents wrote extensively and passionately about how their\nperiod tracker either affects or does not affect them. Overall, it appears as\nthough users either rely on their tracker heavily and that it has a strong\neffect on their feelings and behaviours, or that users have learned to not rely\nsolely on an app to predict period start dates and are no longer affected by its\npredictions. The range of words respondents selected when asked ‘How does/did\nusing a period tracker app make you feel?’ reflects further this range in\nfeelings and behaviours. Although the most frequently selected feelings were\npositive and those that would be expected from using a period tracker, such as\n‘Prepared’ and ‘In control’, feelings such as ‘Frustrated’ and ‘Anxious’ were\nmore commonly selected than ‘Confident’ and ‘Competent’. Feeling ‘Indifferent’\nwas also more frequently selected than other positive feelings such as\n‘Knowledgeable’, ‘Empowered’ and ‘At ease’. Despite this majority selecting to\nfeel positively towards using their tracker, it is likely respondents are more\nlikely to feel this way since they have been interested in downloading and using\none. There is still a proportion, a potentially a much greater proportion who\nwere not included in the sample for this reason, who feel as though using a\nperiod tracker app is, or would, not be beneficial to them. An area of future\nwork could combine previously mentioned further research regarding data\nprotection policies to uncover whether if users were more aware of the apps\nintended use and data protection policies, would their feelings towards using\ntheir tracker change.\nIt emerged that only 6.7% of respondents stated their app always gets the date of\ntheir period correct and that it was more likely for respondents’ periods to\nstart later than the apps predicted start date. A reason for this could be, as\nmentioned by Bull et al. \n 1 \n  and Faust et al., \n 16 \n  that women tend to have a cycle longer than the traditionally and\nclinically cited 28-day cycle. \n 27 \n  Furthermore, Grieger and Norman \n 17 \n  found only 0.17% of women to have a short cycle (<21 days), compared\nto 8.60% to have a long cycle (>35 days). When partnered with a finding from\nLevy and Romo-Avilés, \n 6 \n  which described how app-facilitated period tracking promotes the idea\nthat completely regular menstrual cycles are automatically associated with good\nhealth, this inaccuracy could be causing unnecessary worry. Although it is\nimportant for women to recognize that certain, and normally large,\nirregularities can be signs of pathology, only when it is possible to take a\npatient case as whole can this be confirmed. Irregular menstrual cycles are\ncommon, not always pathological, and caused by a multitude of other factors.\nThis is consistent with previous work investigating variation in menstrual cycle\nlength, where 29.3% of the 2865 women showed >14 days variation. \n 28 \n  This study concluded by opposing the idea that intra-individual variation\nof >5 days should be associated with the disease. With further research into\nthis field, it may be possible to increase the understanding of menstrual\nregularities and the irregularities associated with pathology in order to refine\nthe definition of a ‘normal’ menstrual cycle length. Once this greater\nunderstanding is achieved, it could then be possible for period tracker apps to\nbe more in tune with their varied users.\nThe need for this research is further demanded when comparing the overall\nfeelings described by respondents when their period is earlier than predicted,\nversus when their period is later than predicted. In general, when a period was\nlate, it appeared women were more likely to be negatively affected, either by\nfeelings of anxiety, disappointment, upset and frustration. However, an earlier\nperiod meant respondents were more likely to describe feeling unprepared or it\nbeing an inconvenience and slightly frustrating. This is consistent with the\nidea that the strongest feelings in either scenario were centred around\npregnancy; a thought much more likely to cross users’ minds when their period is\nlate.\nAnalysis of the question ‘How did it make you feel when your period started\nearlier than the app predicted?’ produced four key themes: feeling unaffected,\nbeing frustrated and unprepared, feeling anxious and stressed, and being\nconfused and intrigued. As previously discussed, although the majority of\nrespondents felt either unaffected or frustrated at being unable to be prepared,\na few described more concerning feelings of being frustrated at their own period\nand blaming their body. Not only does this highlight the trust some users have\nin their period tracker app but also, on a wider scale, illustrates the negative\neffects modern technology can have on users’ mental health and body confidence.\nOne study investigated the different uses of technology and the relationship\nwith physical and mental well-being in 244 undergraduate students. \n 29 \n  They found dependence on technology and devices, which users of period\ntracker apps are susceptible to, was associated with body image dissatisfaction,\ndepression, and anxiety. The ease of being able to complete so many day-to-day\ntasks on a smartphone, including tracking periods, could mean our society has\nbecome too reliant on technology for the validation of our lifestyles and\nbodies.\nAnalysis of the question ‘How did it make you feel when your period started later\nthan the app predicted?’, produced 6 key themes: anxious and concerned about\nbeing pregnant, disappointed about not being pregnant, seeking advice and\ninforming HCPs, thoughts about the menopause, feeling unaffected and being\nbetter prepared. The most frequently cited was feeling anxious and concerned\nabout being pregnant, highlighting the sensitivity and importance of pregnancy\nto women, whether planned or unplanned. For some respondents, there were\nthoughts and concerns regarding the onset of menopause when their period was\nlate. Although in this scenario, it is helpful to pick up a delay in the period\nstart date, it further highlights the sensitive topics of gynaecological health\nthese apps are dealing with and how essential it is apps are clear on the extent\nthey are able to understand and predict individuals’ cycles.\nRespondents’ comments about the menopause demonstrate how app-facilitated period\ntracking has the potential to be an insightful and constructive habit, as early\nperi-menopause is defined by increased variation in menstrual cycle length. \n 30 \n  The ability to monitor and then recognize any changes or extremes in\nperiod dates and symptoms allows users to get to know their usual cycle\ncharacteristics. If predictions were more accurate, any variation from the\npredicted dates could be taken more seriously. This would not only help women to\nrecognize when they might be entering the peri-menopause, but also in the\ndiagnosis of reproductive health conditions that remain a challenge to diagnose,\nsuch as poly-cystic ovarian syndrome (PCOS). \n 31 \n  Therefore, the ability for patients to recognize any extremes in cycle\nlength and the increase in accurate information patients are able to provide to\ntheir HCP through data from their period tracker may improve the rates of\nefficient and beneficial diagnoses.\nCertain respondents who were on contraception appeared less anxious and worried\nwhen their period was later than predicted. Not only does this reflect the need\nfor users to be educated and apps to be clearer that they cannot be used as a\nreliable form of contraception, but also shows the importance of access to\neffective contraception. The WHO describes how access to preferred contraceptive\nmethods encompasses more than just health benefits, with increased empowerment\nand education for women – an overall aim of this present study. \n 32\nAs with any survey, this study is limited to the responses of the people who\ncompleted it. Promoting surveys on social media gives a bias to the social media\nfollowers of the person advertising the survey. The majority of women were from\nthe United Kingdom but not all were.\n\nThis study shows that period tracker apps have the potential to have a positive\nimpact on women’s lives, but only if users are aware of the limitations of\napp-facilitated period tracking and are able to understand the signs, symptoms and\nvariations of their individual menstrual cycle and reproductive health. This study\nalso demonstrates the responsibility period tracker apps have and the trust users\nhave in them, as the impact of inaccurate predictions extends into other aspects of\nusers’ health, including their mental health. Period tracker apps must be more\ntransparent with the extent of their ability to accurately predict menstrual cycle\ndates, as well as their data protection policies. This study calls for period\ntracker app companies to update their apps to be clearer to their users about their\nintended use and capabilities. Alongside this, the increased regulation of such apps\nthat are available to download freely is essential. Despite popular publications,\nsuch as Your Fertile Years, initiating unprecedented discussions, this study\nhighlights a need for increased research into menstrual health. This will not only\nwarrant evidence-based predictions by period trackers, but also ensure women are\nadequately educated about this consuming, sensitive, and constant aspect of their\nreproductive lives. On a global scale, this demonstrates the wider need for\nincreased education and research in women’s health to address the inequalities in\nbiomedicine.\n\nClick here for additional data file.\nSupplemental material, sj-doc-1-whe-10.1177_17455057221095246 for A survey of\nwomen’s experiences of using period tracker applications: Attitudes, ovulation\nprediction and how the accuracy of the app in predicting period start dates\naffects their feelings and behaviours by Anna Broad, Rina Biswakarma and Joyce C\nHarper in Women’s Health","source_license":"CC-BY-4.0","license_restricted":false}