{"paper_id":"eca644b4-e192-495e-9839-5402ecb7421a","body_text":"npj | women's health Perspective\nhttps://doi.org/10.1038/s44294-025-00094-8\nMenstrual health and endometriosis:\ncosts incurred by women, health systems\nand society\nCheck for updates\nManjulaa Narasimhan1 , Jennifer J. K. Rasanathan1,M i c h e l l eR e m m e2, Caitlin Kennedy3,\nMaclaine Barré-Quick3,P a s c a l eA l l o t e y1,G o o d n e s sO d e y4 &S e r g i oT o r r e s - R u e d a5,6\nSexual and reproductive health and rights (SRHR) are central to overall health and well-being.\nAdvancing women’s gynaecological health is an aspect of SRHR that has been inadequately\nprioritized. We highlight the costs incurred by women, health systems and societies associated with\nmenstrual health and endometriosis to underscore critical unmet women ’s health needs and call for\ninterventions to mitigate society-wide economic repercussions of poor gynaecological health\nin women.\nComprehensive sexual and reproduc tive health and rights (SRHR) are\ncentral to realizing overall health and well-being for all individuals and are\nintegral to national efforts to achieve universal health coverage\n1. The reali-\nzation of comprehensive SRHR for women is compromised by the way in\nwhich many elements of SRHR have been underprioritized, insufficiently\nresearched or inadequately financed, including women ’s gynaecological\nhealth2. In many settings, including high-income countries, women lack\naccess to the full range of gynaecological health services, including education\nregarding the physiologic process of menstruation\n3 as well as timely diag-\nnosis of conditions like endometriosis or vulvodynia.\nFailures to support women’s gynaecological health can incur a steep, if\noften invisible, toll on women’s health since it is directly associated with\nquality of life and impacts other aspects of health, including mental health4.\nPoor gynaecological health may also limit women’s autonomy, hinder social\nrelationships or curtail their economic participation in some settings.\nConversely, since health is an important determinant of school attendance\nand labour force participation, efforts to support the comprehensive reali-\nzation of SRHR could promote economic prosperity. However, existing\ndata on the costs associated with either implementing SRHR programmes\nor failing to address SRHR have tended to focus on contraception and\nmaternal health interventions, with less attention to women’s gynaecolo-\ngical health\n2,5–7. Thus, the economic case for greater prioritization of\nwomen’s gynaecological health beyond reproductive functions and sexually\ntransmitted infections has not yet been suf ficiently well made, and the\nassociated costs and cost-effectiveness of services and products are\nunderstudied.\nThis article highlights available evidence regarding the costs entailed in\nrealizing women’s gynaecological health\n2,b yf o c u s i n go nt w oc r i t i c a l\ncomponents: menstrual health and endometriosis 8,9.W et a k eab r o a d\napproach to defining these costs and include out-of-pocket costs incurred by\nwomen (e.g., costs of purchasing menstrual products), costs incurred by\nhealth systems (e.g., the direct costs of providing treatment for endome-\nt r i o s i s ) ,a sw e l la st h eg r e a t e ro p p o r t u nity costs accruing to society (e.g.,\nreductions in women’s productivity as a result of absenteeism). We specify\nwhich type of costs we refer to throughout the article. We adopt the Ter-\nminology Action Group of the Global Menstrual Collective’sd efinition of\nmenstrual health:“a state of complete physical, mental, and social well-being\nand not merely the absence of disease or infirmity, in relation to the men-\nstrual cycle.”\n10 By sharing existing evidence on the costs associated with\nmenstrual health and endometriosis, we aim to draw the attention of pol-\nicymakers and health system administrators to under-recognized SRHR\nneeds and priorities of women and to support the allocation of greater\nfinancial resources for quality sexu al and reproductive health service\nprovision.\nIn this article, the term ‘women’ is used inclusively to refer to all\nwomen, girls, and gender-diverse individuals who identify as women across\ntheir life course and the diversity of li ved experiences, including but not\nlimited to women with disabilities, experiencing homelessness, undergoing\nincarceration and/or institutionalization, displaced due to conflicts, climate\nchange or other humanitarian crises, living with human immunodeficiency\nvirus (HIV), belonging to minori ty, racial or ethnic groups, and\nIndigenous women.\n1Department of Sexual and Reproductive Health and Research, World Health Organization, includes the UNDP/UNFPA/UNICEF/WHO/World Bank Special\nProgramme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland. 2Thematic Cluster for Human Rights, Gender\nand Health Equity, The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland. 3Social and Behavioural Interventions Program, Department of\nInternational Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. 4Department of Health Policy, London School of Economics and\nPolitical Science (LSE); London, United Kingdom & London School of Hygiene and Tropical Medicine (LSHTM), London, UK. 5Department of Global Health and\nDevelopment, London School of Hygiene & Tropical Medicine, London, UK. 6Genesis Analytics, Johannesburg, South Africa. e-mail: narasimhanm@who.int\nnpj Women's Health |            (2025) 3:54 1\n1234567890():,;\n1234567890():,;\n\nGender inequality and intersecting determinants shape\nwomen’s economic status and gynaecological health\nGender inequality and patriarchalgender norms shape and limit women’s\neconomic agency and preclude women from making autonomous decisions\non critical aspects of their own health. At a structural level, gender inequality\ninteracts with economic status and other social, political, and commercial\ndeterminants of health – such as housing, access to clean water and sani-\ntation, food (in)security , educational attainment, and environmental\nexposures– to broadly give rise to the exposures and conditions that shape\nwomen’sh e a l t h11. For instance, various structural, social, and commercial\ndeterminants may compel women to make decisions regarding their\ngynaecological health that have detrimental downstream impacts on their\noverall health or quality of life\n12.T h i si sh a p p e n i n gi nI n d i a ,f o re x a m p l e ,\nwhere young women working in sugar canefields are choosing to undergo\nhysterectomies to stop menstruating in order to maintain paid employment\nand improve their ability to survive, at times experiencing subsequent\nchronic pain13. This situation is a marker of gender inequality and reflects\nthe lack of appropriate and acceptable services for women’s gynaecological\nhealth common to many settings, particularly affecting women with low\neconomic power. While women in some settings have greater access to\nhealth services than men by virtue of seeking perinatal health care, services\nto address women ’s SRHR needs beyond reproduction are frequently\nunaffordable, unavailable, inaccessible, or unacceptable.\nExisting economic evidence: the costs of women’s\ngynaecological health\nWe conducted a rapid, semi-systematic review of existing evidence on the\ncosts associated with menstrual health and endometriosis, as well as the\ncost-effectiveness of related services in order to build a narrative under-\nstanding of costs. We restricted our search to peer-reviewed articles pub-\nlished in English and indexed in PubMed between 1 January 2000 and 13\nNovember 2023. We used a variety of search terms based on published\nsystematic reviews in these areas and used economic search terms to capture\nab r o a dd efinition of costs. We did not employany geographical restrictions\nto the search. Retrieved articles were reviewed for and sorted by relevance\nand full text availability by one author, comprising most of the evidence\ndescribed here. The reference lists of relevant articles were also reviewed to\nidentify peer-reviewed manuscripts and grey literature not yet retrieved.\nFinally, where relevant, additional references were included from authors’\npersonal libraries. We report currency as United States dollars (US$) with\nthe year of reporting, when provided in referenced sources.\nMenstrual health\nAcross the world, more than 2 billion women menstruate each month14,a n d\ndysmenorrhoea, or pain associated with menstruation, is the most common\nmenstrual symptom among adolescent girls and young women, with pre-\nvalence rates ranging from 50% to 90%\n15,16.E v e nw h e ne x p e r i e n c e da sa n\nuncomplicated physiologic process, menstruation incurs regular costs to\nwomen and girls. These include out-of-pocket costs for over-the-counter\nanalgesics or products to reduce discomfort; out-of-pocket costs for man-\nufactured menstrual products such as pads, tampons, hormone-containing\nmedications, absorbent underwear, sponges, or menstrual cups; and indirect\ncosts related to the time and energy spent procuring these products or\nwashing materials such as cloth or rags to manage menses\n17.\nCosts of menstrual products . Period poverty, or the lack of access to\nmenstrual products due to financial constraints, disproportionately\naffects women and girls in low-income, con flict-affected and humani-\ntarian settings18,19. A non-peer-reviewed study investigating the monthly\ncosts of a set package of 20 tampons, 25 panty-liners and 24 200 mg\ntablets of ibuprofen based on online prices listed for local pharmacies and\nsupermarkets in 107 countries of all income levels found that costs ranged\nin 2023 from US$ 1.09 in El Salvador to US$ 34.05 in Algeria\n20. Afford-\nability was lowest in Algeria, Zambia and Nigeria, where women would\nhave to spend between 10 –15% of their average monthly income on\nmenstruation products\n20. A cost-effectiveness and cost-benefit analysis of\nan open cluster randomized controlled pilot study providing either\nmenstrual cups or one year’s worth of sanitary pads to girls aged 14 to 16\nyear in rural Kenya found that providing menstrual cups and sanitary\npads would cost annually US$ (2019) 3.27 and 24 per girl reached,\nrespectively, where the gross living wage is approximately US$ 200 per\nmonth\n21.\nW o m e ni nm a n ys e t t i n g sm a yb es u b j e c tt ot h e“rural premium,”\nwhereby menstrual products often cost more in rural areas than in urban\ncentres due to supply chain inefficiencies, transportation costs, and limited\nmarket competition\n22. A systematic review and meta-analysis published in\n2021 suggests that reusable menstrual pads are likely less costly over time23,\nbut single use/disposable menstrual products may be less expensive\ninitially\n9,21. Further, many countries of all income levels impose standard\nvalue added tax (VAT) on menstrual products24. Higher prices in rural areas\nand the economic burden of taxation on sanitary products dis-\nproportionately affect economically vulnerable populations, exacerbating\nperiod poverty22.C o m m u n i t y - b a s e dfinancing and/or subsidy models could\nimprove the affordability of menstrual products. Programmes like AFRI-\npads and Huru International provide cost-effective reusable pads through\nlocal distribution networks, maki ng menstrual health products more\nfinancially accessible to low-income women and girls\n25,26.E x e m p t i n g\nmenstrual products from VAT– or applying a reduced tax rate– may also\nimprove their affordability and could have broader positive externalities for\neducation and health. However, research suggests that VAT exemptions\nalone are insufficient to make menstrual products more affordable, as price\ncontrols and distribution policies must also be in place to ensure consumer\nprices are reduced\n27. Digital and community-driven innovations may\nadditionally reduce economic barriers and improve access to menstrual\nhygiene products in low-resource settings, although evidence is more lim-\nited. For example, apps could map and share locations where menstrual\nproducts are cheaper or freely available while geographic information sys-\ntems could be used to improve distribution and avoid stockouts\n28.\nEfforts focused on reducing consumer prices and improving accessi-\nbility of menstrual products may not adequately address the additional\nresource requirements associated with menstruation, including waste dis-\nposal options as well as access to spaces to change menstrual materials and\nwater to wash or dry menstrual products and clean hands and bodies\n9,17.I n\nregions with limited access to clean w ater, women spend additional time\ncollecting and managing water for hygiene during menstruation, equating\nto indirect costs when monetized against local wages\n19.\nSchool attendance and labour force participation . The costs of\nmenstrual health are not limited to menstrual products and practices.\nInadequate access to sustainable, acceptable menstrual products and lack\nof cleanliness, privacy and safety in the physical environment may\nobligate women and girls to engage in menstrual practices that interfere\nwith their participation in school or the labour force, often leading to\nlong-term economic disadvantages for individuals and society\n9,29. For\nexample, a 2016 systematic review and meta-analysis of 97,070 girls\nacross 138 studies in India found that one in four girls missed one or more\ndays of school during their menses\n30. Similarly, in a 2013 cross-sectional\nstudy of 2332 girls aged 11 to 17 years from 700 schools in Bangladesh,\n931 girls (41%) reported missing school during menses, and 82% of girls\ndeemed school facilities to be inappropriate for menstrual hygiene\n31.A\npilot study in Ghana involving 120 girls aged 12 to 18 years from\n2008–2009 found that providing puberty education – with or without\nmenstrual pads – improved school attendance compared to girls who had\nnot received either, possibly re flecting the value of destigmatizing men-\nstrual health information for improving school attendance during\nmenstruation in some settings\n32. Evidence on the overall effectiveness of\nmenstrual health interventions for improving school attendance is scarce\nand limited by the challenges of implementing and evaluating these\ninterventions in low and middle income countries (LMICs), including\nlow comparability of educational outcomes across contexts\n33. Overall,\nhttps://doi.org/10.1038/s44294-025-00094-8 Perspective\nnpj Women's Health |            (2025) 3:54 2\n\ncurrent evidence suggests that menstruation has variable consequences\non education, related to multiple aspects of menstrual experience\nincluding fear and stigma, unavailable or unreliable products, inadequate\nknowledge among girls and unsupportive infrastructure\n9.\nThe growing body of evidence suggests that when menstruation is\nexperienced negatively, it in fluences the economic empowerment of\nwomen, leading to absenteeism from school and the workplace 34 or\nreductions in labour productivity. For example, in Japan, a 2011 cross-\nsectional, survey-based study involving a nationally representative sample of\n19,254 women ages 15 to 49 years found that increasing severity of men-\nstrual symptoms and self-reported heavy bleeding were found to be asso-\nciated with greater work productivity losses in the order of US$ (2022) 11.4\nbillion per year\n35. There is less data on the impact of supplying menstrual\nproducts to women on their participation in the workforce and very little\na v a i l a b l ee v i d e n c eo nt h ei m p a c t so fm e n s t r u a t i o ni na d u l tw o m e no v e r a l l\n33\n,36. The economic costs of menstruation-related workplace absenteeism and\nfuture productivity losses are likely g r e a t e ri ns o m es e t t i n g sa n df o rs o m e\nwomen than others. For example, unl ike women in formal employment,\nmany informal workers, including those in the Africa region, lack paid sick\nleave or workplace accommodations,exacerbating economic insecurity37.\nCosts of unmet needs for health care. In addition to recurring out-of-\npocket costs related to buying menstrual products, women with men-\nstrual health issues or concerns who lack access to health and social\nprotection schemes must either pay high out-of-pocket fees for health\nservices or forego menstrual health care altogether, having no choice but\nto endure the health consequences that arise from their unmet needs for\ncare\n38. Affordability is an integral aspect of access and encompasses direct\npayment(s) for health services, medicines and other commodities as well\nas transportation costs, payments to cover childcare or other care-taking\nresponsibilities, and wages lost while seeking care. For example, women\nattending a sexual and reproductive health care facility in urban South\nAfrica seeking care for menstrual problems had to spend US$ (2022) 45\nout of pocket over the course of two visits in addition to foregoing income\nof US$ (2022) 20, on average\n39. Costs also accrue to health systems when\nwomen with longstanding unmet needs for care or who previously\nreceived poor-quality health care present to secondary, urgent or emer-\ngent care services.\nEndometriosis\nEndometriosis is the growth of endome trial tissue outside of the uterus,\noften giving rise to heavy menstrual bleeding, dysmenorrhoea or even severe\nchronic pelvic pain, and a range of other symptoms such as dyspareunia and\nfatigue\n40. Approximately 10% of women of reproductive age are estimated to\nbe affected by endometriosis globally41. Women with endometriosis have\ndouble the risk of infertility compared to women without endometriosis42.\nDiagnosis of endometriosis currently requires laparoscopic surgery, which is\ncostly, where available. Sensitive, non-surgical diagnostic modalities have\nthe potential to increase rates of diagnosis and reduce the costs associated\nwith endometriosis, but an inexpensive, widely accessible diagnostic test is\ncurrently lacking (a saliva-based diagnostic test is in clinical trials)43,44.A t\npresent, the diagnostic delay for women with endometriosis is 6 to 7 years on\naverage\n45, and in some settings may be as long as 11 to 20 years46.I nm a n y\nAfrican countries, the diagnosis of endometriosis is often delayed due to a\nlack of specialized healthcare serv ices, limited awareness among both\nhealthcare providers and patients, as well as limited access to gynaecological\nspecialists and diagnostic tools such as laparoscopy\n47. Delays may also result\nfrom pervasive normalization of pain related to menstruation, stigmatiza-\ntion, or dismissal of women’s reported symptoms. Women with endome-\ntriosis often visit multiple healthcare providers before receiving a correct\ndiagnosis, incurring significant out-of-pocket expenses for consultations,\nmedications, and ineffective treatments48,49.\nDirect and indirect costs . There is some evidence - mostly from high-\nincome countries and which varies widely in terms of study type, data\nsources and participants - on the direct health care costs related to\nendometriosis, or the costs incurred via medical management of symp-\ntoms. Until recently, little data on indirect costs had been reported\n50,51,a s\nindirect costs for endometriosis are difficult to quantify comprehensively\nand studies have de fined these costs inconsistently. For example, an\nindustry-funded systematic review of studies published in English\nbetween 2000 and 2013 included 12 primary studies that reported direct\nor indirect costs associated with endometriosis\n51. Across the 5 studies in\nthis systematic review reporting indirect costs, they were de fined and\ncalculated as: sick leave and unemployment due to endometriosis per\npatient per year; productivity loss per patient per unit time; lost pro-\nductivity and leisure per patient per year; absenteeism-related cost per\nemployed woman per week; and presenteeism-related cost (reduced\nproductivity at work due to symptoms) per woman per week\n51.\nIn this systematic review, ten studies were conducted in or included\ndata exclusively from high-income cou n t r i e si nN o r t hA m e r i c aa n dE u r o p e ,\none was conducted in Brazil, and another study reported data from\nArgentina, Belgium, Brazil, China, England, Ireland, Italy, Nigeria, Spain\nand the US. Estimates of total direct costs including inpatient and outpatient\ncosts, medicines and other services ranged from US$ (2013 dollars) 1,109 in\nCanada to 12,118 in the United States (US). The estimated indirect costs\nwere higher and ranged from US$ (2013dollars) 3,314 per patient per year\nin Austria and 3854 in Canada up to 15,737 in the US\n51. For reference, the\nannual combined (direct and indirect) cost per woman with endometriosis\nin the US is estimated to be 11–70% higher than the annual cost per patient\nwith diabetes in the US\n52.\nIn contrast, absent quality, available, accessible, and acceptable diag-\nnosis and treatment services, direct costs for endometriosis among women\nin low-income settings – measured by proxy variables such as heavy\nmenstrual bleeding or dysmenorrhoea– m a ya p p e a rf a l s e l yl o wa su n m e t\nneeds persist\n39,47 while indirect costs, namely lifelong productivity losses, are\nlikely substantial49. Evidence from LMIC regarding the economic costs of\nendometriosis and health-related quality of life is limited 45. One cross-\nsectional study of 410 women in Northern Cyprus reports lower direct costs\nto individuals and society but that productivity losses comprise the biggest\nproportion of the overall annual cost53.\nProfessional outcomes . Endometriosis and endometriosis-related\nsymptoms have been associated with negative professional outcomes\nin women before and after formal diagnosis and treatment, including\nincreased sick leave and work impai rment, in addition to productivity\nlosses at work\n49,54,55. For example, a multi-centre study assessing the\nimpact of endometriosis on quality of life and work productivity via\nquestionnaires administered to women with and without endome-\ntriosis in Argentina, Belgium, Brazil, China, England, Ireland, Italy,\nNigeria, Spain and the US between 2008 –2010 found that women with\nendometriosis lost on average 10.8 hours of work per week and were\nabsent nearly 3 hours more than women without endometriosis\n48.\nFurther, increased absenteeism ma y result in longer-term reduced\nearning potential. One industry-fu nded retrospective cohort study\nassessing insurance claims from 1999 –2017 for 42 companies covering\n4.4 million bene ficiaries in the US compared work loss events and\nsalary/growth in women ages 18 to 49 with endometriosis to women\nwithout endometriosis (6851 matched pairs) for five years following\nendometriosis diagnosis. Women with endometriosis had average\nannual salaries that were lower by US$ (2020) 3697 –6600 in years 2 to 5\nand experienced less year-on-year salary growth than women without\nendometriosis\n56.\nCosts of longer-term sequelae . Few – if any – studies that attempt to\nestimate the costs of endometriosis have included the costs of medium-\nto-long term sequelae, such as endometriosis-related infertility42,51, either\nas direct costs (medical care of infertility and assisted-reproductive\ntechnologies) or as indirect costs (loss of productivity, absenteeism and\npresenteeism associated with seeking and undergoing infertility care).\nhttps://doi.org/10.1038/s44294-025-00094-8 Perspective\nnpj Women's Health |            (2025) 3:54 3\n\nDiscussion\nThe costs of women’s gynaecological health, as exemplified by menstrual\nhealth and endometriosis, can be substantial for women, health systems and\nsociety. The true economic burden associated with menstrual health and\nendometriosis is likely underestimated, and existing data is not compre-\nhensive for several reasons. First, existing economic evidence regarding the\ncosts of women’s gynaecological health includes almost entirely non-dis-\nabled, cis-gender, heterosexual women. Research targeting speci fics u b -\npopulations would likelyreveal higher costs. Second, most data come from\nhigh-income countries where the average ability of women to afford out-of-\npocket costs is greater, averting further financial or health consequences.\nAvailable data, particularly for endometriosis, is somewhat homogenous\nand not representative of the diverseexperiences for most women across the\nworld. Third, most of the literature regarding menstrual health, its impacts\non education and employment, and the associated economic costs considers\nthe average experience of uncomplicated menstruation. These studies do\nnot explicitly include or account for the costs (to the individual or the health\nsystem) of challenges associated with menstruation, such as dysmenor-\nrhoea, heavy menstrual bleeding resulting in iron-deficiency anaemia, or\nabnormal menstrual bleeding.\nFourth, while some economic studies of both menstrual health and\nendometriosis include indirect costs such as loss of productivity, many\nclosely related, short- and long-term health and well-being outcomes (and\ntheir relevant additional costs) are not considered in existing evaluations.\nFor example, when women do not have access to needed health services,\nthey must often accept negative, multi-dimensional consequences such as\npain and poor individual health, social exclusion or isolation and lower\neconomic power\n57,58 that result in poor mental health outcomes and/or\nnegative impacts on family and co mmunity relationships. The con-\nsequential costs of these outcomes (including out-of-pocket expenditures\nborne by women and health system costs) are not systematically captured.\nEconomic evaluations pertaining t o gynaecological health needs must\ntherefore also consider the pain and losses in well-being and opportunity\nthat result from an inability to access services due to individual or national\nfinancial constraints. In addition, and as is the case in many health areas,\nevaluations tend to remain siloed across sectors. Investments in water,\nsanitation and hygiene (WASH) co uld lead to large improvements in\nmenstrual health\n59. Not only are studies quantifying the economic benefits\nof WASH interventions lacking, but studies to date have tended to measure\nfew health outcomes, potentially missing positive externalities within health\nthat could imply even greater cost-effectiveness of interventions. This\nincludes, for example, accounting for the impact of improved menstrual\nhealth on the incidence of bacterial vaginosis and sexually transmitted\ninfections (STIs)\n60,61.\nFurther, some gynaecological events have a cumulative effect over time.\nEvaluation of these long-term and complex impacts is crucial62, but they are\nrarely taken into account in economic evaluations. For instance, dropping\nout of school due to lack of access to appropriate toilets and other\nmenstruation-related challenges in school can result in diminished eco-\nnomic opportunities for girls co mpared to boys, as well as reduced\nknowledge about SRHR. They may, consequently, be at increased risk of\nunintended pregnancies, STIs, early marriage and gender-based violence,\nfurther compromising their health and well-being\n63. Life course approaches\nhave been used to better capture the complexities of cumulative health needs\nover time, particularly as life expectancy increases3, and could be used more\nexplicitly to guide or structure economic evaluations. A life course approach\nmight additionally facilitate greater attention to women ’s gynaecological\nhealth beyond reproduction, including peri-menopause and menopause,\nfor which services are often lacking64. To inform a more efficient, equitable,\npeople-centred allocation of health resources, further research on both the\nbreadth and magnitude of economic costs related to women ’sS R H Ri s\nneeded.\nIn order to better understand the hidden costs related to poor gynae-\ncological health that many women fa ce globally, a programme of future\nresearch needs to include: (a) a thorough mapping of sexual and\nreproductive health and well-being issues that women face across their life\ncourse; (b) the development of a more fulsome framework for evaluating the\neconomic impacts related to women’s SRHR that captures women in all\ntheir diversity as well as downstream health impacts; (c) a greater\nexploration of out-of-pocket costs borne by women in accessing these ser-\nvices and in their ability to self-care; (d) systematic surveying of women’s\nsexual and reproductive health services included in, and excluded from,\nhealth benefit packages and social insurance programmes across countries;\nand (e) a broader and more inclusive approach to measuring disease burden\nof women’s health, in addition to greater quanti fication of consequences\nbeyond the health sector. Future research should also explore integrated\ninterventions that address menstrual health as both a public health priority\nand an economic development issue, recognizing its multidimensional\nimpact on education, labour, and gender equity. Health system andfinan-\ncing policies that include explicit protection for and link benefits to women’s\nneeds, includingfinancial incentives for health and care workers to promote\ngender-responsive care, could help progress women’s SRHR.\nThere are some limitations to our analysis. First, we did not conduct a\nfull systematic review. We limited ou r search to manuscripts written in\nEnglish in only one database, PubMed, and prioritized manuscripts for\nwhich the full text was readily available. However, PubMed is the largest\ndatabase of its kind, we reviewed a large proportion of relevant articles\nretrieved in the search, and there was a great deal of coherence across studies\nincluded in the review, allowing us to characterize the likely economic\nburden of menstrual health and endometriosis on women, health systems\nand society (as well as associated gaps). Second, we draw on this subset of\navailable evidence of the costs associated with menstrual health and endo-\nmetriosis to highlight under-recognized SRHR needs and priorities of\nwomen and to call for further research. It is possible that studies of other\naspects of women ’s gynaecological health h a v em o r ec o m p r e h e n s i v e l y\ndescribed the associated costs. Third, while we attempted to include data\nfrom a wide range of settings and did not restrict our search by geography or\ncountry income level, most publish ed studies come from high-income\ncountries. Economic costs may be higher in these settings because of greater\nearning potential and heightened costs of medical care, but the absolute\nhealth and well-being impacts may be most acute in lower-income settings,\nincluding for women who go without quality health care that isfinancially\nunattainable. Finally, while economic analyses help to draw attention to\nwomen’s health issues, economics is not the sole lens through which these\nissues should be evaluated. The notion that a physiological process requires\nmedical management amounts to medi calization, and raising concerns\nregarding productivity losses to help justify greater attention to women’s\nempowerment and well-being is a capitalistic argument\n65,66. Women deserve\nautonomy, time to rest and the freedomto prioritize their health and well-\nbeing without being reduced to the sum of their economic contributions.\nPolicies should strive to balance economic arguments with holistic health\nperspectives\n67,68.\nConclusion\nMenstrual health and endometriosis incur substantial costs to individual\nwomen, health systems and society that are underestimated. Further, the\nfinancial, physical and emotional burden of poor gynaecological health on\nwomen is not well understood or quantified. Menstrual health is an aspect of\nhealth that can signi ficantly impact the overall health and well-being of\nwomen, but which has received insuf ficient attention in public health\nresponses\n69. Addressing the multifaceted and substantive costs associated\nwith menstrual health, endometriosis, and other sexual and reproductive\nhealth issues that accrue to women, their families, communities, and\nsocieties requires comprehensive healthcare strategies, including preven-\ntion, early intervention, and support for affected women to mitigate the\noverall economic burden.\nWe intentionally situated women’s gynaecological health outcomes\nwithin the context and complexities of the structural and social determi-\nnants of health, reinforcing the linkages between women’s economic status\nand their ability to realize the highest attainable state of SRHR. As such,\nhttps://doi.org/10.1038/s44294-025-00094-8 Perspective\nnpj Women's Health |            (2025) 3:54 4\n\nfuture research and priority-setting regarding women’sS R H Ra n dw e l l -\nbeing must prioritize equity and centre the communities rendered vulner-\nable in their specific social, cultural, and political context(s). There is a need\nfor researchers to engage in - and for donors to fund - research that advances\nthe economic case for realizing SRHR with explicit attention to populations\nwho have been excluded from economi c evaluations to date and where\nevidence of impact is currently lacking. Such a programme of research could\ninfluence intervention targeting and resource prioritization on the road\ntowards improving health and well-being of women and universal health\ncoverage.\nData availability\nNo datasets were generated or analysed during the current study.\nReceived: 18 March 2025; Accepted: 23 July 2025;\nReferences\n1. World Health Organization. Sexual and Reproductive Health for All: 20\nYears of the Global Strategy. https://www.who.int/news/item/16-05-\n2024-sexual-and-reproductive-health-for-all-20-years-of-the-\nglobal-strategy (16 May 2024).\n2. Ghebreyesus, T. A., Allotey, P. & Narasimhan, M. 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All authors reviewed and contributed to the\nmanuscript.\nCompeting interests\nThe authors declare no competing interests.\nAdditional information\nCorrespondenceand requests for materials should be addressed to\nManjulaa Narasimhan.\nReprints and permissions informationis available at\nhttp://www.nature.com/reprints\nPublisher’s noteSpringer Nature remains neutral with regard to jurisdictional\nclaims in published maps and institutional affiliations.\nhttps://doi.org/10.1038/s44294-025-00094-8 Perspective\nnpj Women's Health |            (2025) 3:54 6\n\nOpen Access This article is licensed under a Creative Commons\nAttribution-NonCommercial-NoDerivatives 4.0 International License,\nwhich permits any non-commercial use, sharing, distribution and\nreproduction in any medium or format, as long as you give appropriate\ncredit to the original author(s) and the source, provide a link to the Creative\nCommons licence, and indicate if you modi fied the licensed material. 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