{"paper_id":"3a992062-5bac-484d-8359-c1c7ff34f7a3","body_text":"New Zealand Medical Journal \nTe ara tika o te hauora hapori\n2023 Feb 17; 136(1570). ISSN 1175-8716\nhttps://journal.nzma.org.nz/ ©PMA \narticle\n42\nThe role of menstrual apps in healthcare: \nprovider and patient perspectives\nBryndl E Hohmann-Marriott, Tiffany Williams, Jane E Girling\nabstract\naim: This study aimed to understand the role that menstrual apps (“period tracking apps” or “fertility apps”) could perform in  \nhealthcare.\nmethods: Expert stakeholders including healthcare providers, app users, and patients offered perspectives on potential benefits,  \nconcerns, and role of apps in healthcare. Responses from an online qualitative survey ( N=144) and three online focus groups ( N=10) \nwere analysed using reflexive thematic analysis. \nresults: The role of menstrual apps in healthcare could include keeping a record of cycle dates and symptoms and assisting in the \nmanagement of menstrual disorders, diseases and conditions linked to the menstrual cycle such as endometriosis, PCOS, infertility, \nand perimenopause. Respondents are using app calendars and symptom tracking to improve communication between healthcare \nproviders and patients, while also expressing concerns about inaccuracies and other uses of data. Respondents wished for assistance \nin managing their health, while noting that apps currently are limited and suggesting that apps need to be better suited to Aotearoa \nNew Zealand specific menstrual disorders, diseases and life stages.\nconclusions:  Menstrual apps may have a role in healthcare, but further research needs to develop and evaluate app functions and \naccuracy as well as providing education and guidelines for whether and when apps are appropriate for healthcare. \nD\nigital mobile applications (apps) for \ntracking menstrual cycles, also known \nas “period tracking apps” and “fertility \napps”, are a widely used and rapidly growing \narea of mobile health and digital health, with \nover 500 million downloads worldwide. 1 These \nmenstrual apps position themselves as contrib -\nuting to health and wellbeing. Some types of \ninformation collected by menstrual apps, includ -\ning last menstrual cycle (LMC) and menstrual \nsymptoms, are used in healthcare for diagnosis \nof menstrual disorders and diseases linked to the \nmenstrual cycle, such as abnormal uterine bleed -\ning.2,3 Most menstrual apps offer features that \npurport to assist fertility and conception such \nas predictions of ovulation timing and the “fer -\ntile window”.4,5 Some offer their users screening \nand clinical advice for endometriosis, polycystic \novary syndrome (PCOS), and menopause.6,7 While \nwe do know that menstruators are using these \nfunctions in their apps, 8,9 including menstrua -\ntors in Aotearoa New Zealand and those with \nmenstrual disorders, 10,11 it is unknown whether \nhealthcare providers or patients rely on apps as a \nrecord of menstrual cycles or other information.  \nMenstrual tracking apps offer benefits \nbut also risks \nTo perform their functions, most menstrual \ntracking apps require users to input informa -\ntion at signup (e.g., typical cycle length) and \nusers are requested to input ongoing informa -\ntion about dates of menstruation. 12 Apps may \nalso allow users to track a variety of symptoms \n(e.g., amount of bleeding, pain, mood). Apps \nwill usually have an interface showing users \nthe past dates and symptoms they have logged, \narranged by calendar and/or cycle. 12 Most apps \nhave algorithms that produce predictions and \nsuggestions for users. This process is not trans -\nparent, as algorithms are treated as commer -\ncially sensitive and not revealed. 4 There appear \nto be two types of predictive algorithm used \nby apps: 5 (1) period tracking algorithms, which \ntake user-input dates of menstruation along \nwith standardised information about menstrual \ncycles and ovulation timing, and (2) fertility \nalgorithms, which incorporate user-input men -\nstruation dates along with one or more user-in -\nput physiological indicators of ovulation (e.g., \ntemperature, urine test, cervical fluid). Both \ntypes of predictive algorithms offer estimates \nof date of next menstruation and date of ovu -\nlation, 4,5,13 although these estimates have ques -\ntionable accuracy. 4,13,14  Another issue is that the \ninformation collected and created by apps may \nbe leaked, sold and shared, revealing sensitive \npersonal information to marketers, law enforce -\nment, and others. 15\n\nNew Zealand Medical Journal \nTe ara tika o te hauora hapori\n2023 Feb 17; 136(1570). ISSN 1175-8716\nhttps://journal.nzma.org.nz/ ©PMA \narticle\n43\nSymptoms related to menstrual cycles \nhave substantial effects\nMenstrual disorders and diseases are of sub -\nstantial concern in Aotearoa New Zealand and \nworldwide. Endometriosis, an inflammatory dis -\nease where tissue resembling the endometrium \nis present outside the uterus, 16 affects approxi -\nmately 11% of reproductive-age women and can \ncause severe and chronic pain, organ damage and \ninfertility.17,18 PCOS, a chronic condition defined \nby androgen excess and ovarian dysfunction, is \none of the most common endocrine and meta -\nbolic disorders among women and is also linked \nwith infertility. 19 Infertility, when pregnancy is \nnot established after 12 months of regular unpro-\ntected sexual intercourse or where a person’s \ncapacity to reproduce is impaired, 20 can have \nmultiple causes and is experienced by up to 26% \nof women in Aotearoa New Zealand who attempt \nto become pregnant. 21 Everyone with cycles will \neventually experience the cessation of their \ncycles at menopause, with the years leading up \nto menopause frequently associated with debili -\ntating symptoms.22 For all of these menstrual dis -\norders, symptoms are frequently unrecognised or \nmisdiagnosed, with research consistently finding \nthat the concerns and experiences of women and \nreproductive health patients are dismissed. 23,24 \nDiagnoses often take considerable time; for \ninstance, recent data from Aotearoa New Zealand \nsuggests a diagnostic delay of 8.7 years for endo -\nmetriosis.23 Delays in diagnosis lead to increased \nseverity, prolonged pain, decreased quality of life \nand psychosocial distress.25 Further, the economic \nburden from healthcare costs and loss of produc -\ntivity is substantive at both individual and pop -\nulation levels. 26,27 To more effectively diagnose, \ntreat and manage menstrual disorders and dis -\neases, patients are pleading for better options.26\nAim and research question\nMenstrual disorders and diseases linked to the \nmenstrual cycle could potentially be addressed by \ndigital health applications; however, an under -\nstanding of potential possibilities and limitations \nis lacking. Our study aims to understand men -\nstrual tracking apps and menstrual disorders and \ndiseases in Aotearoa New Zealand, and begins by \nasking the question: how do expert stakehold -\ners, including healthcare providers, app users \nand patients, view the role of menstrual apps in \nhealthcare?\nMethods\nStudy design\nOur study involved an online qualitative survey \nfollowed by online focus groups. Ethical approval \nfor the study was granted by the University \nHuman Ethics Committee (reference: #D21/418).\nRecruitment\nThe study aimed to engage experts and stake -\nholders with an interest in menstrual tracking \napplications and menstrual disorders and dis -\neases including endometriosis, PCOS, infertility, \nand menopause, namely healthcare providers, \npatients, app users, app developers or regula -\ntors, and researchers. A purposive sampling tech-\nnique was used to recruit participants. First, a \nlist of individuals and organisations who fit the \nstudy aim was generated by the research team. \nThe researchers then sent email invitations, \nwhich organisations shared with their members \nvia newsletters or social media. All invitations \nincluded links to study information and the online \nsurvey. At the end of the online survey there was \na link to a separate form (to ensure anonymity of \nsurvey responses) where respondents could reg -\nister interest in participating in a focus group. \nRespondents were considered eligible to partici -\npate in this study if they were aged 18 years or \nolder and gave consent based on the participant \ninformation provided. \nQualitative survey\nThe purpose of the survey was to gather initial \nperspectives from those who may be interested in \nparticipating in a focus group, and to give those \nwho could not participate in a focus group the \nchance to share perspectives. Our online quali -\ntative survey was hosted on Qualtrics and open \nfor four weeks in February 2022. Following par -\nticipants’ consent to participate in the study, the \nsurvey asked demographic information and open-\nended questions related to menstrual tracking \napps. Respondents were able to opt-out of any \nquestion. The three key questions focused on 1) \nperceived benefits; 2) perceived concerns; and 3) \nthe potential role of menstrual apps in healthcare. \nFocus groups\nFocus groups were held to expand on and \nenhance understanding of the online survey \nresponses. All interested respondents were invited \nvia email to a focus group held over a two-week \nperiod in March/April 2022. Three focus groups \n\nNew Zealand Medical Journal \nTe ara tika o te hauora hapori\n2023 Feb 17; 136(1570). ISSN 1175-8716\nhttps://journal.nzma.org.nz/ ©PMA \narticle\n44\nwere hosted on Zoom and followed a semi-struc -\ntured format. Verbal confirmation of consent \nto participate in the study and permission to \naudio-record was sought prior to commencement. \nPreliminary results from the online survey were \nshared with focus group participants to prompt \nrelevant discussion. Participants received an elec-\ntronic gift card to acknowledge their contribution. \nAnalysis\nQualitative survey responses and focus group \ndiscussions were analysed using Braun and Clarke’s \nReflexive Thematic Analysis.28 Our analysis took a \ncritical realist and semantic approach that focused \non the explicit and overt content of the responses. \nWe answered our research question by following \nthe six steps of analysis:28 To 1) familiarise ourselves \nwith the dataset we read all survey responses and \nfocus group transcripts, then 2) coded data using \nNVivo12.29 The codes were used to 3) generate ini-\ntial themes, which we 4) developed and reviewed by \ndiscussing with team members, checking against \nthe data, and revising. Finally, we 5) defined and \nnamed themes, and 6) wrote up the themes.\nResults \nRespondents\nWe received 144 responses to the online qual -\nitative survey. Just under half (45%) were par -\nticipating as app users, one-quarter (26%) were \nhealthcare providers, 17% were patients/health \nadvocates, 3% were researchers, and 3% were \napp developers or regulators. Respondent ages \nranged from 19–55 years and 92% identified their \ngender as female. Ethnicity was identified by 80% \nas NZ European, 6% as Māori and 1% as Pacific \npeoples. About half (49%) had ever used a men -\nstrual app, with the most common being Flo and \nClue, and 94% reported that they had knowledge \nand/or experience with one or more of menstru -\nation, endometriosis, PCOS, infertility, and peri/\nmenopause. A table of participant characteristics \nis included in Table 1.\nOf the survey respondents, 37 individuals \nexpressed interest and were invited to partici -\npate in a virtual focus group, held on Zoom. A \ntotal of 10 participants attended three focus group \nsessions (Healthcare Providers Group, n=4; App \nUsers Group A, n=3; App Users Group B, n=3). \nRole of menstrual apps in healthcare \nThe analysis began by considering all responses \nto the survey and focus groups to understand \nrespondents’ overall views on the role of men -\nstrual apps and their medical information in \nhealthcare. We found four main roles described \nby participants: record-keeping, management, \nself-knowledge and self-diagnosis. The first two \nroles were described consistently and had wide \nagreement, and these will be the focus of the cur -\nrent paper. The more complex and ambiguous \nroles of self-knowledge and self-diagnosis will be \nexplored in a further article.\nMenstrual apps as record-keeping\nAnalysis of survey responses and focus group \ndiscussions relating to the role of apps in record \nkeeping developed three main themes: 1) Keeping a \nrecord of past cycle dates and symptoms; 2) Showing \ncycle dates and symptoms to healthcare providers ; \nand 3) Problems with record keeping using apps.  \nThese themes are described in the following text \nand illustrative quotes are given in Table 2. \nKeeping a record of past cycle dates and symp -\ntoms was recognised most consistently by respon-\ndents as a positive function of menstrual apps. \nThe calendar aspect was mentioned as helpful \nby all types of participants, including app users \nand healthcare providers. Participants noted \nthat apps may offer improvements over other \nmethods of cycle histories. Apps are convenient \nand “easy to track as it’s on my phone, I never did \nit reliably on the calendar. ” A participant in the \nhealthcare provider focus group made the com -\nparison that “in the old days, you’d be told to write \ndown things and keep a diary, and I thought it was \nalways very difficult to do. And so now it seems \nlike actually, you could just log that ‘I had tummy \npain on these days’ .”Participants also described \napps as more accurate than memory when tak -\ning cycle histories: “ It remembers; I am amazed \nat how quickly time moves on and how easy it is \nto forget when your periods were last ”; and par -\nticularly for those with irregular cycles: “ I have \nPCOS so I find it handy to be able to track my  \nperiods as sometimes I can go months without \nhaving one .” Further, participants noted that \napps offer the option of recording symptoms. \nRespondents described menstrual apps allowing \nfor “better habits of tracking to start monitoring \nholistic symptoms ,” such as supporting users “ to \nrecord issues with pain or other symptoms .” The \nsymptom options in apps may be unsuitable, \nhowever. For some users, there were too many \noptions: “I thought the apps had an overwhelming \nnumber of fields, making it more difficult to find \nthe info I was interested in .” Conversely, other \nusers expressed that they “need more options i.e., \nwhere pain is located .”\n\nNew Zealand Medical Journal \nTe ara tika o te hauora hapori\n2023 Feb 17; 136(1570). ISSN 1175-8716\nhttps://journal.nzma.org.nz/ ©PMA \narticle\n45\nTable 1: Descriptive characteristics of online qualitative survey respondents \nN %\nExpertise\nApp user 65 45\nHealth professional 37 26\nPatient or health advocate 24 17\nResearcher 5 3\nApp developer, evaluator and/or regulator 4 3\nNo response 9 6\nTotal 144 100\nAge\nRange 19–55\nGender\nFemale 132 92\nMale 1 1\nAnother gender 3 2\nNo response 8 6\nTotal 144 100\nEthnicity\nNZ European 115 80\nMāori 8 6\nPacific peoples 2 1\nAsian 2 1\nOther/no response 17 12\nTotal 144 100\nMenstrual apps\nFlo 36 51\nClue 21 30\nPeriod Tracker 4 6\nOther1 10 14\nTotal 71 49\nKnowledge/ \nExperience\nOne or more of: menstruation, endometriosis, PCOS, infertility, \nperi/menopause 136 94\n1Other apps: My Calendar, Period Diary, Balance, Apple Health, Fitbit, Lily, Ava, Daysy, Kindara.\n\nNew Zealand Medical Journal \nTe ara tika o te hauora hapori\n2023 Feb 17; 136(1570). ISSN 1175-8716\nhttps://journal.nzma.org.nz/ ©PMA \narticle\n46\nTable 2: Menstrual apps as record-keeping – illustrative quotes from survey respondents.\nTheme 1: Recording past cycle dates and symptoms \nConvenient to enter and view data \nEasy to track as it’s on my phone, I never did it reliably on the calendar\nEasy to add data to, with you whenever you need it, has information on the app \nAccurate record of past cycle dates \nMonths fly by quickly and keeping a reminder of my cycle is why I use an app  \nIt remembers; I am amazed at how quickly time moves on and how easy it is to forget when your periods were last \n Helps keep track of more accurate data re: cycle length etc\nThey provided a useful record to look back on and compare my (irregular) cycles from month to month \nI have PCOS so I find it handy to be able to track my periods as sometimes I can go months without having one\nRecording symptoms  \nAllows for better habits of tracking to start monitoring holistic symptoms\nSimple way of monitoring menstruation cycle and the symptoms accompanying it\nTo record issues with pain or other symptoms \nEasy to add symptoms and self-assess severity \nTrack a large range of symptoms associated with the cycle \nI can track anything menstrual cycle, IBS [irritable bowel syndrome] and migraine stuff \nCan track symptoms over all cycles (from start of documentation)\nUnsuitability of recording symptoms \nI thought the apps had an overwhelming number of fields, making it more difficult to find the info I was interested in \nSometimes asks for too much information (like all the associated symptoms of bloating, acne blah blah, I don’t care \nabout those)\nNeed more options, i.e., where pain is located \nTheme 2: Showing cycle dates and symptoms to healthcare providers  \nCalendar history  \nHelp improve communication in consultation \nEasy to share the information tracked with specialist \nOne stop shop for years of records when seeing specialists \nIf you have any problems there is a good record to share with your health professional \nHaving a chronological reference of the dates and length of my periods when I need that info for doctors etc\nEasy to track symptoms/side effects of periods to take to the GP [general practitioner]/ specialists when trying to work \nout why everything hurts\n\nNew Zealand Medical Journal \nTe ara tika o te hauora hapori\n2023 Feb 17; 136(1570). ISSN 1175-8716\nhttps://journal.nzma.org.nz/ ©PMA \narticle\n47\nTheme 2: Showing cycle dates and symptoms to healthcare providers  \nCalendar history  \nThey could provide a longitudinal report of women’s health for HCPs [healthcare providers] to draw from instead of \nsimply treating symptoms\nAs a practitioner myself I find it super helpful to look through the history of the app if a woman presents with  \ninconsistent periods, infertility or even pregnancy that needs to be dated \nCredible evidence  \nAs a doctor, it gives me an objective record of a patient’s cycles, rather than relying on them to remember their LMP \n[last menstrual period] or cycle regularity  \nHaving a good way of recording symptoms regularly might help with getting an earlier diagnosis – help get doctors to \ntake people more seriously\nHaving used a tracking app for years, I could rely on objective data to convince doctors that I need surgery to confirm \nand remove endometriosis \nIf patients present this information to a doctor, it could help them get a diagnosis more quickly\nIf you need to go see a fertility specialist, it’s incredibly helpful to have information around usual cycle lengths and \nsymptoms to help them diagnose any issues, rather than uncertain answers\nTheme 3: Problems with record keeping using apps \nInaccurate data \nWhen you forgot got track and the data gets mucked up\nTrying to remember to actually update it \nTargeted to people with normal cycles \nData security and 3rd party use\nHuge security issue – what is [the] company doing with my data? \nWho else is using the information you input \nInformation not being secure – and sold to 3rd parties \nI guess I don’t really know where the data goes \nMy only concern is having the data wiped or hacked\nTable 2 (continued): Menstrual apps as record-keeping – illustrative quotes from survey respondents.\n\nNew Zealand Medical Journal \nTe ara tika o te hauora hapori\n2023 Feb 17; 136(1570). ISSN 1175-8716\nhttps://journal.nzma.org.nz/ ©PMA \narticle\n48\nTable 3: Apps as management – illustrative quotes from survey respondents.\nTheme 1: Currently helpful  \nHelpful \nHelpful when facing issues \nTracking symptoms \nTo record issues with pain or other symptoms \nCan track when you experience symptoms \nTracking severity of symptoms \nEndo/PCOS – pain locations and weight gain, also a guide/info of symptoms of both \nPreparing for symptom onset \nA way to track your symptoms leading up to and during [menstruation] so [you] can prepare to manage\nHelping woman track periods better – could mean having more information on when periods is due – and can take  \nmedications earlier which may help symptoms \nTracking has been really helpful in me identifying and understanding some of the physical premenstrual symptoms I \nget. As I take [medication] for these symptoms and there is an option to just take these for one premenstrual week it \nwould be good for that \nInformation and advice \nOffer advice on things one can do to lessen the symptoms or to support symptoms \nComfort in reading the associated information and advice \nHas forum where other people [are] going through same problems \nAlso, it shows that you are not alone in this, more often than not, there are a lot of women out there with the same \nissues\nTheme 2: Potentially helpful but need to be more suitable  \nPotentially helpful \nThey could … support a better understanding of future health \nTracking menstruation could help you prepare for life with menopause\nThey should help to bring those topics into the society \nNeed to suit place   \nIt’s still a bit generic, not NZ [New Zealand] based \nInformation is … often not specific to country – mostly American based \nNeed to suit life stages  \nIt would be great to have an option that is simple for younger girls not interested in fertility \nApps that aren’t age appropriate (for teens but not suitable for older women) \nI could picture an app that was targeted at 13-year-olds, once they’re just starting to get their period, versus an app \nthat’s targeted at people wanting to get pregnant\n\nNew Zealand Medical Journal \nTe ara tika o te hauora hapori\n2023 Feb 17; 136(1570). ISSN 1175-8716\nhttps://journal.nzma.org.nz/ ©PMA \narticle\n49\nTable 3 (continued): Apps as management – illustrative quotes from survey respondents.\nTheme 2: Potentially helpful but need to be more suitable\nNeed to be more suitable   \nCurrent one doesn’t work for IVF [in-vitro fertilisation]\nWhen you battle with fertility and a [message] comes up that you may need to consider a pregnancy test, because you \nare a few days late \nThey can be very rigid. The one I use is unable to understand why I had a very long cycle immediately after the birth of \nmy baby\nI have endometriosis, and there’s not much info about it or what women can expect to experience on each day of the \ncycle if you are an endo sufferer \nA lot of them do not adapt very well to things like PCOS, where your period isn’t very regular \nNot a one-size-fits-all, especially with PCOS \nNot too informative or helpful for someone with PCOS like myself\nMore focused on normal bodies not really with health related i.e, pcos \nEveryone might want different things. So surely you need different apps, which is why there are heaps of different apps \nout there\nShowing cycle dates and symptoms to health -\ncare providers is the second theme when consid -\nering the record-keeping role of menstrual apps. \nBoth app users and healthcare providers used app \ninformation to “improve communication in consul-\ntation.” This was described in general terms as a \ncalendar history, having “ a good record to share \nwith your health professional .” This data can be \nparticularly useful in reproductive healthcare: \n“As a practitioner myself I find it super helpful to \nlook through the history of the app if a woman \npresents with inconsistent periods, infertility or \neven pregnancy that needs to be dated .” Calendar \nhistories on apps are further recognised as cred -\nible evidence by healthcare providers. Date of \nlast menstrual period (LMP) is used frequently \nin healthcare: “ As a doctor, it gives me an objec -\ntive record of a patient’s cycles, rather than relying \non them to remember their LMP or cycle regular -\nity.” App users recognised that the app data is \nviewed as credible evidence when they present \nit to their healthcare provider: “ Having used a \ntracking app for years, I could rely on objective \ndata to convince doctors .” Using the app data to \n“help get doctors to take people more seriously \n… might help with getting an earlier diagnosis .” \nProblems with record keeping using apps  were \nexpressed by study participants in two main \nareas. Some noted that histories (and predic -\ntions) will only be accurate if the app is used \ncorrectly and consistently. As a healthcare pro -\nvider in the focus group noted: “ you’re only \ngonna get out of your app, what you put into it as \nwell. So if you’re not inputting the right informa -\ntion or enough information, it can’t tell you any -\nthing.” Survey participants noted that difficulties \noccur: “When you forget to track and the data gets \nmucked up.” Apps may be less suitable for use by \nthose with irregular cycles, as they are “ targeted \nto people with normal cycles .” There was also \nconcern about this data being collected by apps. \nAccidental data loss or leaks were mentioned by \na few respondents: “ My only concern is having \nthe data wiped or hacked .” Most of respondents’ \nconcern was for how the data was being used by \nthe app companies, with some unsure: “ I guess I \ndon’t really know where the data goes”; and other \nparticipants aware that their data and informa -\ntion was being shared but with no transparency \nabout who it was being sold or released to: “Huge \nsecurity issue- what is [the] company doing with \nmy data?”\nMenstrual apps as management\nAnalysis of survey responses and focus group \ndiscussions relating to the role of apps in man -\naging menstrual disorders and diseases showed \ntwo main themes: 1) Currently helpful for man -\n\nNew Zealand Medical Journal \nTe ara tika o te hauora hapori\n2023 Feb 17; 136(1570). ISSN 1175-8716\nhttps://journal.nzma.org.nz/ ©PMA \narticle\n50\nagement;  and 2) Potentially helpful but need to be \nmore suitable. Descriptions of these themes are \ngiven in the following text and illustrative quotes \nare presented in Table 3.\nApps are currently helpful for management  \nin some descriptions offered by survey respon -\ndents. There were a few broad statements such \nas: “ helpful when facing issues .” Participants \ndescribed three ways that menstrual apps could \nhelp. One way was through tracking symptoms \nspecific to the disease or disorder. Some noted \nspecific symptoms such as pain, others noted \ntracking options such as timing or severity of \nsymptoms. Another way was tracking cycles \nto prepare for symptom onset. As one survey \nrespondent described, the app offers “ a way to \ntrack your symptoms leading up to and during \n[menstruation] so [you] can prepare to manage .” \nA further way is through providing information \nand advice. The apps “ offer advice on things one \ncan do to lessen the symptoms or to support symp-\ntoms” as well as having a “forum where other peo-\nple [are] going through same problems .”\nA greater number of participants noted that \nmenstrual apps are potentially helpful but need \nto be more suitable . These respondents were \nmore speculative about app benefits, writing \nabout what apps “could” and “should” do. They \ndescribed apps as unsuitable in several aspects. \nApps need to suit Aotearoa New Zealand context. \nRespondents noted that “it’s still a bit generic, not \nNZ based .” Apps also need to suit age and stage. \nIn particular, there was a call for apps to be bet -\nter suited to younger users: “ It would be great \nto have an option that is simple for younger girls \nnot interested in fertility .” In addition, apps need \nto suit menstrual disorders and diseases. Many \nrespondents noted that apps were unsuited to \nthose experiencing specific menstrual disorders \nand diseases along with their symptoms and \ntreatments. App predictions “ do not adapt very \nwell to things like PCOS, where your period isn’t \nvery regular .” This echoes the theme in the pre -\nvious section where respondents noted that apps \nappear to be designed for those with “normal” \ncycles and are not well-suited to anyone with \nlonger, shorter, or irregular cycles. App notifi -\ncations may also be unsuitable, such as: “ When \nyou battle with fertility and a [message] comes up \nthat you may need to consider a pregnancy test, \nbecause you are a few days late .”\nSumming up these observations, a participant \nin the healthcare provider focus group noted that \n“everyone might want different things. So surely \nyou need different apps, which is why there are \nheaps of different apps out there .”\nDiscussion and conclusion\nOur study invited expert stakeholders to offer \nperspectives about the medical information  \nprovided by menstrual apps and the possible \nrole of this information in healthcare. These \n144 participants included healthcare provid -\ners, menstrual app users, and patients with \nmenstrual disorders and diseases linked to the \nmenstrual cycle including endometriosis, PCOS, \ninfertility, and perimenopause. Our analysis of \ntheir statements in qualitative surveys and focus \ngroups conceptualised four ways that menstrual \napps could play a role in healthcare: as record \nkeeping, management, self-knowledge, and self-  \ndiagnosis. This paper focused on the first two of \nthese roles, with the final two roles the focus of \na separate paper. \nFor record-keeping, participants reported that \nmenstrual apps are currently used in healthcare \nas calendar histories of menstrual cycle dates \nand symptoms. As these records are viewed as \nreliable and credible, the overall perspective was \nthat apps can improve communication between \nhealthcare providers and patients. This improved \ncommunication may offer a way to address exist -\ning delays in recognising and diagnosing men -\nstrual disorders and diseases. 21,22,23 Concerns \nremain, however, about potential inaccuracies \nand misuses of data and information collected \nand provided by the menstrual apps, highlight -\ning this problematic aspect of apps. 4,10,13,14 \nThe participants in our study called for assis -\ntance in managing menstrual disorders and dis -\neases. Although they viewed apps as currently \nable to help to a limited extent, they noted sub -\nstantial need for more appropriate support. This \nindicates that, at this point, apps do not appear to \nbe a viable answer to patient calls for more effec -\ntive treatment and management options. 24\nThis research provided an initial look at the \nperspectives held by experts and stakeholders \nabout the uses of menstrual apps and their med -\nical information in healthcare. The limits of our \nsmall, localised, and self-selected sample and \nqualitative responses means that we have kept \nour conclusions focused on demonstrating the \nexistence of menstrual app use in healthcare, \nconceptualising the possible role of app informa -\ntion, and offering a starting point for developing \nfurther research questions.\n\nNew Zealand Medical Journal \nTe ara tika o te hauora hapori\n2023 Feb 17; 136(1570). ISSN 1175-8716\nhttps://journal.nzma.org.nz/ ©PMA \narticle\n51\nWhat we can do now\nOur findings suggest that healthcare provid -\ners may consider the calendar record on apps \nas an additional form of menstrual cycle history. \nThese calendars may be able to supplement and  \ncorroborate, but not replace, patient experiences. \nThose who have concerns about their cycles and/\nor symptoms can create a calendar record to aid \ncommunication with healthcare providers. Exist -\ning apps could possibly play a role in helping \nthose diagnosed with menstrual disorders and \ndiseases to manage their symptoms (e.g., by pre -\nparing for menstrual cycle phases). We advise \nthat any recommendations or suggestions about \nmenstrual apps should disclose that apps may \nnot be suitable for those with nonstandard cycles \nand may not be applicable to Aotearoa New Zea -\nland. Apps and recommendations also need \nto be transparent about the potential for harm \nthrough apps sending inappropriate and dis -\ntressing notifications, as well as the potential for \npatient information being leaked or stolen, used \nfor commercial and advertising purposes, and/or \nshared with agencies and law enforcement. \nWhat is still needed\nApp users, patients, and healthcare providers \nin our study are calling for the development of \nsuitable apps. All apps need to be able to account \nfor variable and irregular cycles. Further, there \nis a need for apps that support treatment and  \nmanagement of menstrual disorders, diseases and \nsymptoms. Although there may be apps designed \nfor some menstrual disorders and diseases, our \nparticipants were not aware of these, indicating \na need for more information about any existing \napps. Our respondents also sought apps applicable \nto Aotearoa New Zealand and life course stages. \nTo rely on these apps, patients and healthcare \nproviders must be assured of the accuracy and \neffectiveness of menstrual app predications and \ninformation. Our research suggests that further \nresearch should focus on evaluating app function-\nality, comprehensively assessing how apps are used \nin healthcare, and establishing education and guid-\nance for patients and providers on whether, when, \nand how to use menstrual apps in healthcare.\n\nNew Zealand Medical Journal \nTe ara tika o te hauora hapori\n2023 Feb 17; 136(1570). ISSN 1175-8716\nhttps://journal.nzma.org.nz/ ©PMA \narticle\n52\ncompeting interests\nNil.\nacknowledgements\nThis research was supported by a Health Delivery \nResearch Activation Grant from the Health Research \nCouncil of Aotearoa New Zealand. The authors would \nlike to acknowledge additional members of the \nresearch team: Dr Stella Cameron, Romulo Nieva Jr, \nand Agayunus Asby. \nauthor information\nBryndl E Hohmann-Marriott: Associate Professor of \nSociology, School of Social Sciences, University  \nof Otago, Dunedin, Aotearoa New Zealand\nTiffany A Williams: Faculty of Medical and Health \nSciences, University of Auckland, Auckland,  \nAotearoa New Zealand.\nJane E Girling: Associate Professor in Anatomy, \nDepartment of Anatomy, School of Biomedical \nSciences, University of Otago, Dunedin,  \nAotearoa New Zealand.\ncorresponding author\nBryndl Hohmann-Marriott: Sociology, Gender Studies \nand Criminology, University of Otago, PO Box 56, \nDunedin 9054, New Zealand. Ph: +64 3 479 8447.  \nE: bryndl.hohmann-marriott@otago.ac.nz\nreferences\n1. Rampazzo F, Raybould A, Rampazzo P , Barker R. \nFrom the stork to fertility apps. 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