Menstrual experiences of adolescent female school pupils in England

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Maybin, Joyce C Harper This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4692690/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Mar, 2026 Read the published version in BMC Public Health → Version 1 posted 4 You are reading this latest preprint version Abstract Background Menstruation can negatively impact quality of life (QoL), particularly during adolescence. In addition to physical and emotional symptoms, there is a stigma surrounding menstruation and a lack of support and education; which can have detrimental effects on wellbeing. This study aims to ( 1 ) explore if girls in schools across South East England feel that periods affect their wellbeing, ( 2 ) to understand the support and education that girls receive and ( 3 ) to suggest changes to improve menstrual health education and support in English schools. Methods Eight focus groups were carried out in four schools, two in each school, with a total of 49 year-10 girls participating (all cisgender). Four questions were asked in each focus group relating to the girls’ attitudes to having a period, how their period affected their wellbeing, the support they need and how could education be improved. Results The girls had mostly negative attitudes about periods, and said their periods negatively impacted their physical, emotional, and social QoL, affecting areas such as friendships, schoolwork, and socialising. They expressed a desire for more menstrual education and for boys to be included. They wanted improved menstrual support, especially at school, in the form of access to period products, days off school, and emotional support. Conclusion This study highlights the negative impact that menstruation can have on the QoL of girls. It also shows the need for improved support and education for both boys and girls from an early age; which may help dissipate period stigma and increase QoL. Figures Figure 1 Introduction The menstrual cycle is the female reproductive hormone cycle that is controlled by the hypothalamic-pituitary-ovarian (HPO) axis 1 and lasts for approximately 28 days 2 . Menstruation, commonly referred to as a period, is the shedding of the endometrium that occurs during the first part of the menstrual cycle, lasting between 2–8 days 2 . Menarche is defined as the first menstrual period, which typically occurs between the ages of 10–16 3 . Factors including genetics, nutritional status, exercise, and general health determine the age of menarche 3 . The menstrual cycle is typically most irregular and problematic around the beginning and the end of a female’s reproductive life; following menarche and at peri-menopause 4 . In our recent study of perimenopausal women’s menstrual experiences, many referred to menarche as a significant life event and the peri-menopause as a time when they reported irregular and problematic periods 5 . Menarche is often an overwhelming experience for many; one study found that girls described starting their periods as ‘scary’ and ‘horrible’, stating, ‘I thought I was going to die’ and ‘I had no idea’ 6 . In addition to this, the unpredictable nature of menstruation during adolescence can impact a girl’s wellbeing. Symptoms such as pelvic pain, heavy menstrual bleeding and cycle-related emotional disturbance can have significant negative impacts on a girl’s QoL. Periods can stop pupils from being able to go to school, affect concentration in class, limit social interactions and participation in sports and negatively impact mental health 7 . Normal menstruation occurs at regular monthly intervals, with manageable blood loss that is not prolonged and does not have troublesome physical or psychological symptoms that interfere with QoL 8 . Symptoms that signify abnormal menstruation include abnormal uterine bleeding (AUB), which involves changes to the volume, duration, regulation or frequency of menstrual bleeds 1 . Problematic menstruation may also be due to dysmenorrhea (painful periods) and/or pre-menstrual syndrome (PMS) 9 , which is a collection of symptoms occurring pre-menstruation including painful breasts, bloating, irritability, low mood, brain fog, and fatigue. In many cases, the underlying cause of abnormal menstrual symptoms is unknown. These symptoms may be due to endometriosis, a condition in which tissue similar to the lining of the uterus (endometrium) grows outside of the uterus; or polycystic ovary syndrome (PCOS), a condition where the ovaries produce multiple follicles and associated with irregular ovulation 10 . Periods can also negatively impact mental health. Whilst slight mood disturbances are considered normal if they do not interfere with QoL, more significant psychological symptoms during menstruation may be signs of severe premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). PMDD is a severe form of PMS that can cause significant distress and functional impairment, with symptoms including low mood, anxiety, anger, interpersonal conflicts, and sleep disturbances 11 . In addition to this, those with diagnosed mental health conditions such as anxiety and depression may also experience an exacerbation of their symptoms before and during menstruation, which is thought to be due to the relationship between estrogen, progesterone and mood 12 . Stigma is defined as ‘a strong feeling of disapproval that most people in society have about something’ 13 . Menstruation has always held a particularly strong sense of stigma and shame 14 . As a result of this, periods are often not talked about and the education and support for menstruation it is poor 15 . Period stigma leads to a lack of discussion around periods, which in turn impacts knowledge, meaning that many girls do not know how to manage their periods or what to do when they have a problem with them. This has a domino effect on other areas, as unresolved period issues such as heavy bleeding, cramps, and emotional issues can impact a person’s ability to go to school or work, take part in activities, and socialise 6 . In addition to this, period stigma often leads to feelings of shame; a negative, self-conscious emotion that can significantly impact a person’s wellbeing. Shame also leads to girls being too embarrassed to speak to their parents, teachers or healthcare providers about issues with their period, which can have significant negative implications on their wellbeing and the support they receive 16 . In a UK-based study, 14% of girls admitted that they did not know what was happening when they had their first period, and 1 in 4 did not know what to do when it happened 6 . Secondary schools throughout the United Kingdom (UK) have a curriculum for relationship and sex education (RSE) that includes menstruation, however, it is heavily focused on the biology of periods rather than experiences, management, support and stigma 17 . The 2019 survey for the Women’s Health Strategy found that less than 1 in 5 women feel they have enough information on menstrual wellbeing 18 . Lack of support in schools and good quality education around menstruation also leads to increased rates of school dropouts and low attendance, due to the challenges that girls face trying to manage menstruation in unsupportive environments 19 . This research project aims to determine how periods are affecting girls within schools in England. Using focus groups enabled discussions with girls about their attitudes to their period, the effect of their periods on their physical, emotional, and social wellbeing, the support they had received from friends, family and school, and what support they need and the education they had received about periods and what education they need. Methods Informal surveying was conducted with adolescent girls in schools in England prior to designing this study. Reproductive health was discussed and anonymous answers questions highlighted that menstruation was significantly affecting the wellbeing of adolescent girls. Focus group questions were designed by the research team to represent the areas that had been highlighted by the informal survey to prioritise the experiences of adolescent girls. Some of the questions were used in a sister project on perimenopausal women 29 . School teachers reviewed the questions prior to the focus groups to ensure they were suitable and accurately represented the areas in which adolescents were reporting issues. The focus groups consisted of four questions. 1. How do you feel about having a period? 2. How does your period affect your wellbeing? 3. What support do you need to manage your menstrual cycle/period? 4. How could we improve education around periods? Ethics Ethical approval was obtained from the ethics committee at University College London (UCL) reference 9831/008. Informed consent was obtained from the parents and the participant. Recruitment and Data Collection Focus groups were carried out in four schools across England in London, Hertfordshire and Essex, with 49 girls in Year 10. Demographic data for each school is shown in table 1. Individual demographic data was not collected for the study to protect the confidentiality of participants, as they were all under the age of 18. Two focus groups were carried out at each school, making a total of eight focus groups. Each group contained between five and nine girls, totalling 49 girls overall. The girls were all in year 10, making them between 14 and 15 years old. Once potential schools had expressed interest in the study, they were sent the participant information sheet and consent form and distress guidelines. The participant information sheet contained information regarding inclusion criteria for the focus groups; details of the research team; aims of the study; what the focus groups will involve; risks and benefits of taking part; data protection; and a consent form. The distress guidelines contained information on how distress will be identified and minimized, including a step-by-step response guide for the researchers to follow. Each participant and their parent/guardian was required to read and sign the consent form before the focus groups. Dates for focus groups were arranged with a staff member at each school. The first and last authors obtained DBS checks and attended four schools between May and June 2023. They carried out two focus groups at each school, with each session lasting approximately 60 minutes. The schools provided a suitable room for the focus groups. At the beginning of each session, two phones were set to record. The research team introduced themselves and explained the study to the girls. They explained how the focus groups would work and ensured the girls knew what to do if they felt distressed at any point. The researchers also checked throughout the sessions for signs of distress. The girls were asked each question in turn and the researchers ensured that all girls answered all questions. Once the focus groups were finished, transcripts were made from the recordings, they were checked for accuracy, and the audio recordings were deleted. Qualatative Analysis Immediately following each focus group, the team discussed the main findings from the group and gave feedback to the teachers. A summary of each session was written to accurately encapsulate the discussion and tone and begin understanding initial thoughts and ideas. After completion of all eight focus groups, each session’s transcript was read closely to ensure familiarization 29 . Transcripts were then broken apart by question, allowing answers to each question to be read in full, and was then analysed individually to identify initial codes. By using notes gathered during familiarization based on answers to each question, initial codes were systematically distinguished, and relevant data was sorted into each code. This allowed for further familiarization with the data, as well as a chance to better recognize patterns. Repeated thoughts and particularly meaningful sentiments were noted alongside initial thoughts and ideas pertaining to the data. Codes were then sorted into themes that were reviewed against the overall dataset to ensure that it was representative. Themes were refined iteratively by both researchers until it was determined that the overall narrative of the girls was adequately conveyed. Results All the girls were engaged in the focus groups and were keen to share their stories, thoughts, and opinions. Many were passionate about the topic and were eager about the prospect of change within menstrual support and education. 1. How do you feel about having a period? Every girl had their own unique experiences of menstruation. Most girls described negative feelings towards menstruation, although a few spoke about positive aspects. Figure 1 shows a word cloud illustrating some of the words and phrases used by the participants when asked how they feel about having a period. Three themes were identified for this question: negative feelings: it would be so much better if they did not exist ; neutral feelings: it is just part of life ; and positive feelings: it unifies girls . Negative Feelings: It Would Be So Much Better if They Did Not Exist The majority of girls had negative feelings about their periods, and described them as “annoying”, “painful”, and “horrible”. They wished they did not have to have periods, and felt it was unfair that they had to go through it, but that boys did not have to. They said their periods were very uncomfortable and got in the way of a lot of actitivies and impacted them by affecting their mood, school life, social life, sports, and home life. They explained that being on their period altered their outlook on the day and that not being able to control it was inconvenient. They also talked about how they hated having their period because it made them anxious about bleeding through their clothes: “It’s unfair. Because we have to have this every month for like most of our whole lives, and then when it stops as well it’s not like easy as well, and then the boys have nothing.” “I hate my period so much. I really struggle with it, and it’s just, like, it would be so much better if I didn’t have it.” Neutral Feelings: It Is Just a Part of Life A few of the girls felt that whilst periods were annoying, they were a normal experience that did not get in the way of their lives. They explained how they would rather not have them, but they just accepted it: “Obviously I’d prefer not to have it, just because it’s like… it does complicate things, but at the end of the day, like, it’s a natural process of life and it’s just something that you have to like, accept, and kind of go through life having.” “I think that it’s a neutral thing like I don’t think it’s good or bad, it just happens once a month and I’m like ‘Oh, okay, here it goes!’” Positive Feelings: It Unifies Girls A few girls said that they saw periods as a blessing. They explained that in earlier years, periods were viewed as a curse, but as they got older it became less of a big deal and unified girls: “It’s seen as the dreaded thing when you’re about… when you’re in year 6 and year 5 and whatever, and everyone’s like ‘oh my god period, first birthday’, whatever… but I feel like once you get to like, a bit older and a bit more mature, it’s like, it kind of unifies girls, because it’s something you can like, talk to each other about freely, and it’s not something that boys have, so maybe, in a way that like, it’s first viewed as like a curse and whatever, depending on how much trouble it brings you it’s kind of a blessing as well, cos you can like, like, talk about it with people.” 2. How does your period affect your wellbeing? Five themes were identified for this question: physical symptoms: everything hurts ; emotions and mental health: I feel so unstable ; school: it is unbearable to be there ; social life: I do not want to go out ; and sport: I just cannot do it . Physical Symptoms: Everything Hurts The majority of girls reported having dealt with menstrual pain. Some girls had mild pain, whilst others had moderate-severe pain that affected their QoL. They said that their cramps stopped them from being able to do things such as go to school or go out with friends. They added that paracetamol does not help them, so they had to try and cope with the pain: “When it gets to like, the point, it’s like my first, second and third day, where I just cannot move, like it’s so bad I like, I’m actually like screaming sometimes, and like, I’ll be shaking. It can be really bad.” “I literally can’t get out of bed. That’s how bad they are like I literally can’t get up.” Several girls said they experienced pre-menstrual symptoms such as fatigue, back pain, cramps, and nausea. They described feeling “heavy” and “exhausted” and said that this time in their cycle was “hell”. They told us how these symptoms affected them being able to leave the house: “The week before my period is hell! Like I feel so heavy and exhausted.” “The week before my period I always feel really nauseous, it makes me feel really ill, like, faint. So, that’s not great, ‘cos it just stops me from like going out ‘cos I don’t wanna like, feel sick or be sick or anything like that. And then cramps on top of that is not great!” Emotions and Mental Health: I Feel So Unstable Many girls reported that they experienced emotional difficulties before and during their period such as mood swings, anxiety, anger, crying, irritability and low mood. They spoke about how these symptoms affected their day-to-day life, their home environment, and their relationships with others. They spoke about how much stronger their emotions were during their period, and they also said they felt emotionally unstable and had many different emotions at once. They said that they were much less able to cope with day-to-day life when they were menstruating: “I think I get really grumpy, and I experience my emotions more.” “I just get like, really irritable, like really easily.” Some of the girls had mental health difficulties such as eating disorders, body image issues, anxiety and depression, which they said were worse during menstruation. A variety of issues relating to mental illness and menstruation came up, such as worsened body image, panic attacks, depressed mood, suicidal thoughts, and binge eating urges: “I think my period affects like, how I feel about myself. So, usually before and during my period I’m really bloated, and then that just makes me feel ten times worse about my body image.” “This is like really kinda personal, but I get like incredibly like, really, like, really badly depressed and suicidal, like on the week before.” School and Education: It Is Unbearable to Be There Several girls reported having struggled to go to school because of their symptoms. A few said they had to take days off school, and others went to school but struggled to get through the day. They felt they missed out on classwork as well as time with their friends, and described having to go to school on their period as “unbearable”: “It’s like, unbearable to be in school when you have such bad period cramps. Sometimes it’s even unbearable to get out of bed.” “Usually the first couple of days I’m just in so much pain, last time I had to go home, I just couldn’t concentrate or anything.” The girls said their period affected their concentration at school. They said that they did not have the same motivation as usual and that their cramps and other symptoms made them unable to focus during class: “I think it does like, make concentration kind of like, changes quite a lot, and then I can’t focus and then I miss a lesson. It’s annoying have to like go back and then be like, have to do it over again on my own, just ‘cos like, I wasn’t able to before ‘cos of really bad cramps.” “You can’t be bothered to revise when you’re on your period, you can’t be bothered to do anything.” Several girls reported that menstruation affected them during exam time, by reducing their motivation and affecting their performance. They explained how they often ended up getting lower grades than usual when they were on their period, and that they had to put a lot more effort in to motivate themselves to study. They also told us how getting cramps during exams distracted them: “If I’m on my period during an exam, I tend to do worse than I usually do.” “I think, especially during exam time, if you get your period it like, it like takes a toll on your mood. So then you’re like less motivated to do like, say, put that extra hour work in. But then if you get a cramp in the middle of the exam hall and you’re just thinking ‘Oh no! What have I done!’” Social Life: I Do Not Want to Go Out The main issue regarding social life was that some girls did not want to go out during their period because of their symptoms. They often wanted to stay in bed, but that they then felt sad about missing out on fun with their friends, which affected their mood. Some of the girls also spoke about feeling bad about having mood swings when they were on their period, as they did not want to upset any of their friends: “When I’m on my period I just don’t feel like going out. I just don’t get excited because I’m on my period.” “I feel, like, I don’t really, sometimes when I would normally wanna go out, I don’t want to, and then I feel sad about not wanting to go out, and it all just gets spiralled into one big thing that’s not really anything!” Some girls said they felt anxious about potentially leaking in public. Many said they had to pay close attention to what they wore when they were menstruating out of fear of being embarrassed if they leaked, which took the fun out of socialising: “It’s always like, I’m always nervous going out, because it’s like, I have to watch what I wear and stuff. I mean, I went to tennis the other day and I came back and my whole shorts were like, completely ruined, ‘cos I thought I’d finished but then obviously, and it’s like, you’re always weary when you go out, cos you don’t wanna, you know leak or anything because it’s known as embarrassing when you leak – and I don’t think it should be – but I think now everyone just thinks it’s embarrassing when you have it.” “I always get scared just in case I won’t have a pad on, like ‘what if I leak’, ‘how is everyone gonna react’. I always carry my pads with me and everything, but then like, I always think like, just in case, what’s gonna happen if like, I’m out with my friends and then I suddenly get it and I didn’t even know. It’s always that like, fear.” Sport and Exercise: I Just Cannot Do It Many girls did sports such as rowing, dancing, football and running. They spoke about how their period affected their training and competitions because of cramps, fatigue, and reduced motivation, and mentioned that the unpredictable nature of periods affected their sport. They also said that their overall performance was worse and that they sometimes had to miss training because of their period: “I miss training if it’s that bad, like, ‘cos I can throw up quite a lot like I won’t be able to move ‘cos it hurts that bad, so I just have to get my mum to phone my coach and be like ‘she’s not coming ‘cos she’s on her period’.” “So I play football and it really affects me sometimes. Training is so hard, and I have really bad cramps.” Many girls said they struggled with physical education and did not want to take part. They said they felt uncomfortable exercising on their period, and that the teachers were not understanding about letting them sit out: “It’s quite uncomfortable like, just that feeling inside your body. And then you have to go and like, run about and stuff like that. It’s just not nice really.” “I’ve had friends who have had like, really bad cramps and have gone to the P.E teacher to like, ask to sit out, and then the P.E teachers are just like ‘I get a period too’, like, ‘just deal with it’.” 3. What kind of support do you need to manage your period? The level of support that each girl had varied depending on several factors such as family dynamics, their friendship group, and which school they attended. Three themes were identified for this question: school: no one will help me; family: it is complicated ; and peers: they are there for me . School: No One Will Help Me Overall, the support received at school was poor. The girls did not feel supported and felt as though there was a major lack of understanding. Often teachers told them to ‘just deal with it’ and that ‘everybody gets a period’, and they felt that in general, teachers were more focused on education than on student wellbeing. They gave examples what teachers had said to them about periods, which highlighted the extent of misunderstanding among staff. The girls expressed a need for having someone at school that they could talk to about periods, which would make them feel more supported: “I don’t really talk to any teachers at school about it because I just feel like they don’t really care that much. It’s more, it’s more like focusing on your education rather than like, how you feel and your health, I feel.” “Teachers they just don’t… I dunno, like, if I was to say to like, a random teacher, ‘Oh I’m on my period’ like, ‘I need to go to the toilet’, or something, ‘I need to do this’, like, they’d look at me as if I’m gross. And I just feel like, oh, and then I think I’m gross.” The girls said that when they went to see the school nurse about their period, often they were not allowed to go home, and they got sent back to class or told to sit in the medical room and drink a glass of water. They were frustrated that they were made to stay in school even though they could not focus - so there was not much point in them being there anyway. Some of them had even been advised by their GP to take time off school during their period and they had produced notes to confirm this. There were also reports of parents lying to the school about why their daughter needed to come home from school, as this was the only way the school allowed it. The girls wanted improved school support: some needed to be allowed to have days off or to be sent home from school when they were on their period: “Every time I go down to student reception I’ll be like, ask to go home, and they won’t let me go home. So then I have to message my mum – we’re not supposed to, but I had to message my mum – to say like, I’m in so much pain, I wanna come home. So she has to make up some excuse like I’ve got a doctor’s appointment and phone them up so I can sign out, ‘cos they won’t let me go home. And I’ll literally sit down there for hours, and they still just won’t let me go.” “…They’d say just the most horrible things when you’re on your period, like, they’d be like, ‘Oh everybody goes through their period, you don’t need to be this emotional and this dramatic about it’ or like ‘you just need to go back to your lesson and deal with it, every single woman deals with this, even I deal with this’.” At every school, the girls spoke about how teachers often did not let them go to the toilet during class, even if they explained that they were on their period. They said that different teachers had different rules. One school said it was their policy that girls could go to the toilet during lessons, but this rarely happened. The girls said this affected their concentration and that it sometimes caused them to leak. One girl expressed how not being allowed to go to the toilet at school was one of the reasons she did not want to come in when she was on her period. They asked to be better supported: “In a lesson when I wanna go, the teachers don’t let me, and I can’t concentrate. I remember this one time I asked my biology teacher, I asked her three times, and the second and third time I was literally crying, and she didn’t let me go.” “I remember in year 8, ages ago but I can still remember ‘cos it was that embarrassing I can still remember it now, and I asked every two minutes she was like ‘no, no, no’ and then I leaked, and I was like yeah, that’s why I needed to go!” There was a difference in how they were treated by male versus female teachers when it came to needing to go to the toilet during lessons. Most said male teachers were more likely to let them go to the toilet, maybe because they felt uncomfortable. However, a few said that the male teachers did not let them go because they did not understand periods: “If you say to a male teacher you’re on your period, they don’t wanna talk about it, so they just say ‘go!’” “Some teachers are like, really strict about not letting you go to the toilet, and it’s awkward having to say, especially to like, a male teacher, ‘I’m on my period I need to go to the toilet’, and then, then again sometimes they won’t let you go. And especially like, men, they don’t understand, and for them to sit there and say you can’t go to the toilet is like, really bad.” Female teachers were stricter about letting them go to the toilet and that they often made comments about them also being on their period and having to deal with it too: “The female teachers say, ‘Well we’re on ours so how do you think we’re coping with it’ – they try argue with you about it.” “I feel like it’s a lot of like, really older, like female teachers as well. I don’t know if they’ve just, gotten so used to it or something like that but they just don’t have any empathy. You can literally be like ‘I really need to go to the bathroom, I’m on my period’ and they’re like ‘no’ – and I’m like, I guess I’ll just bleed on your seat.” At all of the schools, the girls reported issues with the toilets. They were frequently described as “disgusting”, and were reported to have been very busy, especially at breaktime. Girls from one school reported that blocks of toilets were regularly locked which reduced access, and that there were always teachers present in the toilets which made them feel uncomfortable. “At break and lunch, there’s not enough space in the toilets anyway, so we’ve got three years of girls in one toilet set, so there’s not really enough space anyway.” “Along with the toilets being locked, for a while, a lot of the toilets were like, out of order, like, all the time. And just like, there’s never any room in there really, and like, there’s always like, a teacher standing there and like, telling you to get out, so you don’t really have any time. And there’s always a queue outside, to like, get in.” The access to period products varied between schools. One school had period products available in the toilets, but this was usually empty. However, if they needed them, they could get them from the school nurse, but this was inconvenient if they suddenly got their period without realising it. In one school they had to go to the administration office, which most felt uncomfortable about. One school had a facility called ‘the hive’ which had a cupboard with a range of period products including period pants and tights. All of the girls said they would like easier access to period products in the toilets. “I think they should be in the toilets because I’d feel awkward going to the office for stuff like that.” “I’d much prefer being able to quietly grab what I need instead of having to ask.” There were varying views about free period products in the toilets: “Putting sanitary products in bathrooms – I think it’s a good idea, but you can’t control how many people take or like, how they use it because sometimes bathrooms are just quite awful. So, if they put it in the bathrooms, what’s to say someone won’t put them on the floor, take too many, make a mess… and then it just like, defeats the purpose.” “I think it’s about a collective maturity and I feel like that comes when like, periods are brought into discussion more. So like, for example, I mean, it’s kind of immature to be messing up sanitary products, that could’ve saved someone’s day or something, but I feel like, the more periods are talked about, and like, normalised, the more it becomes seen as like, a thing that people need to understand, and as it’s been talked about more in schools and it like, brings awareness to the male teachers and the ability to go to the bathroom I think it’s really, it’s really a necessity if you’re on your period – and if someone’s telling you you can’t go, you can’t just sit there! And it’s hard to like, build a common ground with the teachers where they understand, because like, as a teenager or a pre-teen, it’s quite hard to say like ‘oh I really need to go’, there’s like an embarrassment that comes with that. And I feel like just being able to talk to our teachers and like, normalise the period, I feel like that would help a lot.” Family: It Is Complicated The girls had different experiences of support at home, as well as varying family dynamics, relationships and circumstances. Generally, most girls spoke very positively about their relationships with their mums. Many said they had open conversations and felt like they could talk to their mum about anything. “My mum is my bestest friend out of everyone, and I always talk to her about everything.” “My mum and I, we’re very open about it, and she’s very into learning more about it, like, menopause and things, so we have very good conversations about how periods affect us and everything.” Generally, dads were awkward about the topic but tried to support them. Some dads did what they could by buying chocolate or other things they needed: “I’m a lot more awkward talking to my dad about it because he doesn’t understand it as much.” “My dad isn’t like, awkward about it, but when it does come up in conversations he like, kind of edges out of the conversation a bit.” However, having a supportive family environment was not the case for all. Some girls said they felt their parents were not understanding of the issues they had with their periods. They reported having parents who did not take their menstrual symptoms seriously and who told them to ‘stop being dramatic’. Others said their parents told them off when they had mood swings. A few explained that because their mums never had difficult periods, they did not understand, which led to them feeling unsupported: “…I just can’t really do anything about it because I’ll tell my parents and they’ll just say, ‘Everybody gets a period, you don’t have to be this dramatic about it’.” “…And obviously like, my family don’t understand, ‘cos, my mum’s like handled her period really well like she literally never got cramps or anything, but it’s just so bad.” Having separated parents was associated with more turbulent support depending on which parent they lived with. A few of the girls described the differences they felt in support between the two households. Several girls talked about how their dads were generally great, but they felt uncomfortable talking about periods. They spoke about how, when they stayed with their dads, they did not feel as much support compared to when they stayed with their mums, where they felt much more supported, had period products available, and could talk openly about their period. Some of them even said that when they first started their period, they wouldn’t stay at their dad’s house because they felt so embarrassed: “My parents don’t live together, so when I’m at my dad’s house it’s completely different to when I’m at my mum’s because my dad’s attitude towards it is to kind of avoid it, just don’t talk about it. And cos I live with my little brother as well, he just gets all like, icky about it. Whereas when I’m at my mum’s, it’s like, a lot calmer. Like, I can tell her that I’ve got really bad cramps – whereas my dad’s like, ‘Ohhhh’. I don’t know… I just don’t think… like lots of people just don’t understand.” “When I first started my period I didn’t talk to my dad about it at all, and so I wouldn’t stay at his for like, whenever I was on, ‘cos I just didn’t want to talk to him about it… but then eventually, like as I got older, I was like, it’s something that every girl goes through and there’s no point in being embarrassed about it.” The girls with older sisters felt well-supported and were comfortable talking about periods. They told us that periods were a topic of conversation early in their life, which meant they were prepared when they reached menarche. They explained how this made periods feel less shameful, and that they felt they could have more open conversations about periods and their symptoms: “I’m pretty comfortable, like, talking about it and I knew about it early on in life as well because I have an older sister, so I’ve always spoken about it with her, and my mum as well, but mainly my sister.” “I have like, two sisters, and my mum obviously, so like, a predominantly like, female household, so we’re all like really open about it and I feel like it’s really nice.” The girls with brothers ran into issues with being teased. They felt the need for boys and dads to be more educated about periods so that they could offer more support. The girls with brothers had much more negative experiences compared to those with sisters. One girl said her younger brother bullied her when she was on her period and called her disgusting. However, some of the girls had more supportive brothers, who wanted to learn about periods: “I have a younger brother and he sort of bullies me to get me upset. And if I’m on the toilet for a while like, sorting myself out, he’ll like bang on the door and like, say ‘you’re disgusting’, he like, really bullies me. It’s really awful.” Peers: They Are There for Me Many of the girls spoke highly of the support they received from friends. They spoke about how comfortable they felt talking about periods, and how understanding their friends were. They said their friends supported them through everything and that they never felt judged by them. Manyl said that if they needed a period product at school, they would ask their friends rather than a teacher: “Well, I think I’d just feel comfortable saying anything to them. Like, ‘Check me’ or like, ‘Have you got anything’…I just feel really comfortable with them, and I think they feel comfortable with me to talk about it.” “I love being able to talk about like, anything with my friends… it’s really nice to know that I have friends that are there for me and support me.” Some girls however spoke about how they had more reserved friendship groups: “It does come up every now and again, but the conversation does move on quite quickly.” “It’s not like, a super open thing, and I won’t randomly go up to my friends and be like ‘Oh yeah guys I’m on my period today’, like, it just, unless I need help from them, I don’t bring it up. I feel like, my group, it’s not talked about particularly.” On the other hand, the girls did not have such positive experiences with boys. They said that most boys were disgusted by periods and could sometimes made mean comments or jokes towards them. They said they can give them a really hard time and do not offer much support. They explained that they think boys behave this way because they had not been taught about periods, and therefore did not understand them: “A lot of my friends are male, and they tend to get really disgusted about it and tease me about it. They’re not very understanding, and they’re really mean about it. They don’t support me that much.” “They’re almost disgusted by it, and they just give you a hard time about it.” However, a few mentioned some positive experiences where boys were interested in learning and were considerate about what kind of support the girls might have need. One of the girls said an experience they had where a boy expressed to her that he was interested in periods, and another girl said that boys tended to be a lot more caring when they were on their own and not in big groups: “…he said, ‘I’m actually interested in them’, and he asked me all these questions.” “The girls, we’re able to have the most open conversations. But with the boys I think, when they’re on their own they’re like ‘Do you want chocolate, do you want me to buy you something’, but when they’re together they try to show off in front of each other.” 4. How can we improve education about periods? None of the girls had received good menstrual education at school. Overall, four themes were identified for this question: level of education: I have barely learnt a thing ; content of education: we need to know more ; teaching style: how and when we are taught ; and educating boys: they do not understand. Level of Education: I Have Barely Learnt a Thing Many girls told us that they had never had lessons about periods at secondary school, and a few of them said that they did not get taught at primary school either. Those who did learn about periods in primary school said it was very minimal. Some girls said their parents told them a bit about periods, but they had to figure a lot of it out by themselves. Others said their parents did not tell them about it and they found out from friends who started before them. “I don’t really remember learning anything about it. Like, when I came into secondary school, no one really spoke about it – like teachers, and I never got taught about it, so I just had to find out on my own. Obviously, I had my mum telling me and my dad telling me ‘This is going to happen’, but from the school, there wasn’t really anything said about it.” “I’ve not learnt anything about periods when I came to secondary school. Like, the only time I learnt about it was in primary and from my parents, that’s the only time, and then the rest I just had to figure out myself.” Content of Education: We Need to Know More The girls that had been taught about periods in school told us how the content was mainly scientific, and that what they were taught was vague, and only really explained the basics of how and why periods happen. They felt it would be better if they were taught how to deal with periods, about what kind of symptoms can occur, how much blood there should be and how many days the bleeding should last, as well as about conditions related to menstruation. A few girls also said they had learnt more on social media than they had from school or their parents, and without this, they would not know what they do about periods: “We need to have lessons on how to deal with it. How are we supposed to deal with it emotionally and physically if we just don’t know?” “I think we talked a little about it in school, but I’ve actually learnt more – like, you get lots off TikTok and everything, you get loads of like, ‘what your period blood should look like’, like, actually have like, examples on pads and everything. We do have some education, but not really in schools, and I think that like, learning about how your blood should look like, and how long your blood should come for – because obviously it varies like some people can have it all week and sometimes I only have it for like two days and I was really confused about that for ages because obviously, some people have it for a whole week…I think we should have more education on that”. Several girls said how they would like to be taught more about their whole menstrual cycle rather than just about periods. They spoke about how it was not just their period that affected them, and that they would therefore like to learn about how each stage of the menstrual cycle can affect people: “I feel like I would want to know like, about my entire menstrual cycle, because it’s not just a period, and we get a lot of education on just the period, but the days surrounding, the days after, how it affects you, like your appearance, your like, mental state, etc. I feel like instead of just focusing on ‘you get five or seven days a month that might be really horrible, here’s what you can do’, like, embracing the period and like, utilising it at your peak. It helps you to manage it more. So like, a deeper education that’s not just in biology would help I think.” “I think they should know about the actual cycle itself, so I think if they understood the cycle, they would understand about like when you’re on your period and ovulation and things like that, and sort of understand what you’re going through.” The girls did not know what a normal period should be like. They said they needed to be taught more about how to recognise what is normal and when they should see a doctor. They told us that at school they were told that ‘everything is normal’, but this resulted in the girls feeling confused about the symptoms they were having. Even the girls with severe symptoms felt like they had to just put up with their symptoms until they learned that they were not normal from social media. They expressed a need to learn more about knowing when to seek help from a medical professional: “No, because they love telling us that everything is normal! That’s like the favourite phrase, it’s like ‘everything’s normal don’t worry’, and it’s like, it’s great, ‘cos it’s like, it’s good, I see why they do it, ‘cos then it’s like removing the ‘different isn’t normal and you’re weird’, but at the same time, it’s like ‘but should I be going through this much pain’ or ‘should this actually be happening’” “Not really, and then like sometimes I see things on TikTok like I saw this thing on TikTok saying like, if your periods are like, actually proper painful like it’s not normal, and I didn’t realise that. I get really bad cramps, and I’ve always just thought that’s normal.” Teaching Style: How and When We Are Taught Many girls said that the age when they first learnt about periods should have been younger. Some of them got their period before they had learnt about it, which meant they had no idea what was happening. They said whilst some of them had family members who educated them about periods, they are aware that not everyone had this, and therefore schools need to be more proactive in teaching younger years about periods: “I think that maybe there should be more introduction especially, at least year 5 or 6 in primary school, because I know some of my close friends from primary school got their periods in year 6, or like, late in year 5, and they kind of had no idea what was going on. I got mine, not very early, but like in the summer I think of going into year 7. So, I had spoken to my sister and my mum about it so I knew what was going on, but I think especially if you grow up in maybe a household where there are more men than women, then maybe you don’t know as much about it, then I think learning about it at school when you’re younger will help.” “When I started I didn’t know anything about it, I was really shocked.” The girls said that who taught them about periods was an important factor in how comfortable they felt and how well they learned. They also expressed a need for male teachers to be more educated. They said that some of the teachers seemed to find it an awkward subject to teach which created a tense learning environment. Some girls suggested that there is a need for teachers to undergo reproductive training whilst they are studying for their teaching qualification so that they can provide students with more engaging, informative lessons and menstrual support: “The teachers seem to find it a bit awkward and a bit of a taboo subject, and the class is sitting there like all tense, and they start laughing at the smallest thing.” “Some teachers aren’t necessarily that open about it, so I feel like especially for these sort of like lessons, maybe some teachers that are better than others, and it’s kind of just luck whether you get a good one or not.” Educating Boys: They Do Not Understand All of the girls said that they think boys need to be better educated about periods. They explained that boys were immature when it came to periods, which often led to them teasing the girls, making jokes, and sometimes being nasty. They said that they thought they were like this because they had not been properly educated about what periods are and what it is like for girls to experience them, and therefore, they thought that if they were taught about them, their behaviour towards girls would improve. They mentioned how beneficial it would be if men and boys had a better understanding of periods and how to support the people in their lives who menstruate: “They’re not supportive because they don’t understand it. So I think if you taught them about it, like if you make it, like if you actually get it into their heads ‘this is important’, ‘this is what happens’, I think that they’d understand it more.” “The boys don’t actually have enough education to know what it’s like.” Many girls said they were separated in both primary and secondary school classes about periods and that they did not think that they should have been. They all said that they think boys and girls should have been together, as this would have allowed for the development of a more open environment. They also said that it would have been more impactful for boys to have girls in the lessons, as they could have heard first-hand what they go through. They said that separating them taught boys that periods were something that should be kept secret: “I feel like they should definitely be in the room because periods are like, the butt of a lot of jokes, like, some men will be like ‘Are you moody because you’re on your period’, like a lot of people I know do that, and I feel like they don’t really, like, fully understand like, what it’s like, and what we go through. So I feel like they should definitely be in the room so they can like, get a better understanding and like, so that periods aren’t like, jokey subjects.” “From a young age, I was also separated in a classroom, and I don’t think it should be that way.” Several girls spoke on this issue more specifically concerning the creation of stigma and shame. They said they felt that the separation of boys and girls for period education caused stigma, and made girls feel like they have something to be embarrassed about. They explained how separating boys and girls contradicted the idea that periods were being normalised, and reinforced the idea that periods were something to be kept hidden. Therefore, they felt that having mixed classes would normalise periods and reduce stigma: “It’s almost like, causing the stigma. It’s making us feel embarrassed about it. Whereas if we just like, learnt it all together, then we know that the other people know everything.” “I think when you split up the boys and girls it kind of contradicts the men normalising it. If you split them up and they’re not learning about as much as we are how is it going to be normal to them as well? I think it should be as a whole normalised.” However, a few girls had mixed feelings and explained that they thought some girls may feel uncomfortable with boys being in the room for lessons, but they did agree that at least some of what is taught should be all together. Others said that when girls find out about periods for the first time in primary school it can be quite overwhelming, and therefore they think that these earlier lessons should be girls only, but as they get older, lessons should be mixed. Most girls with this perspective were mainly concerned about the risk of boys misbehaving, making jokes and embarrassing girls: “Some girls are very private about it and might feel uncomfortable in there. So I think the main part, like how to support people when they’re on it, I think they should be in the room for it, but then everything else I don’t think they should be in the room, ‘cos I feel like they’d just take the mick out of it.” “I feel like when you’re first learning about it, it’s, if it’s a new thing as well some people haven’t learnt about it before so they’re gonna be a bit confused, and I think some comments and questions are better separate when you’re first learning about it. But when everyone has an understanding of it, I think that’s when they could come together a little bit more.” Discussion This study aimed to explore how adolescent females in schools across South East England feel about their periods, and how periods affect their physical, social, and emotional wellbeing. All of the girls in the study found menstruation had negative impacts on their wellbeing, with each of them dealing with a variety of challenges because of menstruation. Overall, the findings of this study highlight the crucial need for menstrual care, advocacy, support and education to be prioritised in England. A separate study needs to be carried out with transgender, non-binary and gender-diverse people who menstruate. In this paper we use the term ‘girls’, as the focus groups only included cisgender girls. Attitudes In the study, all of the girls had negative feelings about their period, expressing sentiments of hatred and annoyance, such as ‘Why me?’ and ‘Why do boys not have to go through it?’. Previous studies have observed that negative menstrual attitudes are associated with worse experiences of menstruation, which is reflected in the high reports of menstrual difficulties in the study. Negative attitudes may also arise from the stigma and shame that is attached to periods, especially in those who started their periods earlier than others. Several of the girls in the study told us that they did not know what was happening to them when they had their first period, which can be a traumatic experience with effects that may persist throughout life, portraying periods as scary, negative experiences 20 . It is clear that a lack of support and open discussion about menstruation perpetuates negative attitudes and allows for the maintenance of period stigma. Our previously published study examining effects of menstruation on perimenopausal women, found that women had similar negative attitudes towards menstruation as the girls in this study 5 . Perimenopausal women had negative feelings about their period, but some additionally talked about positive aspects. They frequently referred back to what happened to them during puberty and said the trauma of this has remained with them throughout their lives 5 . In this study, there were a few girls who expressed more neutral and sometimes positive attitudes towards periods. Neutral and positive experiences applied more to those who have minimal symptoms and may be associated with advanced reproductive health literacy and a supportive home environment 21 . Therefore, improving education and support for periods could contribute towards improving menstrual experiences and attitudes towards periods overall. Further research is required in this area to identify the specific factors that influence period attitudes and to develop intervention strategies. Additionally, positive attitudes and support for periods should be taught in school. Wellbeing Periods significantly affect the wellbeing of women and girls throughout their lives. Teenage years are often a turbulent time with the onset of puberty, body changes, and the first years of menstruation; which can be particularly challenging due to the social and psychological challenges that come along with this transitionary period. This sentiment was reflected in our research, with many girls reporting detrimental effects on their physical, emotional, and social wellbeing. Our partner project on perimenopausal women had similar results, with women reporting physical and emotional symptoms as well as impacts on their work, self-esteem, relationships, and social life 5 . Many girls reported severe menstrual cramps and heavy bleeding. The prevalence of heavy menstrual bleeding in the UK is around 1 in 4 22 , and as many as 91% of women and girls experience dysmenorrhea 23 . These rates are typically on the higher end in adolescent populations due to the immaturity of the HPO axis 24 . Plan International found that 79% of girls experience symptoms that concern them, but that they have not seen a doctor about it. This is likely because of a variety of factors including the normalisation of menstrual symptoms, making it more likely for women and girls to feel they have to just ‘put up with it’; as well as social influences that stigmatise periods and encourage secrecy around them 6 . Periods impacting emotional and mental wellbeing were a common theme in the focus groups. A study found that 67% of girls have psychological problems related to their period, including changes in mood, irritability, and stress 7 . Psychological changes during menstruation may be caused by both physiological and social factors. The menstrual period can also amplify psychiatric conditions such as depression and anxiety 12 . The girls in this study also reported changes in symptoms of other conditions related to disordered eating and body image, however, the research on conditions such as these in relation to the menstrual cycle is sparse and this should be addressed as a research priority. Poor education, lack of support, and period stigma are all factors which contribute towards making school a difficult environment for girls while they are menstruating. A study by Brown et al found that teachers in the UK feel that menstruation affects school attendance, participation in lessons, pupil confidence, and attitude and behaviour 25 , and Plan International found that 64% of girls in the UK have missed at least one day of school because of their period, with 66% of girls having missed school because of physical symptoms, 34% because they were worried about leaking, and 22% because of anxiety linked to periods 6 . This aligns with our study, with reports of girls struggling to concentrate in class, attend school and perform well in exams because of their period. The girls in our study also reported issues with teasing from boys at school, as well as anxiety around leaking, which also contributed to making school a difficult place to be while menstruating. Socialising is an integral part of a young person’s wellbeing. Some girls in our study reported feeling unable to leave the house when they were menstruating, which was mainly due to physical and emotional symptoms, as well as anxiety around leaking. Additionally, the girls felt anxious about being moody with their friends. Our data agrees with that reported by Plan International 6 . Many of the girls in the focus groups were keen sportswomen and reported a variety of negative effects on their sport. Research to identify barriers to physical exercise while menstruating and campaigns to tackle them should be prioritised to increase physical, social and mental wellbeing. Support This study identified that having a solid support system at home and school is crucial for the wellbeing. Unfortunately our focus groups revealed that girls did not feel well supported at school. A commonly raised issue was poor access to toilets. At every school we visited, there were consistent reports of girls not being allowed to go to the toilet during class, despite it being a school policy in one school. Typically, teachers do not want to let students go to the toilet during class to maintain order in the classroom and prevent students from purposefully missing class time 26 . In addition, there were several reports of toilets not being fit for purpose. All participating schools in our study had period products that were free to access, but they were not easily accessible; for example, period products were kept in the school office rather than in the toilets, which made girls feel uncomfortable about asking for them. In England, there is a period product scheme which allows for state schools to access free period products 27 . However, this scheme does not require schools to have period products available in the toilets or at all and is just an ‘opt-in’ service. For all pupils to have easily accessible period products at all times, the provision of period products in schools should become law, as it is in Scotland 28 , and they should be provided in the toilets rather than in the school office. Teachers should be encouraged to support the period product scheme by raising awareness of the availability of period products to those who need them, as well as improving the accessibility to products. This study revealed that support from teachers and other members of staff is generally insufficient, which is consistent with the literature 6 . This may be due to a lack of training and/or personal perceptions and understanding of menstruation 25 . Teachers could improve support by ensuring they are approachable for period conversations, allowing toilet access, supplying free period products and, as suggested by one girl in this study, undergoing reproductive health training for school staff. This may result in increased attendance and participation and would contribute to the reduction of period stigma, by making it a more open and normal topic of conversation. In 2023 the British Standards Institution (BSI) produced a report on menstruation menstrual health and menopause in the workplace. We recommend that this should be extended to schools 29 . Generally, the best support received was from peers and sisters. The support received from parents varied widely, with several reports of fathers not understanding periods and therefore not being able to offer support. Culture and religion have a significant impact on views of menstruation 30 and may affect support within families. Other factors which have been shown to influence the level of support received include socioeconomic status, education, and access to healthcare 6 . Education The need for improved menstrual health education was highlighted, with all of the girls reporting a lack of good quality menstrual health education in school. These agree with findings by Brown et al who found that menstrual cycle education in UK schools is ‘inconsistent and inadequate’. 25 They found that teachers feel that they lack the knowledge, confidence and time to approximately teach pupils on the subject and that over 80% of them felt that they would benefit from further training to teach menstrual education. Participants in the same study reported that teachers were too embarrassed to discuss menstruation and therefore avoided teaching it 25 . We therefore recommend that schools have designated, trained teachers for menstrual education. These teachers could also provide wellbeing support to students with problematic menstruation. Over recent years, the International Reproductive Health Education Collaboration (IRHEC) have developed a free reproductive health guide for teachers. This was open to consultation in 2023 and will be released in 2024, which will hopefully address some of these issues and provide teachers with the resources that they need to teach reproductive health 31 . In addition, we recommend that all teachers undergo reproductive health training as part of their qualified teacher status (QTS) or postgraduate certificate in education (PGCE). The girls in the study reported that they need more education on how to cope with periods and that the lessons are too focused on the science of menstruation. This is reflected in literature, with teachers in the UK reporting that less than 14% of lessons focused on the lived experience of periods 25 , and reports that just 2–3% of 16-18-year-olds in England have been taught about PCOS and endometriosis. 32 Whilst the science of the menstrual cycle is important, it is also integral to include teaching overall period management and self-care, what a ‘normal’ period looks like in terms of length, flow and symptoms, as well as introducing period-related conditions such as endometriosis, PCOS, and PMDD. It is essential that girls have an understanding of these conditions to allow them to recognise symptoms and make informed decisions about their health. This may in turn contribute towards reducing the negative impacts that periods can have on girls’ wellbeing, as they would become more able to manage their menstrual cycles and recognise when they need to seek help. The girls also expressed a need for menstrual education to be delivered at a younger age, as a significant amount of them started their periods before being taught about it. Studies show that in the UK, menstrual education generally begins in years 5–6, between the ages of 9-11 25 . Whilst the average age of menarche is 12 3 , it is not uncommon for girls to start as early as age 8 33 , and therefore miss out on the essential education that they need before they start having periods. Therefore, menstrual health education to be introduced at an earlier age. The findings of this study have highlighted that boys must receive menstrual health education. The girls in the focus groups reported teasing and bullying from boys, as well as a lack of understanding and support. Plan International found that 20% of girls have experienced bullying around their periods, with 67% of this taking place in schools 6 . It is well known that lack of education about periods leads to stigma 29 which contributes towards issues like bullying. Therefore, we recommend improvements to the menstrual education that boys receive and consideration of integration of boys and girls together for some lessons on reproductive health. Strengths and Limitations A strength of this study is that the use of focus groups allows those participating to express themselves more freely compared to other methods such as surveys 34 . In addition, the participants and researchers were able to interact in real-time, which allowed for the conversation to naturally digress away from the main questions and for additional relevant questions to be asked by both parties. This study included both mixed and single-sex schools, as well as both state schools and private schools, which allows for results that are more representative of the population as a whole. A limitation of this study is selection bias, as those who are confident in a group setting and comfortable discussing menstruation may have been more willing to participate in our focus groups. This could potentially mean that attitudes and experiences of menstruation are typically worse than those represented in our study. In addition to this, because parental consent was required for participation in this study, the daughters of parents who have more stringent beliefs about menstruation and hold a stigma around the topic themselves, could have been inadvertently excluded from this study, as their parents may not have wanted them to be involved. Indeed, the schools reported that some parents did not consent. Furthermore, whilst there are several thousand secondary schools across England, only four were included in this study. Therefore, the results may not be truly representative of the population as a whole. In addition to this, the views of teachers were not collected, and our recommendations require their input. Finally, the girls included in this study represent a group whose early secondary education was affected by the COVID-19 pandemic. As they were in Year 7 during the pandemic, when menstruation is usually taught, some were not given this lesson. Conclusion This study offers key insights into the negative effects that periods have on the wellbeing of girls, as well as highlighting the negative attitudes around menstruation that exist in our society. We recommend improvements in education and support systems (table 2); by providing training to teachers, implementing a school menstruation policy, improving the curriculum to cover all aspects of menstruation at an earlier age, ensuring boys are included in menstrual education, and ensuring appropriate support systems are in place with teachers to improve the wellbeing of all menstruators. Declarations Acknowledgements Thank you to the 4 schools who helped with this project, including the staff and girls who took part in the focus groups: Hitchin School for Girls, Saffron Walden County High School, Wimbledon High School and Joyce Frankland Academy. Thank you to Elizabeth Ray for her advice with the protocol. -Ethics approval and consent to participate Ethical approval was obtained from the ethics committee at University College London (UCL) reference 9831/008. Informed consent was obtained from the parents and the participant. -Consent for publication All authors consent to publication. -Availability of data and materials This will be on a case by case basis to comply with UCL ethics committee. -Competing interests JH gives paid talks on reproductive health education and has written a book, Your Fertile Years. She advises a number of companies on reproductive health. JM provides consultancy (non paid) to Gedeon Richter and supervise an iCASE PhD studentship with AstraZeneca Emerging Innovations, AE at Reproduction and Journal of Endometriosis and Uterine Disorders to Gedeon Richter -Funding This project was funded by the Institute for Women’s Health, UCL. -Authors' contributions JH thought of the initial idea. JH, AB and Elizabeth Ray designed the protocol, JH and AB conducted the focus groups, analysed the data, and wrote the first draft of the paper. 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ReedBG,CarrBR.Endotext[Internet].In: The Normal Menstrual Cycle and the Control of Ovulation .2018.FeingoldKR,AnawaltB,BlackmanMR,etal.,editors.Available:https://www.ncbi.nlm.nih.gov/books/NBK279054/. RayE,MaybinJM,HarperJC.Perimenopausal women’s voices: How does their period at the end of reproductive life affect wellbeing?Post Rep Health 2023;4:201–221. doi:10.1177/20533691231216162. Plan International.BreaktheBarriers:Girls’ExperiencesofMenstruationintheUK.2018.Available:https://plan-uk.org/file/plan-uk-break-the-barriers-report-032018pdf/download?token=Fs-HYP3v. SundariT,GeorgeAJ,SinuE.Psychosocial Problems of Adolescent Girls during Menstruation.J Mental Health Edu 2022;3(2):47–63. SriprasertI,PakrashiT,KimbleT,et al.Heavy menstrual bleeding diagnosis and medical management.Contracept Reprod Med 2017;2:20.doi:10.1186/s40834-017-0047-4. 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JaafarH,IsmailSY,AzzeriA.Period Poverty: A Neglected Public Health Issue.Korean J Fam Med 2023;4:183–188.doi:10.4082/kjfm.22.0206. OlsonMM,AlhelouN,KavatturPS,et al..The persistent power of stigma: A critical review of policy initiatives to break the menstrual silence and advance menstrual literacy.PLOS Glob Public Health 2022;7.doi:10.1371/journal.pgph.0000070. Bowen-VinerK,WatsonDL.Addressing menstrual stigma through sex education in England – taking a sociomaterial turn.Sex Ed 2022;1:1–16.doi:10.1080/14681811.2022.2145461. Department of Health & Social Care.[Internet].Resultsofthe‘Women’sHealth–Let’stalkaboutit’survey.2022.Available:https://www.gov.uk/government/calls-for-evidence/womens-health-strategy-call-for-evidence/outcome/results-of-the-womens-health-lets-talk-about-it-survey. TegegneTK,SisayMM.Menstrual hygiene management and school absenteeism among female adolescent students in Northeast Ethiopia.BMC Public Health 2014.doi:10.1186/1471-2458-14-1118. ÖztürkR,GüneriSE.Symptoms experiences and attitudes towards menstruation among adolescent girls.Gynaecol 2020;3:471–476.doi:10.1080/01443615.2020.1789962. HolmesK,CurryC,Sherry,et al.Adolescent Menstrual Health Literacy in Low, Middle and High-Income Countries: A Narrative Review.Int J Environ Res Public Health 2021;5:2260.doi:10.3390/ijerph18052260. Kiran A, Geary RS, Gurol-Urganci I, et al. Sociodemographic differences in symptom severity and duration among women referred to secondary care for menorrhagia in England and Wales: a cohort study from the National Heavy Menstrual Bleeding Audit. BMJ open. 2018;2. 10.1136/bmjopen-2017-018444 . Ju H, Jones M, Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev. 2014;1:104–13. 10.1093/epirev/mxt009 . Buttram Jr. VC. The immature HPO axis. J Reprod Med 1975;1. BrownN,WilliamsR,BruinvelsG,PiaseckiJ,ForrestL J.Teachers’ Perceptions and Experiences of Menstrual Cycle Education and Support in UK Schools.Front Glob Womens Health 2022;3.doi:10.3389/fgwh.2022.827365. LundbladB,HellströmA,BergM.Children’s experiences of attitudes and rules for going to the toilet in school.Scand J Caring Sci 2010;2:219 – 23.doi:10.1111/j.1471-6712.2009.00707.x. Department for Education.Periodproductschemeforschoolsandcolleges.2023.Available:https://www.gov.uk/government/publications/period-products-in-schools-and-colleges/period-product-scheme-for-schools-and-colleges-in-england#:~:text=All%20pupils%20and%20students%20in,cannot%20afford%20products. Scottish Government.[Internet].PeriodProducts(FreeProvision)(Scotland)Act2021:EqualityImpactAssessment.2022.Available:https://www.gov.scot/publications/period-products-free-provision-scotland-act-2021-equality-impact-assessment/. British Science Association.Inclusivemenstrualhealtheducationisessentialforequality.2021.Available:https://www.britishscienceassociation.org/blog/inclusive-menstrual-health-education-is-essential-for-equality. Garg S, Anand T. Menstruation related myths in India: strategies for combating it. J Family Med Prim Care. 2015;2:184–6. 10.4103/2249-4863.154627 . ESHRE.[Internet].InternationalReproductiveHealthEducationCollaboration(IRHEC).Available:https://www.eshre.eu/irhec. Maslowski;M.,Biswakarma;R.,Reiss;MJ.,Harper,JC(2024)What have 16–18-year-olds in England learnt about reproductive health? A survey of school students.Health Education Journal10.1177/00178969241227314. Morris DH, Jones ME, Schoemaker MJ, et al. Determinants of age at menarche in the UK: analyses from the Breakthrough Generations Study. Br J Cancer. 2010;11:1760–4. 10.1038/sj.bjc.6605978 . Tausch AP, Menold N. Methodological Aspects of focus Groups in Health Research. Glob Qual Nurs Res. 2016;3. 10.1177/2333393616630466 . Tables Table 1: Table showing the demographic data of each school involved in the focus groups, including local authority, school type, OFSTED rating, gender of entry and number of pupils. Local Authority School Type OFSTED Rating Gender of Entry Number of Pupils School 1 Merton Independent N/A Girls 1050 School 2 Essex Academy Converter Outstanding Mixed 2147 School 3 Hertfordshire Academy Converter Outstanding Girls 1368 School 4 Essex Academy Coverter Good Mixed 1022 Table 2: Recommendations for schools regarding menstruation education and support Free and easy access to period products should be made available in all secondary schools. Schoolwide policies to ensure appropriate toilet facilities and access. When designing new school buildings, single cubicle toilets that contain a sink are recommended, and dark furnishings Dark uniforms to prevent anxiety around menstrual leaking. Mandatory reproductive health training should be provided for all teachers. Improvements to the mandatory curriculum on menstrual health, ensuring a range of topics that cover all aspects of menstruation are included and delivered over several years. That menstrual health education should be introduced in primary schools by Year 4 in a simple, age-appropriate way. That both boys and girls are given comprehensive education about periods and should not be separated for reproductive health education by default, but the option of having separate group lessons should be available when requested by pupils. The assignment of teachers as specialists in reproductive health who can deliver education and support, rather than the use of form tutors who are out of their comfort zone. Online reproductive health resources for parents should be offered by the local council. Investment in further research to explore the experiences of menstruators in the UK, including non-binary and transgender individuals and other minority groups. Agreements should be made between relevant organisations and media outputs to accurately portray menstruation and work to break down menstrual stigma. Additional Declarations Competing interest reported. JH gives paid talks on reproductive health education and has written a book, Your Fertile Years. She advises a number of companies on reproductive health. JM provides consultancy (non paid) to Gedeon Richter and supervise an iCASE PhD studentship with AstraZeneca Emerging Innovations, AE at Reproduction and Journal of Endometriosis and Uterine Disorders to Gedeon Richter Cite Share Download PDF Status: Published Journal Publication published 26 Mar, 2026 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 08 Jul, 2024 Editor assigned by journal 07 Jul, 2024 Submission checks completed at journal 06 Jul, 2024 First submitted to journal 05 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4692690","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":324130894,"identity":"3a905944-45e9-47e4-adaf-ab368ebdf549","order_by":0,"name":"Alice Brooks","email":"","orcid":"","institution":"University College London","correspondingAuthor":false,"prefix":"","firstName":"Alice","middleName":"","lastName":"Brooks","suffix":""},{"id":324130895,"identity":"3367d0f6-9793-4d66-b0c1-41c59ec5ef1a","order_by":1,"name":"Jacqueline A. Maybin","email":"","orcid":"","institution":"The University of Edinburgh","correspondingAuthor":false,"prefix":"","firstName":"Jacqueline","middleName":"A.","lastName":"Maybin","suffix":""},{"id":324130896,"identity":"e256e94e-db6b-4c5d-80d8-d47ac7a16f26","order_by":2,"name":"Joyce C Harper","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYBACxgYwdQDC+8DAIMOALEBQC+MMBgYegloYkFUw8xCjhbm9x/DDB4Y78uazm499tm2z42FgP/yAmecMHof1nDGWnMHwzHDOnWPJs3PbknkYeNIMmHlu4NEyI8cM6J7DjDMkcoyZc9sOAB2WA3ThBwJa/jActp8hkf+Z2RKkhf8NEVoYGA4nAm1hZmYEaZEA2YLPYT3HiiV7DA4nz5A5ZszYcy6Zh03imcHBOXi8b9jevPHDj4rDtjOkmx8z/Cizk+PnT3744M0xPFoaOAwYGICIQQIqwsZAICLlGdgfQFgSeFSNglEwCkbByAYAVkxL+w5XoskAAAAASUVORK5CYII=","orcid":"","institution":"University College London","correspondingAuthor":true,"prefix":"","firstName":"Joyce","middleName":"C","lastName":"Harper","suffix":""}],"badges":[],"createdAt":"2024-07-05 13:51:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4692690/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4692690/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-24681-1","type":"published","date":"2026-03-26T16:13:12+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":61407518,"identity":"fceac115-d40e-4742-ac6e-927863d0baaf","added_by":"auto","created_at":"2024-07-30 11:22:48","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":147553,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eAttitudes about Periods. \u003c/em\u003eA word cloud representing attitudes towards periods, created from the answers to the focus group question “How do you feel about having a period?”.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4692690/v1/8fd933c38a47e3e2725126a5.jpeg"},{"id":105755093,"identity":"2d21f670-e0d6-4c5f-b61e-8e40a24a9766","added_by":"auto","created_at":"2026-03-30 16:25:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1122216,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4692690/v1/d234ed39-09a3-4ddc-83dd-cbaa9b0f1a36.pdf"}],"financialInterests":"Competing interest reported. JH gives paid talks on reproductive health education and has written a book, Your Fertile Years. She advises a number of companies on reproductive health.\nJM provides consultancy (non paid) to Gedeon Richter and supervise an iCASE PhD studentship with AstraZeneca Emerging Innovations, AE at Reproduction and Journal of Endometriosis and Uterine Disorders to Gedeon Richter","formattedTitle":"Menstrual experiences of adolescent female school pupils in England","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe menstrual cycle is the female reproductive hormone cycle that is controlled by the hypothalamic-pituitary-ovarian (HPO) axis\u003csup\u003e1\u003c/sup\u003e and lasts for approximately 28 days\u003csup\u003e2\u003c/sup\u003e. Menstruation, commonly referred to as a period, is the shedding of the endometrium that occurs during the first part of the menstrual cycle, lasting between 2\u0026ndash;8 days\u003csup\u003e2\u003c/sup\u003e. Menarche is defined as the first menstrual period, which typically occurs between the ages of 10\u0026ndash;16\u003csup\u003e3\u003c/sup\u003e. Factors including genetics, nutritional status, exercise, and general health determine the age of menarche\u003csup\u003e3\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe menstrual cycle is typically most irregular and problematic around the beginning and the end of a female\u0026rsquo;s reproductive life; following menarche and at peri-menopause\u003csup\u003e4\u003c/sup\u003e. In our recent study of perimenopausal women\u0026rsquo;s menstrual experiences, many referred to menarche as a significant life event and the peri-menopause as a time when they reported irregular and problematic periods\u003csup\u003e5\u003c/sup\u003e. Menarche is often an overwhelming experience for many; one study found that girls described starting their periods as \u0026lsquo;scary\u0026rsquo; and \u0026lsquo;horrible\u0026rsquo;, stating, \u0026lsquo;I thought I was going to die\u0026rsquo; and \u0026lsquo;I had no idea\u0026rsquo;\u003csup\u003e6\u003c/sup\u003e. In addition to this, the unpredictable nature of menstruation during adolescence can impact a girl\u0026rsquo;s wellbeing. Symptoms such as pelvic pain, heavy menstrual bleeding and cycle-related emotional disturbance can have significant negative impacts on a girl\u0026rsquo;s QoL. Periods can stop pupils from being able to go to school, affect concentration in class, limit social interactions and participation in sports and negatively impact mental health\u003csup\u003e7\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eNormal menstruation occurs at regular monthly intervals, with manageable blood loss that is not prolonged and does not have troublesome physical or psychological symptoms that interfere with QoL\u003csup\u003e8\u003c/sup\u003e. Symptoms that signify abnormal menstruation include abnormal uterine bleeding (AUB), which involves changes to the volume, duration, regulation or frequency of menstrual bleeds\u003csup\u003e1\u003c/sup\u003e. Problematic menstruation may also be due to dysmenorrhea (painful periods) and/or pre-menstrual syndrome (PMS)\u003csup\u003e9\u003c/sup\u003e, which is a collection of symptoms occurring pre-menstruation including painful breasts, bloating, irritability, low mood, brain fog, and fatigue. In many cases, the underlying cause of abnormal menstrual symptoms is unknown. These symptoms may be due to endometriosis, a condition in which tissue similar to the lining of the uterus (endometrium) grows outside of the uterus; or polycystic ovary syndrome (PCOS), a condition where the ovaries produce multiple follicles and associated with irregular ovulation\u003csup\u003e10\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePeriods can also negatively impact mental health. Whilst slight mood disturbances are considered normal if they do not interfere with QoL, more significant psychological symptoms during menstruation may be signs of severe premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). PMDD is a severe form of PMS that can cause significant distress and functional impairment, with symptoms including low mood, anxiety, anger, interpersonal conflicts, and sleep disturbances\u003csup\u003e11\u003c/sup\u003e. In addition to this, those with diagnosed mental health conditions such as anxiety and depression may also experience an exacerbation of their symptoms before and during menstruation, which is thought to be due to the relationship between estrogen, progesterone and mood\u003csup\u003e12\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eStigma is defined as \u0026lsquo;a strong feeling of disapproval that most people in society have about something\u0026rsquo;\u003csup\u003e13\u003c/sup\u003e. Menstruation has always held a particularly strong sense of stigma and shame\u003csup\u003e14\u003c/sup\u003e. As a result of this, periods are often not talked about and the education and support for menstruation it is poor\u003csup\u003e15\u003c/sup\u003e. Period stigma leads to a lack of discussion around periods, which in turn impacts knowledge, meaning that many girls do not know how to manage their periods or what to do when they have a problem with them. This has a domino effect on other areas, as unresolved period issues such as heavy bleeding, cramps, and emotional issues can impact a person\u0026rsquo;s ability to go to school or work, take part in activities, and socialise\u003csup\u003e6\u003c/sup\u003e. In addition to this, period stigma often leads to feelings of shame; a negative, self-conscious emotion that can significantly impact a person\u0026rsquo;s wellbeing. Shame also leads to girls being too embarrassed to speak to their parents, teachers or healthcare providers about issues with their period, which can have significant negative implications on their wellbeing and the support they receive\u003csup\u003e16\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn a UK-based study, 14% of girls admitted that they did not know what was happening when they had their first period, and 1 in 4 did not know what to do when it happened\u003csup\u003e6\u003c/sup\u003e. Secondary schools throughout the United Kingdom (UK) have a curriculum for relationship and sex education (RSE) that includes menstruation, however, it is heavily focused on the biology of periods rather than experiences, management, support and stigma\u003csup\u003e17\u003c/sup\u003e. The 2019 survey for the Women\u0026rsquo;s Health Strategy found that less than 1 in 5 women feel they have enough information on menstrual wellbeing\u003csup\u003e18\u003c/sup\u003e. Lack of support in schools and good quality education around menstruation also leads to increased rates of school dropouts and low attendance, due to the challenges that girls face trying to manage menstruation in unsupportive environments\u003csup\u003e19\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis research project aims to determine how periods are affecting girls within schools in England. Using focus groups enabled discussions with girls about their attitudes to their period, the effect of their periods on their physical, emotional, and social wellbeing, the support they had received from friends, family and school, and what support they need and the education they had received about periods and what education they need.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eInformal surveying was conducted with adolescent girls in schools in England prior to designing this study. Reproductive health was discussed and anonymous answers questions highlighted that menstruation was significantly affecting the wellbeing of adolescent girls. Focus group questions were designed by the research team to represent the areas that had been highlighted by the informal survey to prioritise the experiences of adolescent girls. Some of the questions were used in a sister project on perimenopausal women\u003csup\u003e29\u003c/sup\u003e. School teachers reviewed the questions prior to the focus groups to ensure they were suitable and accurately represented the areas in which adolescents were reporting issues.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe focus groups consisted of four questions.\u003c/p\u003e\n\u003cp\u003e1. How do you feel about having a period?\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2. How does your period affect your wellbeing?\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3. What support do you need to manage your menstrual cycle/period?\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4. How could we improve education around periods?\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the ethics committee at University College London (UCL) reference 9831/008. Informed consent was obtained from the parents and the participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRecruitment and Data Collection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFocus groups were carried out in four schools across England in London, Hertfordshire and Essex, with 49 girls in Year 10. Demographic data for each school is shown in table 1. Individual demographic data was not collected for the study to protect the confidentiality of participants, as they were all under the age of 18.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo focus groups were carried out at each school, making a total of eight focus groups. Each group contained between five and nine girls, totalling 49 girls overall. The girls were all in year 10, making them between 14 and 15 years old.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOnce potential schools had expressed interest in the study, they were sent the participant information sheet and consent form and distress guidelines. The participant information sheet contained information regarding inclusion criteria for the focus groups; details of the research team; aims of the study; what the focus groups will involve; risks and benefits of taking part; data protection; and a consent form. The distress guidelines contained information on how distress will be identified and minimized, including a step-by-step response guide for the researchers to follow.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEach participant and their parent/guardian was required to read and sign the consent form before the focus groups. Dates for focus groups were arranged with a staff member at each school. The first and last authors obtained DBS checks and attended four schools between May and June 2023. They carried out two focus groups at each school, with each session lasting approximately 60 minutes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe schools provided a suitable room for the focus groups. At the beginning of each session, two phones were set to record. The research team introduced themselves and explained the study to the girls. They explained how the focus groups would work and ensured the girls knew what to do if they felt distressed at any point. The researchers also checked throughout the sessions for signs of distress. The girls were asked each question in turn and the researchers ensured that all girls answered all questions. Once the focus groups were finished, transcripts were made from the recordings, they were checked for accuracy, and the audio recordings were deleted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eQualatative Analysis\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eImmediately following each focus group, the team discussed the main findings from the group and gave feedback to the teachers. A summary of each session was written to accurately encapsulate the discussion and tone and begin understanding initial thoughts and ideas. After completion of all eight focus groups, each session\u0026rsquo;s transcript was read closely to ensure familiarization\u003csup\u003e29\u003c/sup\u003e. Transcripts were then broken apart by question, allowing answers to each question to be read in full, and was then analysed individually to identify initial codes. By using notes gathered during familiarization based on answers to each question, initial codes were systematically distinguished, and relevant data was sorted into each code. This allowed for further familiarization with the data, as well as a chance to better recognize patterns. Repeated thoughts and particularly meaningful sentiments were noted alongside initial thoughts and ideas pertaining to the data. Codes were then sorted into themes that were reviewed against the overall dataset to ensure that it was representative. Themes were refined iteratively by both researchers until it was determined that the overall narrative of the girls was adequately conveyed.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAll the girls were engaged in the focus groups and were keen to share their stories, thoughts, and opinions. Many were passionate about the topic and were eager about the prospect of change within menstrual support and education.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e1. How do you feel about having a period?\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEvery girl had their own unique experiences of menstruation. Most girls described negative feelings towards menstruation, although a few spoke about positive aspects. Figure 1 shows a word cloud illustrating some of the words and phrases used by the participants when asked how they feel about having a period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThree themes were identified for this question: negative feelings: \u003cem\u003eit would be so much better if they did not exist\u003c/em\u003e; neutral feelings: \u003cem\u003eit is just part of life\u003c/em\u003e; and positive feelings: \u003cem\u003eit unifies girls\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNegative Feelings:\u003cem\u003e\u0026nbsp;It Would Be So Much Better if They Did Not Exist\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe majority of girls had negative feelings about their periods, and described them as \u0026ldquo;annoying\u0026rdquo;, \u0026ldquo;painful\u0026rdquo;, and \u0026ldquo;horrible\u0026rdquo;. They wished they did not have to have periods, and felt it was unfair that they had to go through it, but that boys did not have to. They said their periods were very uncomfortable and got in the way of a lot of actitivies and impacted them by affecting their mood, school life, social life, sports, and home life. They explained that being on their period altered their outlook on the day and that not being able to control it was inconvenient. They also talked about how they hated having their period because it made them anxious about bleeding through their clothes:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s unfair. Because we have to have this every month for like most of our whole lives, and then when it stops as well it\u0026rsquo;s not like easy as well, and then the boys have nothing.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I hate my period so much. I really struggle with it, and it\u0026rsquo;s just, like, it would be so much better if I didn\u0026rsquo;t have it.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNeutral Feelings: \u003cem\u003eIt Is Just a Part of Life\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA few of the girls felt that whilst periods were annoying, they were a normal experience that did not get in the way of their lives. They explained how they would rather not have them, but they just accepted it:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Obviously I\u0026rsquo;d prefer not to have it, just because it\u0026rsquo;s like\u0026hellip; it does complicate things, but at the end of the day, like, it\u0026rsquo;s a natural process of life and it\u0026rsquo;s just something that you have to like, accept, and kind of go through life having.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think that it\u0026rsquo;s a neutral thing like I don\u0026rsquo;t think it\u0026rsquo;s good or bad, it just happens once a month and I\u0026rsquo;m like \u0026lsquo;Oh, okay, here it goes!\u0026rsquo;\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePositive Feelings: \u003cem\u003eIt Unifies Girls\u003c/em\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA few girls said that they saw periods as a blessing. They explained that in earlier years, periods were viewed as a curse, but as they got older it became less of a big deal and unified girls:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s seen as the dreaded thing when you\u0026rsquo;re about\u0026hellip; when you\u0026rsquo;re in year 6 and year 5 and whatever, and everyone\u0026rsquo;s like \u0026lsquo;oh my god period, first birthday\u0026rsquo;, whatever\u0026hellip; but I feel like once you get to like, a bit older and a bit more mature, it\u0026rsquo;s like, it kind of unifies girls, because it\u0026rsquo;s something you can like, talk to each other about freely, and it\u0026rsquo;s not something that boys have, so maybe, in a way that like, it\u0026rsquo;s first viewed as like a curse and whatever, depending on how much trouble it brings you it\u0026rsquo;s kind of a blessing as well, cos you can like, like, talk about it with people.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e2. How does your period affect your wellbeing?\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFive themes were identified for this question: physical symptoms: \u003cem\u003eeverything hurts\u003c/em\u003e; emotions and mental health: \u003cem\u003eI feel so unstable\u003c/em\u003e; school: \u003cem\u003eit is unbearable to be there\u003c/em\u003e; social life: \u003cem\u003eI do not want to go out\u003c/em\u003e; and sport: \u003cem\u003eI just\u0026nbsp;\u003c/em\u003ecannot \u003cem\u003edo it\u003c/em\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhysical Symptoms: \u003cem\u003eEverything Hurts\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe majority of girls reported having dealt with menstrual pain. Some girls had mild pain, whilst others had moderate-severe pain that affected their QoL. They said that their cramps stopped them from being able to do things such as go to school or go out with friends. They added that paracetamol does not help them, so they had to try and cope with the pain:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When it gets to like, the point, it\u0026rsquo;s like my first, second and third day, where I just cannot move, like it\u0026rsquo;s so bad I like, I\u0026rsquo;m actually like screaming sometimes, and like, I\u0026rsquo;ll be shaking. It can be really bad.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I literally can\u0026rsquo;t get out of bed. That\u0026rsquo;s how bad they are like I literally can\u0026rsquo;t get up.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral girls said they experienced pre-menstrual symptoms such as fatigue, back pain, cramps, and nausea. They described feeling \u0026ldquo;heavy\u0026rdquo; and \u0026ldquo;exhausted\u0026rdquo; and said that this time in their cycle was \u0026ldquo;hell\u0026rdquo;. They told us how these symptoms affected them being able to leave the house:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The week before my period is hell! Like I feel so heavy and exhausted.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The week before my period I always feel really nauseous, it makes me feel really ill, like, faint. So, that\u0026rsquo;s not great, \u0026lsquo;cos it just stops me from like going out \u0026lsquo;cos I don\u0026rsquo;t wanna like, feel sick or be sick or anything like that. And then cramps on top of that is not great!\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEmotions and Mental Health: \u003cem\u003eI Feel So Unstable\u003c/em\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany girls reported that they experienced emotional difficulties before and during their period such as mood swings, anxiety, anger, crying, irritability and low mood. They spoke about how these symptoms affected their day-to-day life, their home environment, and their relationships with others. They spoke about how much stronger their emotions were during their period, and they also said they felt emotionally unstable and had many different emotions at once. They said that they were much less able to cope with day-to-day life when they were menstruating:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think I get really grumpy, and I experience my emotions more.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I just get like, really irritable, like really easily.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome of the girls had mental health difficulties such as eating disorders, body image issues, anxiety and depression, which they said were worse during menstruation. A variety of issues relating to mental illness and menstruation came up, such as worsened body image, panic attacks, depressed mood, suicidal thoughts, and binge eating urges:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think my period affects like, how I feel about myself. So, usually before and during my period I\u0026rsquo;m really bloated, and then that just makes me feel ten times worse about my body image.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;This is like really kinda personal, but I get like incredibly like, really, like, really badly depressed and suicidal, like on the week before.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSchool and Education: \u003cem\u003eIt Is Unbearable to Be There\u003c/em\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral girls reported having struggled to go to school because of their symptoms. A few said they had to take days off school, and others went to school but struggled to get through the day. They felt they missed out on classwork as well as time with their friends, and described having to go to school on their period as \u0026ldquo;unbearable\u0026rdquo;:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s like, unbearable to be in school when you have such bad period cramps. Sometimes it\u0026rsquo;s even unbearable to get out of bed.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Usually the first couple of days I\u0026rsquo;m just in so much pain, last time I had to go home, I just couldn\u0026rsquo;t concentrate or anything.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe girls said their period affected their concentration at school. They said that they did not have the same motivation as usual and that their cramps and other symptoms made them unable to focus during class:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it does like, make concentration kind of like, changes quite a lot, and then I can\u0026rsquo;t focus and then I miss a lesson. It\u0026rsquo;s annoying have to like go back and then be like, have to do it over again on my own, just \u0026lsquo;cos like, I wasn\u0026rsquo;t able to before \u0026lsquo;cos of really bad cramps.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You can\u0026rsquo;t be bothered to revise when you\u0026rsquo;re on your period, you can\u0026rsquo;t be bothered to do anything.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral girls reported that menstruation affected them during exam time, by reducing their motivation and affecting their performance. They explained how they often ended up getting lower grades than usual when they were on their period, and that they had to put a lot more effort in to motivate themselves to study. They also told us how getting cramps during exams distracted them:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If I\u0026rsquo;m on my period during an exam, I tend to do worse than I usually do.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think, especially during exam time, if you get your period it like, it like takes a toll on your mood. So then you\u0026rsquo;re like less motivated to do like, say, put that extra hour work in. But then if you get a cramp in the middle of the exam hall and you\u0026rsquo;re just thinking \u0026lsquo;Oh no! What have I done!\u0026rsquo;\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocial Life:\u003cem\u003e\u0026nbsp;I Do Not Want to Go Out\u003c/em\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe main issue regarding social life was that some girls did not want to go out during their period because of their symptoms. They often wanted to stay in bed, but that they then felt sad about missing out on fun with their friends, which affected their mood. Some of the girls also spoke about feeling bad about having mood swings when they were on their period, as they did not want to upset any of their friends:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When I\u0026rsquo;m on my period I just don\u0026rsquo;t feel like going out. I just don\u0026rsquo;t get excited because I\u0026rsquo;m on my period.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel, like, I don\u0026rsquo;t really, sometimes when I would normally wanna go out, I don\u0026rsquo;t want to, and then I feel sad about not wanting to go out, and it all just gets spiralled into one big thing that\u0026rsquo;s not really anything!\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome girls said they felt anxious about potentially leaking in public. Many said they had to pay close attention to what they wore when they were menstruating out of fear of being embarrassed if they leaked, which took the fun out of socialising:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s always like, I\u0026rsquo;m always nervous going out, because it\u0026rsquo;s like, I have to watch what I wear and stuff. I mean, I went to tennis the other day and I came back and my whole shorts were like, completely ruined, \u0026lsquo;cos I thought I\u0026rsquo;d finished but then obviously, and it\u0026rsquo;s like, you\u0026rsquo;re always weary when you go out, cos you don\u0026rsquo;t wanna, you know leak or anything because it\u0026rsquo;s known as embarrassing when you leak \u0026ndash; and I don\u0026rsquo;t think it should be \u0026ndash; but I think now everyone just thinks it\u0026rsquo;s embarrassing when you have it.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I always get scared just in case I won\u0026rsquo;t have a pad on, like \u0026lsquo;what if I leak\u0026rsquo;, \u0026lsquo;how is everyone gonna react\u0026rsquo;. I always carry my pads with me and everything, but then like, I always think like, just in case, what\u0026rsquo;s gonna happen if like, I\u0026rsquo;m out with my friends and then I suddenly get it and I didn\u0026rsquo;t even know. It\u0026rsquo;s always that like, fear.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSport and Exercise: \u003cem\u003eI Just\u0026nbsp;\u003c/em\u003eCannot\u003cem\u003e\u0026nbsp;Do It\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany girls did sports such as rowing, dancing, football and running. They spoke about how their period affected their training and competitions because of cramps, fatigue, and reduced motivation, and mentioned that the unpredictable nature of periods affected their sport. They also said that their overall performance was worse and that they sometimes had to miss training because of their period:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I miss training if it\u0026rsquo;s that bad, like, \u0026lsquo;cos I can throw up quite a lot like I won\u0026rsquo;t be able to move \u0026lsquo;cos it hurts that bad, so I just have to get my mum to phone my coach and be like \u0026lsquo;she\u0026rsquo;s not coming \u0026lsquo;cos she\u0026rsquo;s on her period\u0026rsquo;.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So I play football and it really affects me sometimes. Training is so hard, and I have really bad cramps.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany girls said they struggled with physical education and did not want to take part. They said they felt uncomfortable exercising on their period, and that the teachers were not understanding about letting them sit out:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s quite uncomfortable like, just that feeling inside your body. And then you have to go and like, run about and stuff like that. It\u0026rsquo;s just not nice really.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;ve had friends who have had like, really bad cramps and have gone to the P.E teacher to like, ask to sit out, and then the P.E teachers are just like \u0026lsquo;I get a period too\u0026rsquo;, like, \u0026lsquo;just deal with it\u0026rsquo;.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e3. What kind of support do you need to manage your period?\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe level of support that each girl had varied depending on several factors such as family dynamics, their friendship group, and which school they attended. Three themes were identified for this question: school: \u003cem\u003eno one will help me;\u003c/em\u003e family: \u003cem\u003eit is complicated\u003c/em\u003e; and peers: \u003cem\u003ethey are there for me\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSchool: \u003cem\u003eNo One Will Help Me\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, the support received at school was poor. The girls did not feel supported and felt as though there was a major lack of understanding. Often teachers told them to \u0026lsquo;just deal with it\u0026rsquo; and that \u0026lsquo;everybody gets a period\u0026rsquo;, and they felt that in general, teachers were more focused on education than on student wellbeing. They gave examples what teachers had said to them about periods, which highlighted the extent of misunderstanding among staff. The girls expressed a need for having someone at school that they could talk to about periods, which would make them feel more supported:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t really talk to any teachers at school about it because I just feel like they don\u0026rsquo;t really care that much. It\u0026rsquo;s more, it\u0026rsquo;s more like focusing on your education rather than like, how you feel and your health, I feel.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Teachers they just don\u0026rsquo;t\u0026hellip; I dunno, like, if I was to say to like, a random teacher, \u0026lsquo;Oh I\u0026rsquo;m on my period\u0026rsquo; like, \u0026lsquo;I need to go to the toilet\u0026rsquo;, or something, \u0026lsquo;I need to do this\u0026rsquo;, like, they\u0026rsquo;d look at me as if I\u0026rsquo;m gross. And I just feel like, oh, and then I think I\u0026rsquo;m gross.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe girls said that when they went to see the school nurse about their period, often they were not allowed to go home, and they got sent back to class or told to sit in the medical room and drink a glass of water. They were frustrated that they were made to stay in school even though they could not focus - so there was not much point in them being there anyway. Some of them had even been advised by their GP to take time off school during their period and they had produced notes to confirm this. There were also reports of parents lying to the school about why their daughter needed to come home from school, as this was the only way the school allowed it. The girls wanted improved school support: some needed to be allowed to have days off or to be sent home from school when they were on their period:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Every time I go down to student reception I\u0026rsquo;ll be like, ask to go home, and they won\u0026rsquo;t let me go home. So then I have to message my mum \u0026ndash; we\u0026rsquo;re not supposed to, but I had to message my mum \u0026ndash; to say like, I\u0026rsquo;m in so much pain, I wanna come home. So she has to make up some excuse like I\u0026rsquo;ve got a doctor\u0026rsquo;s appointment and phone them up so I can sign out, \u0026lsquo;cos they won\u0026rsquo;t let me go home. And I\u0026rsquo;ll literally sit down there for hours, and they still just won\u0026rsquo;t let me go.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;They\u0026rsquo;d say just the most horrible things when you\u0026rsquo;re on your period, like, they\u0026rsquo;d be like, \u0026lsquo;Oh everybody goes through their period, you don\u0026rsquo;t need to be this emotional and this dramatic about it\u0026rsquo; or like \u0026lsquo;you just need to go back to your lesson and deal with it, every single woman deals with this, even I deal with this\u0026rsquo;.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAt every school, the girls spoke about how teachers often did not let them go to the toilet during class, even if they explained that they were on their period. They said that different teachers had different rules. One school said it was their policy that girls could go to the toilet during lessons, but this rarely happened. The girls said this affected their concentration and that it sometimes caused them to leak. One girl expressed how not being allowed to go to the toilet at school was one of the reasons she did not want to come in when she was on her period. They asked to be better supported:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In a lesson when I wanna go, the teachers don\u0026rsquo;t let me, and I can\u0026rsquo;t concentrate. I remember this one time I asked my biology teacher, I asked her three times, and the second and third time I was literally crying, and she didn\u0026rsquo;t let me go.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I remember in year 8, ages ago but I can still remember \u0026lsquo;cos it was that embarrassing I can still remember it now, and I asked every two minutes she was like \u0026lsquo;no, no, no\u0026rsquo; and then I leaked, and I was like yeah, that\u0026rsquo;s why I needed to go!\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere was a difference in how they were treated by male versus female teachers when it came to needing to go to the toilet during lessons. Most said male teachers were more likely to let them go to the toilet, maybe because they felt uncomfortable. However, a few said that the male teachers did not let them go because they did not understand periods:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If you say to a male teacher you\u0026rsquo;re on your period, they don\u0026rsquo;t wanna talk about it, so they just say \u0026lsquo;go!\u0026rsquo;\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some teachers are like, really strict about not letting you go to the toilet, and it\u0026rsquo;s awkward having to say, especially to like, a male teacher, \u0026lsquo;I\u0026rsquo;m on my period I need to go to the toilet\u0026rsquo;, and then, then again sometimes they won\u0026rsquo;t let you go. And especially like, men, they don\u0026rsquo;t understand, and for them to sit there and say you can\u0026rsquo;t go to the toilet is like, really bad.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFemale teachers were stricter about letting them go to the toilet and that they often made comments about them also being on their period and having to deal with it too:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The female teachers say, \u0026lsquo;Well we\u0026rsquo;re on ours so how do you think we\u0026rsquo;re coping with it\u0026rsquo; \u0026ndash; they try argue with you about it.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel like it\u0026rsquo;s a lot of like, really older, like female teachers as well. I don\u0026rsquo;t know if they\u0026rsquo;ve just, gotten so used to it or something like that but they just don\u0026rsquo;t have any empathy. You can literally be like \u0026lsquo;I really need to go to the bathroom, I\u0026rsquo;m on my period\u0026rsquo; and they\u0026rsquo;re like \u0026lsquo;no\u0026rsquo; \u0026ndash; and I\u0026rsquo;m like, I guess I\u0026rsquo;ll just bleed on your seat.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAt all of the schools, the girls reported issues with the toilets. They were frequently described as \u0026ldquo;disgusting\u0026rdquo;, and were reported to have been very busy, especially at breaktime. Girls from one school reported that blocks of toilets were regularly locked which reduced access, and that there were always teachers present in the toilets which made them feel uncomfortable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;At break and lunch, there\u0026rsquo;s not enough space in the toilets anyway, so we\u0026rsquo;ve got three years of girls in one toilet set, so there\u0026rsquo;s not really enough space anyway.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Along with the toilets being locked, for a while, a lot of the toilets were like, out of order, like, all the time. And just like, there\u0026rsquo;s never any room in there really, and like, there\u0026rsquo;s always like, a teacher standing there and like, telling you to get out, so you don\u0026rsquo;t really have any time. And there\u0026rsquo;s always a queue outside, to like, get in.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe access to period products varied between schools. One school had period products available in the toilets, but this was usually empty. However, if they needed them, they could get them from the school nurse, but this was inconvenient if they suddenly got their period without realising it. In one school they had to go to the administration office, which most felt uncomfortable about. One school had a facility called \u0026lsquo;the hive\u0026rsquo; which had a cupboard with a range of period products including period pants and tights. All of the girls said they would like easier access to period products in the toilets.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think they should be in the toilets because I\u0026rsquo;d feel awkward going to the office for stuff like that.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;d much prefer being able to quietly grab what I need instead of having to ask.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere were varying views about free period products in the toilets:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Putting sanitary products in bathrooms \u0026ndash; I think it\u0026rsquo;s a good idea, but you can\u0026rsquo;t control how many people take or like, how they use it because sometimes bathrooms are just quite awful. So, if they put it in the bathrooms, what\u0026rsquo;s to say someone won\u0026rsquo;t put them on the floor, take too many, make a mess\u0026hellip; and then it just like, defeats the purpose.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it\u0026rsquo;s about a collective maturity and I feel like that comes when like, periods are brought into discussion more. So like, for example, I mean, it\u0026rsquo;s kind of immature to be messing up sanitary products, that could\u0026rsquo;ve saved someone\u0026rsquo;s day or something, but I feel like, the more periods are talked about, and like, normalised, the more it becomes seen as like, a thing that people need to understand, and as it\u0026rsquo;s been talked about more in schools and it like, brings awareness to the male teachers and the ability to go to the bathroom I think it\u0026rsquo;s really, it\u0026rsquo;s really a necessity if you\u0026rsquo;re on your period \u0026ndash; and if someone\u0026rsquo;s telling you you can\u0026rsquo;t go, you can\u0026rsquo;t just sit there! And it\u0026rsquo;s hard to like, build a common ground with the teachers where they understand, because like, as a teenager or a pre-teen, it\u0026rsquo;s quite hard to say like \u0026lsquo;oh I really need to go\u0026rsquo;, there\u0026rsquo;s like an embarrassment that comes with that. And I feel like just being able to talk to our teachers and like, normalise the period, I feel like that would help a lot.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFamily: \u003cem\u003eIt Is Complicated\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe girls had different experiences of support at home, as well as varying family dynamics, relationships and circumstances. Generally, most girls spoke very positively about their relationships with their mums. Many said they had open conversations and felt like they could talk to their mum about anything.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My mum is my bestest friend out of everyone, and I always talk to her about everything.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My mum and I, we\u0026rsquo;re very open about it, and she\u0026rsquo;s very into learning more about it, like, menopause and things, so we have very good conversations about how periods affect us and everything.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGenerally, dads were awkward about the topic but tried to support them. Some dads did what they could by buying chocolate or other things they needed:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m a lot more awkward talking to my dad about it because he doesn\u0026rsquo;t understand it as much.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My dad isn\u0026rsquo;t like, awkward about it, but when it does come up in conversations he like, kind of edges out of the conversation a bit.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, having a supportive family environment was not the case for all. Some girls said they felt their parents were not understanding of the issues they had with their periods. They reported having parents who did not take their menstrual symptoms seriously and who told them to \u0026lsquo;stop being dramatic\u0026rsquo;. Others said their parents told them off when they had mood swings. A few explained that because their mums never had difficult periods, they did not understand, which led to them feeling unsupported:\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;I just can\u0026rsquo;t really do anything about it because I\u0026rsquo;ll tell my parents and they\u0026rsquo;ll just say, \u0026lsquo;Everybody gets a period, you don\u0026rsquo;t have to be this dramatic about it\u0026rsquo;.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;And obviously like, my family don\u0026rsquo;t understand, \u0026lsquo;cos, my mum\u0026rsquo;s like handled her period really well like she literally never got cramps or anything, but it\u0026rsquo;s just so bad.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHaving separated parents was associated with more turbulent support depending on which parent they lived with. A few of the girls described the differences they felt in support between the two households. Several girls talked about how their dads were generally great, but they felt uncomfortable talking about periods. They spoke about how, when they stayed with their dads, they did not feel as much support compared to when they stayed with their mums, where they felt much more supported, had period products available, and could talk openly about their period. Some of them even said that when they first started their period, they wouldn\u0026rsquo;t stay at their dad\u0026rsquo;s house because they felt so embarrassed:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My parents don\u0026rsquo;t live together, so when I\u0026rsquo;m at my dad\u0026rsquo;s house it\u0026rsquo;s completely different to when I\u0026rsquo;m at my mum\u0026rsquo;s because my dad\u0026rsquo;s attitude towards it is to kind of avoid it, just don\u0026rsquo;t talk about it. And cos I live with my little brother as well, he just gets all like, icky about it. Whereas when I\u0026rsquo;m at my mum\u0026rsquo;s, it\u0026rsquo;s like, a lot calmer. Like, I can tell her that I\u0026rsquo;ve got really bad cramps \u0026ndash; whereas my dad\u0026rsquo;s like, \u0026lsquo;Ohhhh\u0026rsquo;. I don\u0026rsquo;t know\u0026hellip; I just don\u0026rsquo;t think\u0026hellip; like lots of people just don\u0026rsquo;t understand.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When I first started my period I didn\u0026rsquo;t talk to my dad about it at all, and so I wouldn\u0026rsquo;t stay at his for like, whenever I was on, \u0026lsquo;cos I just didn\u0026rsquo;t want to talk to him about it\u0026hellip; but then eventually, like as I got older, I was like, it\u0026rsquo;s something that every girl goes through and there\u0026rsquo;s no point in being embarrassed about it.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe girls with older sisters felt well-supported and were comfortable talking about periods. They told us that periods were a topic of conversation early in their life, which meant they were prepared when they reached menarche. They explained how this made periods feel less shameful, and that they felt they could have more open conversations about periods and their symptoms:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m pretty comfortable, like, talking about it and I knew about it early on in life as well because I have an older sister, so I\u0026rsquo;ve always spoken about it with her, and my mum as well, but mainly my sister.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have like, two sisters, and my mum obviously, so like, a predominantly like, female household, so we\u0026rsquo;re all like really open about it and I feel like it\u0026rsquo;s really nice.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe girls with brothers ran into issues\u0026nbsp;with being teased. They felt the need for boys and dads to be more educated about periods so that they could offer more support. The girls with brothers had much more negative experiences compared to those with sisters. One girl said her younger brother bullied her when she was on her period and called her disgusting. However, some of the girls had more supportive brothers, who wanted to learn about periods:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have a younger brother and he sort of bullies me to get me upset. And if I\u0026rsquo;m on the toilet for a while like, sorting myself out, he\u0026rsquo;ll like bang on the door and like, say \u0026lsquo;you\u0026rsquo;re disgusting\u0026rsquo;, he like, really bullies me. It\u0026rsquo;s really awful.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePeers: \u003cem\u003eThey Are There for Me\u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany of the girls spoke highly of the support they received from friends. They spoke about how comfortable they felt talking about periods, and how understanding their friends were. They said their friends supported them through everything and that they never felt judged by them. Manyl said that if they needed a period product at school, they would ask their friends rather than a teacher:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Well, I think I\u0026rsquo;d just feel comfortable saying anything to them. Like, \u0026lsquo;Check me\u0026rsquo; or like, \u0026lsquo;Have you got anything\u0026rsquo;\u0026hellip;I just feel really comfortable with them, and I think they feel comfortable with me to talk about it.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I love being able to talk about like, anything with my friends\u0026hellip; it\u0026rsquo;s really nice to know that I have friends that are there for me and support me.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome girls however spoke about how they had more reserved friendship groups:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It does come up every now and again, but the conversation does move on quite quickly.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s not like, a super open thing, and I won\u0026rsquo;t randomly go up to my friends and be like \u0026lsquo;Oh yeah guys I\u0026rsquo;m on my period today\u0026rsquo;, like, it just, unless I need help from them, I don\u0026rsquo;t bring it up. I feel like, my group, it\u0026rsquo;s not talked about particularly.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOn the other hand, the girls did not have such positive experiences with boys. They said that most boys were disgusted by periods and could sometimes made mean comments or jokes towards them. They said they can give them a really hard time and do not offer much support. They explained that they think boys behave this way because they had not been taught about periods, and therefore did not understand them:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A lot of my friends are male, and they tend to get really disgusted about it and tease me about it. They\u0026rsquo;re not very understanding, and they\u0026rsquo;re really mean about it. They don\u0026rsquo;t support me that much.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They\u0026rsquo;re almost disgusted by it, and they just give you a hard time about it.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, a few mentioned some positive experiences where boys were interested in learning and were considerate about what kind of support the girls might have need. One of the girls said an experience they had where a boy expressed to her that he was interested in periods, and another girl said that boys tended to be a lot more caring when they were on their own and not in big groups:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;he said, \u0026lsquo;I\u0026rsquo;m actually interested in them\u0026rsquo;, and he asked me all these questions.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The girls, we\u0026rsquo;re able to have the most open conversations. But with the boys I think, when they\u0026rsquo;re on their own they\u0026rsquo;re like \u0026lsquo;Do you want chocolate, do you want me to buy you something\u0026rsquo;, but when they\u0026rsquo;re together they try to show off in front of each other.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e4. How can we improve education about periods?\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the girls had received good menstrual education at school. Overall, four themes were identified for this question: level of education: \u003cem\u003eI have barely learnt a thing\u003c/em\u003e; content of education: \u003cem\u003ewe need to know more\u003c/em\u003e; teaching style: \u003cem\u003ehow and when we are taught\u003c/em\u003e; and educating boys: \u003cem\u003ethey do not understand.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of Education: \u003cem\u003eI Have Barely Learnt a Thing\u003c/em\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany girls told us that they had never had lessons about periods at secondary school, and a few of them said that they did not get taught at primary school either. Those who did learn about periods in primary school said it was very minimal. Some girls said their parents told them a bit about periods, but they had to figure a lot of it out by themselves. Others said their parents did not tell them about it and they found out from friends who started before them.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t really remember learning anything about it. Like, when I came into secondary school, no one really spoke about it \u0026ndash; like teachers, and I never got taught about it, so I just had to find out on my own. Obviously, I had my mum telling me and my dad telling me \u0026lsquo;This is going to happen\u0026rsquo;, but from the school, there wasn\u0026rsquo;t really anything said about it.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;ve not learnt anything about periods when I came to secondary school. Like, the only time I learnt about it was in primary and from my parents, that\u0026rsquo;s the only time, and then the rest I just had to figure out myself.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContent of Education: \u003cem\u003eWe Need to Know More\u003c/em\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe girls that had been taught about periods in school told us how the content was mainly scientific, and that what they were taught was vague, and only really explained the basics of how and why periods happen. They felt it would be better if they were taught how to deal with periods, about what kind of symptoms can occur, how much blood there should be and how many days the bleeding should last, as well as about conditions related to menstruation. A few girls also said they had learnt more on social media than they had from school or their parents, and without this, they would not know what they do about periods:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We need to have lessons on how to deal with it. How are we supposed to deal with it emotionally and physically if we just don\u0026rsquo;t know?\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think we talked a little about it in school, but I\u0026rsquo;ve actually learnt more \u0026ndash; like, you get lots off TikTok and everything, you get loads of like, \u0026lsquo;what your period blood should look like\u0026rsquo;, like, actually have like, examples on pads and everything. We do have some education, but not really in schools, and I think that like, learning about how your blood should look like, and how long your blood should come for \u0026ndash; because obviously it varies like some people can have it all week and sometimes I only have it for like two days and I was really confused about that for ages because obviously, some people have it for a whole week\u0026hellip;I think we should have more education on that\u0026rdquo;.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral girls said how they would like to be taught more about their whole menstrual cycle rather than just about periods. They spoke about how it was not just their period that affected them, and that they would therefore like to learn about how each stage of the menstrual cycle can affect people:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel like I would want to know like, about my entire menstrual cycle, because it\u0026rsquo;s not just a period, and we get a lot of education on just the period, but the days surrounding, the days after, how it affects you, like your appearance, your like, mental state, etc. I feel like instead of just focusing on \u0026lsquo;you get five or seven days a month that might be really horrible, here\u0026rsquo;s what you can do\u0026rsquo;, like, embracing the period and like, utilising it at your peak. It helps you to manage it more. So like, a deeper education that\u0026rsquo;s not just in biology would help I think.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think they should know about the actual cycle itself, so I think if they understood the cycle, they would understand about like when you\u0026rsquo;re on your period and ovulation and things like that, and sort of understand what you\u0026rsquo;re going through.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe girls did not know what a normal period should be like. They said they needed to be taught more about how to recognise what is normal and when they should see a doctor. They told us that at school they were told that \u0026lsquo;everything is normal\u0026rsquo;, but this resulted in the girls feeling confused about the symptoms they were having. Even the girls with severe symptoms felt like they had to just put up with their symptoms until they learned that they were not normal from social media. They expressed a need to learn more about knowing when to seek help from a medical professional:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;No, because they love telling us that everything is normal! That\u0026rsquo;s like the favourite phrase, it\u0026rsquo;s like \u0026lsquo;everything\u0026rsquo;s normal don\u0026rsquo;t worry\u0026rsquo;, and it\u0026rsquo;s like, it\u0026rsquo;s great, \u0026lsquo;cos it\u0026rsquo;s like, it\u0026rsquo;s good, I see why they do it, \u0026lsquo;cos then it\u0026rsquo;s like removing the \u0026lsquo;different isn\u0026rsquo;t normal and you\u0026rsquo;re weird\u0026rsquo;, but at the same time, it\u0026rsquo;s like \u0026lsquo;but should I be going through this much pain\u0026rsquo; or \u0026lsquo;should this actually be happening\u0026rsquo;\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Not really, and then like sometimes I see things on TikTok like I saw this thing on TikTok saying like, if your periods are like, actually proper painful like it\u0026rsquo;s not normal, and I didn\u0026rsquo;t realise that. I get really bad cramps, and I\u0026rsquo;ve always just thought that\u0026rsquo;s normal.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTeaching Style: \u003cem\u003eHow and When We Are Taught\u003c/em\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany girls said that the age when they first learnt about periods should have been younger. Some of them got their period before they had learnt about it, which meant they had no idea what was happening. They said whilst some of them had family members who educated them about periods, they are aware that not everyone had this, and therefore schools need to be more proactive in teaching younger years about periods:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think that maybe there should be more introduction especially, at least year 5 or 6 in primary school, because I know some of my close friends from primary school got their periods in year 6, or like, late in year 5, and they kind of had no idea what was going on. I got mine, not very early, but like in the summer I think of going into year 7. So, I had spoken to my sister and my mum about it so I knew what was going on, but I think especially if you grow up in maybe a household where there are more men than women, then maybe you don\u0026rsquo;t know as much about it, then I think learning about it at school when you\u0026rsquo;re younger will help.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When I started I didn\u0026rsquo;t know anything about it, I was really shocked.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe girls said that who taught them about periods was an important factor in how comfortable they felt and how well they learned. They also expressed a need for male teachers to be more educated. They said that some of the teachers seemed to find it an awkward subject to teach which created a tense learning environment. Some girls suggested that there is a need for teachers to undergo reproductive training whilst they are studying for their teaching qualification so that they can provide students with more engaging, informative lessons and menstrual support:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The teachers seem to find it a bit awkward and a bit of a taboo subject, and the class is sitting there like all tense, and they start laughing at the smallest thing.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some teachers aren\u0026rsquo;t necessarily that open about it, so I feel like especially for these sort of like lessons, maybe some teachers that are better than others, and it\u0026rsquo;s kind of just luck whether you get a good one or not.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducating Boys: \u003cem\u003eThey Do Not Understand\u003c/em\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll of the girls said that they think boys need to be better educated about periods.\u0026nbsp;They explained that boys were immature when it came to periods, which often led to them teasing the girls, making jokes, and\u0026nbsp;sometimes being nasty. They said that they thought they were like this because they had not been properly educated about what periods are and what it is like for girls to experience them, and therefore, they thought that if they were taught about them, their behaviour towards girls would improve. They mentioned how beneficial it would be if men and boys had a better understanding of periods and how to support the people in their lives who menstruate:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They\u0026rsquo;re not supportive because they don\u0026rsquo;t understand it. So I think if you taught them about it, like if you make it, like if you actually get it into their heads \u0026lsquo;this is important\u0026rsquo;, \u0026lsquo;this is what happens\u0026rsquo;, I think that they\u0026rsquo;d understand it more.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The boys don\u0026rsquo;t actually have enough education to know what it\u0026rsquo;s like.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany girls said they were separated in both primary and secondary school classes about periods and that they did not think that they should have been. They all said that they think boys and girls should have been together, as this would have allowed for the development of a more open environment. They also said that it would have been more impactful for boys to have girls in the lessons, as they could have heard first-hand what they go through. They said that separating them taught boys that periods were something that should be kept secret:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel like they should definitely be in the room because periods are like, the butt of a lot of jokes, like, some men will be like \u0026lsquo;Are you moody because you\u0026rsquo;re on your period\u0026rsquo;, like a lot of people I know do that, and I feel like they don\u0026rsquo;t really, like, fully understand like, what it\u0026rsquo;s like, and what we go through. So I feel like they should definitely be in the room so they can like, get a better understanding and like, so that periods aren\u0026rsquo;t like, jokey subjects.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;From a young age, I was also separated in a classroom, and I don\u0026rsquo;t think it should be that way.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral girls spoke on this issue more specifically concerning the creation of stigma and shame. They said they felt that the separation of boys and girls for period education caused stigma, and made girls feel like they have something to be embarrassed about. They explained how separating boys and girls contradicted the idea that periods were being normalised, and reinforced the idea that periods were something to be kept hidden. Therefore, they felt that having mixed classes would normalise periods and reduce stigma:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s almost like, causing the stigma. It\u0026rsquo;s making us feel embarrassed about it. Whereas if we just like, learnt it all together, then we know that the other people know everything.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think when you split up the boys and girls it kind of contradicts the men normalising it. If you split them up and they\u0026rsquo;re not learning about as much as we are how is it going to be normal to them as well? I think it should be as a whole normalised.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, a few girls had mixed feelings and explained that they thought some girls may feel uncomfortable with boys being in the room for lessons, but they did agree that at least some of what is taught should be all together. Others said that when girls find out about periods for the first time in primary school it can be quite overwhelming, and therefore they think that these earlier lessons should be girls only, but as they get older, lessons should be mixed. Most girls with this perspective were mainly concerned about the risk of boys misbehaving, making jokes and embarrassing girls:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some girls are very private about it and might feel uncomfortable in there. So I think the main part, like how to support people when they\u0026rsquo;re on it, I think they should be in the room for it, but then everything else I don\u0026rsquo;t think they should be in the room, \u0026lsquo;cos I feel like they\u0026rsquo;d just take the mick out of it.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel like when you\u0026rsquo;re first learning about it, it\u0026rsquo;s, if it\u0026rsquo;s a new thing as well some people haven\u0026rsquo;t learnt about it before so they\u0026rsquo;re gonna be a bit confused, and I think some comments and questions are better separate when you\u0026rsquo;re first learning about it. But when everyone has an understanding of it, I think that\u0026rsquo;s when they could come together a little bit more.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore how adolescent females in schools across South East England feel about their periods, and how periods affect their physical, social, and emotional wellbeing. All of the girls in the study found menstruation had negative impacts on their wellbeing, with each of them dealing with a variety of challenges because of menstruation. Overall, the findings of this study highlight the crucial need for menstrual care, advocacy, support and education to be prioritised in England. A separate study needs to be carried out with transgender, non-binary and gender-diverse people who menstruate. In this paper we use the term \u0026lsquo;girls\u0026rsquo;, as the focus groups only included cisgender girls.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAttitudes\u003c/h2\u003e \u003cp\u003eIn the study, all of the girls had negative feelings about their period, expressing sentiments of hatred and annoyance, such as \u0026lsquo;Why me?\u0026rsquo; and \u0026lsquo;Why do boys not have to go through it?\u0026rsquo;. Previous studies have observed that negative menstrual attitudes are associated with worse experiences of menstruation, which is reflected in the high reports of menstrual difficulties in the study. Negative attitudes may also arise from the stigma and shame that is attached to periods, especially in those who started their periods earlier than others.\u003c/p\u003e \u003cp\u003eSeveral of the girls in the study told us that they did not know what was happening to them when they had their first period, which can be a traumatic experience with effects that may persist throughout life, portraying periods as scary, negative experiences\u003csup\u003e20\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIt is clear that a lack of support and open discussion about menstruation perpetuates negative attitudes and allows for the maintenance of period stigma. Our previously published study examining effects of menstruation on perimenopausal women, found that women had similar negative attitudes towards menstruation as the girls in this study\u003csup\u003e5\u003c/sup\u003e. Perimenopausal women had negative feelings about their period, but some additionally talked about positive aspects. They frequently referred back to what happened to them during puberty and said the trauma of this has remained with them throughout their lives\u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn this study, there were a few girls who expressed more neutral and sometimes positive attitudes towards periods. Neutral and positive experiences applied more to those who have minimal symptoms and may be associated with advanced reproductive health literacy and a supportive home environment\u003csup\u003e21\u003c/sup\u003e. Therefore, improving education and support for periods could contribute towards improving menstrual experiences and attitudes towards periods overall. Further research is required in this area to identify the specific factors that influence period attitudes and to develop intervention strategies. Additionally, positive attitudes and support for periods should be taught in school.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eWellbeing\u003c/h2\u003e \u003cp\u003ePeriods significantly affect the wellbeing of women and girls throughout their lives. Teenage years are often a turbulent time with the onset of puberty, body changes, and the first years of menstruation; which can be particularly challenging due to the social and psychological challenges that come along with this transitionary period. This sentiment was reflected in our research, with many girls reporting detrimental effects on their physical, emotional, and social wellbeing. Our partner project on perimenopausal women had similar results, with women reporting physical and emotional symptoms as well as impacts on their work, self-esteem, relationships, and social life\u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMany girls reported severe menstrual cramps and heavy bleeding. The prevalence of heavy menstrual bleeding in the UK is around 1 in 4\u003csup\u003e22\u003c/sup\u003e, and as many as 91% of women and girls experience dysmenorrhea\u003csup\u003e23\u003c/sup\u003e. These rates are typically on the higher end in adolescent populations due to the immaturity of the HPO axis\u003csup\u003e24\u003c/sup\u003e. Plan International found that 79% of girls experience symptoms that concern them, but that they have not seen a doctor about it. This is likely because of a variety of factors including the normalisation of menstrual symptoms, making it more likely for women and girls to feel they have to just \u0026lsquo;put up with it\u0026rsquo;; as well as social influences that stigmatise periods and encourage secrecy around them\u003csup\u003e6\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePeriods impacting emotional and mental wellbeing were a common theme in the focus groups. A study found that 67% of girls have psychological problems related to their period, including changes in mood, irritability, and stress\u003csup\u003e7\u003c/sup\u003e. Psychological changes during menstruation may be caused by both physiological and social factors. The menstrual period can also amplify psychiatric conditions such as depression and anxiety\u003csup\u003e12\u003c/sup\u003e. The girls in this study also reported changes in symptoms of other conditions related to disordered eating and body image, however, the research on conditions such as these in relation to the menstrual cycle is sparse and this should be addressed as a research priority.\u003c/p\u003e \u003cp\u003ePoor education, lack of support, and period stigma are all factors which contribute towards making school a difficult environment for girls while they are menstruating. A study by Brown \u003cem\u003eet al\u003c/em\u003e found that teachers in the UK feel that menstruation affects school attendance, participation in lessons, pupil confidence, and attitude and behaviour\u003csup\u003e25\u003c/sup\u003e, and Plan International found that 64% of girls in the UK have missed at least one day of school because of their period, with 66% of girls having missed school because of physical symptoms, 34% because they were worried about leaking, and 22% because of anxiety linked to periods\u003csup\u003e6\u003c/sup\u003e. This aligns with our study, with reports of girls struggling to concentrate in class, attend school and perform well in exams because of their period. The girls in our study also reported issues with teasing from boys at school, as well as anxiety around leaking, which also contributed to making school a difficult place to be while menstruating.\u003c/p\u003e \u003cp\u003eSocialising is an integral part of a young person\u0026rsquo;s wellbeing. Some girls in our study reported feeling unable to leave the house when they were menstruating, which was mainly due to physical and emotional symptoms, as well as anxiety around leaking. Additionally, the girls felt anxious about being moody with their friends. Our data agrees with that reported by Plan International\u003csup\u003e6\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMany of the girls in the focus groups were keen sportswomen and reported a variety of negative effects on their sport. Research to identify barriers to physical exercise while menstruating and campaigns to tackle them should be prioritised to increase physical, social and mental wellbeing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSupport\u003c/h2\u003e \u003cp\u003eThis study identified that having a solid support system at home and school is crucial for the wellbeing. Unfortunately our focus groups revealed that girls did not feel well supported at school. A commonly raised issue was poor access to toilets. At every school we visited, there were consistent reports of girls not being allowed to go to the toilet during class, despite it being a school policy in one school. Typically, teachers do not want to let students go to the toilet during class to maintain order in the classroom and prevent students from purposefully missing class time\u003csup\u003e26\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn addition, there were several reports of toilets not being fit for purpose. All participating schools in our study had period products that were free to access, but they were not easily accessible; for example, period products were kept in the school office rather than in the toilets, which made girls feel uncomfortable about asking for them. In England, there is a period product scheme which allows for state schools to access free period products\u003csup\u003e27\u003c/sup\u003e. However, this scheme does not require schools to have period products available in the toilets or at all and is just an \u0026lsquo;opt-in\u0026rsquo; service. For all pupils to have easily accessible period products at all times, the provision of period products in schools should become law, as it is in Scotland\u003csup\u003e28\u003c/sup\u003e, and they should be provided in the toilets rather than in the school office. Teachers should be encouraged to support the period product scheme by raising awareness of the availability of period products to those who need them, as well as improving the accessibility to products.\u003c/p\u003e \u003cp\u003eThis study revealed that support from teachers and other members of staff is generally insufficient, which is consistent with the literature\u003csup\u003e6\u003c/sup\u003e. This may be due to a lack of training and/or personal perceptions and understanding of menstruation\u003csup\u003e25\u003c/sup\u003e. Teachers could improve support by ensuring they are approachable for period conversations, allowing toilet access, supplying free period products and, as suggested by one girl in this study, undergoing reproductive health training for school staff. This may result in increased attendance and participation and would contribute to the reduction of period stigma, by making it a more open and normal topic of conversation. In 2023 the British Standards Institution (BSI) produced a report on menstruation menstrual health and menopause in the workplace. We recommend that this should be extended to schools\u003csup\u003e29\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eGenerally, the best support received was from peers and sisters. The support received from parents varied widely, with several reports of fathers not understanding periods and therefore not being able to offer support. Culture and religion have a significant impact on views of menstruation\u003csup\u003e30\u003c/sup\u003e and may affect support within families. Other factors which have been shown to influence the level of support received include socioeconomic status, education, and access to healthcare\u003csup\u003e6\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eEducation\u003c/h2\u003e \u003cp\u003eThe need for improved menstrual health education was highlighted, with all of the girls reporting a lack of good quality menstrual health education in school. These agree with findings by Brown \u003cem\u003eet al\u003c/em\u003e who found that menstrual cycle education in UK schools is \u0026lsquo;inconsistent and inadequate\u0026rsquo;.\u003csup\u003e25\u003c/sup\u003e They found that teachers feel that they lack the knowledge, confidence and time to approximately teach pupils on the subject and that over 80% of them felt that they would benefit from further training to teach menstrual education. Participants in the same study reported that teachers were too embarrassed to discuss menstruation and therefore avoided teaching it\u003csup\u003e25\u003c/sup\u003e. We therefore recommend that schools have designated, trained teachers for menstrual education. These teachers could also provide wellbeing support to students with problematic menstruation. Over recent years, the International Reproductive Health Education Collaboration (IRHEC) have developed a free reproductive health guide for teachers. This was open to consultation in 2023 and will be released in 2024, which will hopefully address some of these issues and provide teachers with the resources that they need to teach reproductive health\u003csup\u003e31\u003c/sup\u003e. In addition, we recommend that all teachers undergo reproductive health training as part of their qualified teacher status (QTS) or postgraduate certificate in education (PGCE).\u003c/p\u003e \u003cp\u003eThe girls in the study reported that they need more education on how to cope with periods and that the lessons are too focused on the science of menstruation. This is reflected in literature, with teachers in the UK reporting that less than 14% of lessons focused on the lived experience of periods\u003csup\u003e25\u003c/sup\u003e, and reports that just 2\u0026ndash;3% of 16-18-year-olds in England have been taught about PCOS and endometriosis.\u003csup\u003e32\u003c/sup\u003e Whilst the science of the menstrual cycle is important, it is also integral to include teaching overall period management and self-care, what a \u0026lsquo;normal\u0026rsquo; period looks like in terms of length, flow and symptoms, as well as introducing period-related conditions such as endometriosis, PCOS, and PMDD. It is essential that girls have an understanding of these conditions to allow them to recognise symptoms and make informed decisions about their health. This may in turn contribute towards reducing the negative impacts that periods can have on girls\u0026rsquo; wellbeing, as they would become more able to manage their menstrual cycles and recognise when they need to seek help.\u003c/p\u003e \u003cp\u003eThe girls also expressed a need for menstrual education to be delivered at a younger age, as a significant amount of them started their periods before being taught about it. Studies show that in the UK, menstrual education generally begins in years 5\u0026ndash;6, between the ages of 9-11\u003csup\u003e25\u003c/sup\u003e. Whilst the average age of menarche is 12\u003csup\u003e3\u003c/sup\u003e, it is not uncommon for girls to start as early as age 8\u003csup\u003e33\u003c/sup\u003e, and therefore miss out on the essential education that they need before they start having periods. Therefore, menstrual health education to be introduced at an earlier age.\u003c/p\u003e \u003cp\u003eThe findings of this study have highlighted that boys must receive menstrual health education. The girls in the focus groups reported teasing and bullying from boys, as well as a lack of understanding and support. Plan International found that 20% of girls have experienced bullying around their periods, with 67% of this taking place in schools\u003csup\u003e6\u003c/sup\u003e. It is well known that lack of education about periods leads to stigma\u003csup\u003e29\u003c/sup\u003e which contributes towards issues like bullying. Therefore, we recommend improvements to the menstrual education that boys receive and consideration of integration of boys and girls together for some lessons on reproductive health.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eA strength of this study is that the use of focus groups allows those participating to express themselves more freely compared to other methods such as surveys\u003csup\u003e34\u003c/sup\u003e. In addition, the participants and researchers were able to interact in real-time, which allowed for the conversation to naturally digress away from the main questions and for additional relevant questions to be asked by both parties. This study included both mixed and single-sex schools, as well as both state schools and private schools, which allows for results that are more representative of the population as a whole.\u003c/p\u003e \u003cp\u003eA limitation of this study is selection bias, as those who are confident in a group setting and comfortable discussing menstruation may have been more willing to participate in our focus groups. This could potentially mean that attitudes and experiences of menstruation are typically worse than those represented in our study. In addition to this, because parental consent was required for participation in this study, the daughters of parents who have more stringent beliefs about menstruation and hold a stigma around the topic themselves, could have been inadvertently excluded from this study, as their parents may not have wanted them to be involved. Indeed, the schools reported that some parents did not consent. Furthermore, whilst there are several thousand secondary schools across England, only four were included in this study. Therefore, the results may not be truly representative of the population as a whole. In addition to this, the views of teachers were not collected, and our recommendations require their input. Finally, the girls included in this study represent a group whose early secondary education was affected by the COVID-19 pandemic. As they were in Year 7 during the pandemic, when menstruation is usually taught, some were not given this lesson.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study offers key insights into the negative effects that periods have on the wellbeing of girls, as well as highlighting the negative attitudes around menstruation that exist in our society. We recommend improvements in education and support systems (table 2); by providing training to teachers, implementing a school menstruation policy, improving the curriculum to cover all aspects of menstruation at an earlier age, ensuring boys are included in menstrual education, and ensuring appropriate support systems are in place with teachers to improve the wellbeing of all menstruators.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThank you to the 4 schools who helped with this project, including the staff and girls who took part in the focus groups: Hitchin School for Girls, Saffron Walden County High School, Wimbledon High School and Joyce Frankland Academy. \u0026nbsp;Thank you to Elizabeth Ray for her advice with the protocol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e-Ethics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the ethics committee at University College London (UCL) reference 9831/008. Informed consent was obtained from the parents and the participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e-Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors consent to publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e-Availability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis will be on a case by case basis to comply with UCL ethics committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e-Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJH gives paid talks on reproductive health education and has written a book, Your Fertile Years. She advises a number of companies on reproductive health.\u003c/p\u003e\n\u003cp\u003eJM provides consultancy (non paid) to Gedeon Richter and supervise an iCASE PhD studentship with AstraZeneca Emerging Innovations, AE at Reproduction and Journal of Endometriosis and Uterine Disorders to Gedeon Richter\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e-Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was funded by the Institute for Women\u0026rsquo;s Health, UCL.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e-Authors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJH thought of the initial idea. JH, AB and Elizabeth Ray designed the protocol, JH and AB conducted the focus groups, analysed the data, and wrote the first draft of the paper. JM contributed to data analysis and writing the paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;-Acknowledgements(optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThank you to the 4 schools who helped with this project, including the staff and girls who took part in the focus groups: Hitchin School for Girls, Saffron Walden County High School, Wimbledon High School and Joyce Frankland Academy. \u0026nbsp;Thank you to Elizabeth Ray for her advice with the protocol.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMunro MG, Critchley HOD, Fraser IS and. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynecol Obstet. 2018;143:393\u0026ndash;408. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ijgo.12666\u003c/span\u003e\u003cspan address=\"10.1002/ijgo.12666\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJainV,MunroMG,CritchleyHOD.Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO Systems 1 and 2.Int J Gynaecol Obstet 2023;2:29\u0026ndash;42.doi:10.1002/ijgo.14946.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLacroixAE,GondalH,ShumwayKR,et al.Statpearls [Internet].In:\u003cem\u003ePhysiology, Menarche\u003c/em\u003e.Treasure Island (FL):StatPearls Publishing,2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReedBG,CarrBR.Endotext[Internet].In:\u003cem\u003eThe Normal Menstrual Cycle and the Control of Ovulation\u003c/em\u003e.2018.FeingoldKR,AnawaltB,BlackmanMR,etal.,editors.Available:https://www.ncbi.nlm.nih.gov/books/NBK279054/.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRayE,MaybinJM,HarperJC.Perimenopausal women\u0026rsquo;s voices: How does their period at the end of reproductive life affect wellbeing?Post Rep Health 2023;4:201\u0026ndash;221. doi:10.1177/20533691231216162.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlan International.BreaktheBarriers:Girls\u0026rsquo;ExperiencesofMenstruationintheUK.2018.Available:https://plan-uk.org/file/plan-uk-break-the-barriers-report-032018pdf/download?token=Fs-HYP3v.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSundariT,GeorgeAJ,SinuE.Psychosocial Problems of Adolescent Girls during Menstruation.J Mental Health Edu 2022;3(2):47\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSriprasertI,PakrashiT,KimbleT,et al.Heavy menstrual bleeding diagnosis and medical management.Contracept Reprod Med 2017;2:20.doi:10.1186/s40834-017-0047-4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbbasK,UsmanG,AhmedM,et al.Physical and Psychological Symptoms Associated With Premenstrual Syndrome and Their Impact on the Daily Routine of Women in a Low Socioeconomic Status Locality.Cureus 2020;10:10821.doi:10.7759/cureus.10821.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRasquinLI,AnastasopoulouC,MayrinJV.Statpearls [Internet].In:\u003cem\u003ePolycystic Ovarian Disease\u003c/em\u003e.Treasure Island (FL):StatPearls Publishing,2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMishra S, Elliot H, Marwaha R. 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Sociodemographic differences in symptom severity and duration among women referred to secondary care for menorrhagia in England and Wales: a cohort study from the National Heavy Menstrual Bleeding Audit. BMJ open. 2018;2. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2017-018444\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2017-018444\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJu H, Jones M, Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev. 2014;1:104\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/epirev/mxt009\u003c/span\u003e\u003cspan address=\"10.1093/epirev/mxt009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eButtram Jr. VC. The immature HPO axis. J Reprod Med 1975;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrownN,WilliamsR,BruinvelsG,PiaseckiJ,ForrestL J.Teachers\u0026rsquo; Perceptions and Experiences of Menstrual Cycle Education and Support in UK Schools.Front Glob Womens Health 2022;3.doi:10.3389/fgwh.2022.827365.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLundbladB,Hellstr\u0026ouml;mA,BergM.Children\u0026rsquo;s experiences of attitudes and rules for going to the toilet in school.Scand J Caring Sci 2010;2:219\u0026thinsp;\u0026ndash;\u0026thinsp;23.doi:10.1111/j.1471-6712.2009.00707.x.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDepartment for Education.Periodproductschemeforschoolsandcolleges.2023.Available:https://www.gov.uk/government/publications/period-products-in-schools-and-colleges/period-product-scheme-for-schools-and-colleges-in-england#:~:text=All%20pupils%20and%20students%20in,cannot%20afford%20products.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScottish Government.[Internet].PeriodProducts(FreeProvision)(Scotland)Act2021:EqualityImpactAssessment.2022.Available:https://www.gov.scot/publications/period-products-free-provision-scotland-act-2021-equality-impact-assessment/.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBritish Science Association.Inclusivemenstrualhealtheducationisessentialforequality.2021.Available:https://www.britishscienceassociation.org/blog/inclusive-menstrual-health-education-is-essential-for-equality.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarg S, Anand T. Menstruation related myths in India: strategies for combating it. J Family Med Prim Care. 2015;2:184\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/2249-4863.154627\u003c/span\u003e\u003cspan address=\"10.4103/2249-4863.154627\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eESHRE.[Internet].InternationalReproductiveHealthEducationCollaboration(IRHEC).Available:https://www.eshre.eu/irhec.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaslowski;M.,Biswakarma;R.,Reiss;MJ.,Harper,JC(2024)What have 16\u0026ndash;18-year-olds in England learnt about reproductive health? A survey of school students.Health Education Journal10.1177/00178969241227314.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorris DH, Jones ME, Schoemaker MJ, et al. Determinants of age at menarche in the UK: analyses from the Breakthrough Generations Study. Br J Cancer. 2010;11:1760\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/sj.bjc.6605978\u003c/span\u003e\u003cspan address=\"10.1038/sj.bjc.6605978\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTausch AP, Menold N. Methodological Aspects of focus Groups in Health Research. Glob Qual Nurs Res. 2016;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/2333393616630466\u003c/span\u003e\u003cspan address=\"10.1177/2333393616630466\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cem\u003eTable 1: Table showing the demographic data of each school involved in the focus groups, including local authority, school type, OFSTED rating, gender of entry and number of pupils.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"572\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.286713286713287%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.832167832167833%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocal Authority\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.132867132867133%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.832167832167833%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOFSTED Rating\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.734265734265735%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender of Entry\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.181818181818183%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Pupils\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.286713286713287%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSchool 1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.832167832167833%\" valign=\"top\"\u003e\n \u003cp\u003eMerton\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.132867132867133%\" valign=\"top\"\u003e\n \u003cp\u003eIndependent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.832167832167833%\" valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.734265734265735%\" valign=\"top\"\u003e\n \u003cp\u003eGirls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.181818181818183%\" valign=\"top\"\u003e\n \u003cp\u003e1050\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.286713286713287%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSchool 2\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.832167832167833%\" valign=\"top\"\u003e\n \u003cp\u003eEssex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.132867132867133%\" valign=\"top\"\u003e\n \u003cp\u003eAcademy Converter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.832167832167833%\" valign=\"top\"\u003e\n \u003cp\u003eOutstanding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.734265734265735%\" valign=\"top\"\u003e\n \u003cp\u003eMixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.181818181818183%\" valign=\"top\"\u003e\n \u003cp\u003e2147\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.286713286713287%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSchool 3\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.832167832167833%\" valign=\"top\"\u003e\n \u003cp\u003eHertfordshire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.132867132867133%\" valign=\"top\"\u003e\n \u003cp\u003eAcademy Converter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.832167832167833%\" valign=\"top\"\u003e\n \u003cp\u003eOutstanding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.734265734265735%\" valign=\"top\"\u003e\n \u003cp\u003eGirls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.181818181818183%\" valign=\"top\"\u003e\n \u003cp\u003e1368\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.286713286713287%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSchool 4\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.832167832167833%\" valign=\"top\"\u003e\n \u003cp\u003eEssex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.132867132867133%\" valign=\"top\"\u003e\n \u003cp\u003eAcademy Coverter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.832167832167833%\" valign=\"top\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.734265734265735%\" valign=\"top\"\u003e\n \u003cp\u003eMixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.181818181818183%\" valign=\"top\"\u003e\n \u003cp\u003e1022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2: \u0026nbsp;Recommendations for schools regarding menstruation education and support\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"572\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\u003ctd\u003e\u003cul\u003e\n \u003cli\u003eFree and easy access to period products should be made available in all secondary schools.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSchoolwide policies to ensure appropriate toilet facilities and access.\u003c/li\u003e\n \u003cli\u003eWhen designing new school buildings, single cubicle toilets that contain a sink are recommended, and dark furnishings\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDark uniforms to prevent anxiety around menstrual leaking.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMandatory reproductive health training should be provided for all teachers.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eImprovements to the mandatory curriculum on menstrual health, ensuring a range of topics that cover all aspects of menstruation are included and delivered over several years.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThat menstrual health education should be introduced in primary schools by Year 4 in a simple, age-appropriate way.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThat both boys and girls are given comprehensive education about periods and should not be separated for reproductive health education by default, but the option of having separate group lessons should be available when requested by pupils.\u0026nbsp;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThe assignment of teachers as specialists in reproductive health who can deliver education and support, rather than the use of form tutors who are out of their comfort zone.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eOnline reproductive health resources for parents should be offered by the local council.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eInvestment in further research to explore the experiences of menstruators in the UK, including non-binary and transgender individuals and other minority groups.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAgreements should be made between relevant organisations and media outputs to accurately portray menstruation and work to break down menstrual stigma.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\u003c/td\u003e\u003c/tr\u003e\n \u003c/tbody\u003e\u003c/table\u003e\n\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4692690/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4692690/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMenstruation can negatively impact quality of life (QoL), particularly during adolescence. In addition to physical and emotional symptoms, there is a stigma surrounding menstruation and a lack of support and education; which can have detrimental effects on wellbeing. This study aims to (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) explore if girls in schools across South East England feel that periods affect their wellbeing, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) to understand the support and education that girls receive and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) to suggest changes to improve menstrual health education and support in English schools.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eEight focus groups were carried out in four schools, two in each school, with a total of 49 year-10 girls participating (all cisgender). Four questions were asked in each focus group relating to the girls\u0026rsquo; attitudes to having a period, how their period affected their wellbeing, the support they need and how could education be improved.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe girls had mostly negative attitudes about periods, and said their periods negatively impacted their physical, emotional, and social QoL, affecting areas such as friendships, schoolwork, and socialising. They expressed a desire for more menstrual education and for boys to be included. They wanted improved menstrual support, especially at school, in the form of access to period products, days off school, and emotional support.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study highlights the negative impact that menstruation can have on the QoL of girls. It also shows the need for improved support and education for both boys and girls from an early age; which may help dissipate period stigma and increase QoL.\u003c/p\u003e","manuscriptTitle":"Menstrual experiences of adolescent female school pupils in England","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-30 11:22:43","doi":"10.21203/rs.3.rs-4692690/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-08T11:38:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-07T16:58:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-06T13:28:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-07-05T13:48:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c46fdf91-850e-4f8c-9119-ac8eedc4f60f","owner":[],"postedDate":"July 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T16:21:41+00:00","versionOfRecord":{"articleIdentity":"rs-4692690","link":"https://doi.org/10.1186/s12889-025-24681-1","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2026-03-26 16:13:12","publishedOnDateReadable":"March 26th, 2026"},"versionCreatedAt":"2024-07-30 11:22:43","video":"","vorDoi":"10.1186/s12889-025-24681-1","vorDoiUrl":"https://doi.org/10.1186/s12889-025-24681-1","workflowStages":[]},"version":"v1","identity":"rs-4692690","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4692690","identity":"rs-4692690","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}