Experiences of menstrual health and amenorrhoea in eating disorder inpatient units in England: a subgroup analysis from a lived experience led, qualitative study.

In contrast to the above theme, participants with experience of eating disorder units reported that staff often overlooked menstruation, and patients’ needs related to this. While this experience was reported by participants across psychiatric setting types, those in eating disorder units discussed this within the context of staff assuming that patients would not menstruate due to the physical consequences of their eating disorders. This assumption – and how menstruation was overlooked – was reported to heighten feelings of shame and self-consciousness for patients who were menstruating. “Menstruation was not mentioned or any support offered regarding it […] I believe this is due to the assumption that no patients were menstruating due to extremely low BMI and other physical consequences of having an eating disorder” – Questionnaire participant 2, experience of adult eating disorder unit “They just didn’t have them [menstrual products] I think, especially in eating disorder units because in eating disorder units obviously like they expect most people to lose periods and stuff like that. But I get them through very low weight. […] It probably like enhanced like shame that you had around it [menstruation] and stuff as well. I guess like especially in eating disorders units because most people wouldn’t experience them [periods].” – Interview participant 3, experience of a number of ward types including eating disorder units “Menstruation was not mentioned or any support offered regarding it […] I believe this is due to the assumption that no patients were menstruating due to extremely low BMI and other physical consequences of having an eating disorder” – Questionnaire participant 2, experience of adult eating disorder unit “They just didn’t have them [menstrual products] I think, especially in eating disorder units because in eating disorder units obviously like they expect most people to lose periods and stuff like that. But I get them through very low weight. […] It probably like enhanced like shame that you had around it [menstruation] and stuff as well. I guess like especially in eating disorders units because most people wouldn’t experience them [periods].” – Interview participant 3, experience of a number of ward types including eating disorder units Participants also reported a lack of discussions regarding amenorrhea and how patients’ menstrual cycles may be impacted by their eating disorders – even when this information was specifically requested. “No one talked to me about how/why my [menstrual] cycle might stop whilst experiencing an eating disorder. When I asked for advice on what to do when my period stopped I was ignored and mocked because it was “my fault”.” – Questionnaire participant 7, experience of CAMHS, locked rehabilitation and low secure wards “In the eating disorder unit, I wasn’t given information on how my menstrual cycle might return, when or if it would be different at first.” – Questionnaire participant 1, experience of NHS acute wards and private eating disorder unit “No one talked to me about how/why my [menstrual] cycle might stop whilst experiencing an eating disorder. When I asked for advice on what to do when my period stopped I was ignored and mocked because it was “my fault”.” – Questionnaire participant 7, experience of CAMHS, locked rehabilitation and low secure wards “In the eating disorder unit, I wasn’t given information on how my menstrual cycle might return, when or if it would be different at first.” – Questionnaire participant 1, experience of NHS acute wards and private eating disorder unit This was reported to negatively affect participants, for example one participant discussed how the way her menstrual pain was dismissed hindered her ability to develop a more positive relationship with her body and food. “I felt so trapped and it did not help me heal my relationship with my body or food at all, it made me feel my pain was irrelevant, my own feelings were meaningless and that food and periods were associated with pain and discomfort.” – questionnaire participant 8, experience of CAMHS and adult eating disorder units “I felt so trapped and it did not help me heal my relationship with my body or food at all, it made me feel my pain was irrelevant, my own feelings were meaningless and that food and periods were associated with pain and discomfort.” – questionnaire participant 8, experience of CAMHS and adult eating disorder units Furthermore, for one interview participant, the lack of discussion around her menstrual health meant that her pain, associated with suspected endometriosis, was overlooked by staff. “I wasn’t really given any aftercare for that [resuming menstruation] but for me, my period had been quite linked with my eating disorder, and it was one of the reasons why I… why I got so unwell in the first place. But no one thought to check ‘Oh, how does she feel because it returned’.” – Interview participant 4, experience of adult eating disorder unit “I wasn’t really given any aftercare for that [resuming menstruation] but for me, my period had been quite linked with my eating disorder, and it was one of the reasons why I… why I got so unwell in the first place. But no one thought to check ‘Oh, how does she feel because it returned’.” – Interview participant 4, experience of adult eating disorder unit Later in her interview, she described being in too much pain to attend groups or therapy sessions and feeling too nauseous to eat. Despite her attempts to explain her pain, staff interpreted her withdrawal as being related to her mental health, overlooking the complex interactions between her menstrual health and eating disorder. “They would always be so quick to assume that you were skipping therapy or meals or socializing because of mental health when it wasn’t, it was physical health. Like they didn’t seem to understand the connection between the two. Like, you know, on my period […] I won’t be able to eat because I just feel so sick. Again, that’s not mental health. That’s not my eating disorder, that is physical health” – Interview participant 1, experience of adult eating disorder unit “They would always be so quick to assume that you were skipping therapy or meals or socializing because of mental health when it wasn’t, it was physical health. Like they didn’t seem to understand the connection between the two. Like, you know, on my period […] I won’t be able to eat because I just feel so sick. Again, that’s not mental health. That’s not my eating disorder, that is physical health” – Interview participant 1, experience of adult eating disorder unit However, the staff questionnaire respondents reported that their services provide support and information to patients, particularly in relation to loss and resumption of menstruation associated with eating disorders. “ Young people with eating disorders are spoken to about their menstrual history ” – Staff questionnaire respondent 1, Staff Nurse, CAMHS ward “ [I] discuss restarting periods once the body is at a healthier weight. Due to working with children(12-18) with eating disorders ” – Staff questionnaire respondent 2, Clinical Nurse Specialist, ‘CAMHS SEDU’ (presumed to be specialist eating disorder unit) “ Young people with eating disorders are spoken to about their menstrual history ” – Staff questionnaire respondent 1, Staff Nurse, CAMHS ward “ [I] discuss restarting periods once the body is at a healthier weight. Due to working with children(12-18) with eating disorders ” – Staff questionnaire respondent 2, Clinical Nurse Specialist, ‘CAMHS SEDU’ (presumed to be specialist eating disorder unit) Although staff participants reported that patients would be spoken to about menstruation, the lived experience participants expressed that their practical, physical and emotional needs related to menstruation, were generally not addressed or supported. For some participants, this was described as affecting their attitudes towards menstruation, even following being discharged from hospital, or being unhelpful in their eating disorder recovery.

This paper reports a subgroup analysis of individuals with experience of treatment in inpatient eating disorder services, and staff who work in services providing specialist eating disorder treatment, from a former concurrent triangulation mixed methods study using a qualitative and quantitative questionnaire and semi-structured interviews [ 21 , 22 ]. The research was explicitly survivor-led, rooted in – and motivated by – my positionality as someone with lived experience of anorexia. Within mental health research, Survivor Research centres the researcher’s lived experience standpoint, prioritising topics which are important to mental health service users (or refusers), and challenges traditional power dynamics and assumptions of knowledge production [ 31 ]. A more in-depth description of the study methodology, and the quantitative data, can be found at [ 22 ]. Both questionnaires and interview topic schedules were informed by the definition of menstrual health developed by the Global Menstrual Collective [ 11 ] which supported discussion of each domain of menstrual health. This includes access to information and experiencing an environment free from stigma and shame. The concept of menstrual health reflects the range of experiences related to menstruation, emphasising this as a matter of health, and not merely hygiene [ 34 ]. Participants: Lived experienced participants reported experiences of treatment in an eating disorder inpatient service in England within the previous five years were included in the subgroup analysis; participants who mentioned experiences of an eating disorder, but not specialised eating disorder inpatient treatment were not included. Staff participants who reported working in an eating disorder inpatient service in England were included in the subgroup analysis, this included CAMHS units which treat patients with and without eating disorders where it was explicit that eating disorder treatment was provided. Ethics : Ethical approval was granted by the NHS Health Research Authority. Interview participants were offered a peer support debrief session with someone external to the research team following the interview. Data collection: All data was collected by HP. The questionnaires were distributed in April 2023 and the interviews were conducted in August and September 2023. All interviews were held online at the preference of participants. Interviews were audio recorded and transcribed verbatim. Data analysis: The data analysis was conducted by HP. The analysis involved separating the responses of participants who had experienced inpatient eating disorder services and conducting thematic analysis for the qualitative questionnaire responses and interview transcripts. Themes were constructed to reflect experiences which were specific and unique to the eating disorder service context. I am a white British, disabled, autistic, non-binary person. I have lived experience of inpatient hospital admissions, including for anorexia treatment; participants were aware of my lived experience positionality. Elsewhere I have shared these experiences including how my menstruation was exposed during inpatient eating disorder treatment due to a policy of weighing patients naked, in only underwear – something I experienced as coercive and traumatic [ 23 ]. A reflexive approach was essential throughout, acknowledging my preexisting knowledge, lived experiences, and the emotional impact of the research, and considering how this shaped my approach to data analysis [ 17 ]. This included written reflection on my personal experiences, to support explicit identification of accounts which mirrored these experiences and acknowledging how this informed my approach to the research conduct and analysis. There were 13 questionnaire respondents with lived experience of eating disorder inpatient services, two staff questionnaire respondents described experiences of working in CAMHS eating disorder services, and three interviewees reported experiences of eating disorder services (including adult or child and adolescent services) from the original 178 study participants. 3 Of the lived experience questionnaire respondents, 12 were female and one identified as “trans masc” [masculine]. Eleven participants were white, one respondent was of mixed/multiple ethnic background, and one identified as ‘other ethnic group’. 4 Eight participants were aged between 18 and 24, two participants were aged 25–34, two 35–44, and one was aged 45–54. Two staff respondents were both nurses working in CAMHS units. Of the interview participants, two were female and one was non-binary. Two were of mixed/multiple ethnic background, and one was white. Two were aged 18–24 and the other was aged 25–34. Two themes were derived from the data: conceptualisations of menstruation and ‘health’ in relation to eating disorders and support needs, and care provision related to eating disorders and menstrual health. These themes reflect approaches to assessment of menstruation and its relationship to ‘health’, and the associated support – or lack thereof – patients received.

This article discusses findings of a subgroup qualitative analysis examining experiences of menstruation in eating disorder inpatient settings in England. Two eating disorder-specific subthemes were constructed in addition to the experiences which were reported across inpatient setting types. Across all types of psychiatric inpatient setting, this research highlighted a contradiction in psychiatric inpatient units where menstruation was both highly visible, but also overlooked, and patients’ needs were often unmet. In the context of experiences of eating disorder services, patients’ menstrual cycles were closely monitored, with some patients even being forced to show menstrual blood to staff members, whilst not providing adequate support with the physical and emotional aspects of these experiences. Menstruation is undoubtedly an important consideration when evaluating the physical well-being of patients in eating disorder treatment. However, the focus must go beyond simply equating the return of menstruation with health and recovery. There is a need for eating disorder services to offer more comprehensive support, addressing the emotional significance that menstruation may hold, as well as the influence of underlying gynaecological or menstrual conditions and how these may interact with someone’s eating disorder. This includes providing both emotional support and practical treatment options. Additionally, it is vital that assessments of menstrual status do not reinforce negative attitudes towards menstruation or lead to coercive practices, such as forcing patients to display their underwear or menstrual products to staff.

The two themes: “conceptualisations of menstruation and ‘health’ in relation to eating disorders”, and “support needs and care provision related to menstruation and eating disorders”, reflected that, whilst patients’ practical, physical and emotional support needs were often reported as being overlooked, menstruation was also closely scrutinised. For some, menstruation was monitored as an indicator of health, and used to inform patient treatment, meal plans and weight targets. Indeed, the Maudsley Method for treatment of anorexia nervosa in adolescents states, “ there is no strong argument for increasing their weight further ” beyond the weight at which a patient resumes menstruation, even if this is below the average BMI for their age and height [ 8 ]. However, observing one menstrual period is insufficient to assess for regular menstruation. There does not appear to have been any research comparing patient outcomes when resumption of menstruation – rather than BMI or weight percentiles – is used an indicator of ‘healthy’ weight, especially if this occurs at a low weight (e.g. [ 5 ]. Conversely, lower BMI at discharge from inpatient anorexia nervosa treatment is associated with increased risk of relapse [ 10 ]. Resumption of menstruation has also been used to determine treatment outcomes for patients with anorexia nervosa. Originally developed in 1975, The Morgan-Russell Outcome Assessment Schedule (MROAS) [ 16 ] is a tool for assessing treatment outcomes in patients with anorexia. The MROAS identifies three outcome categories: good, intermediate and poor, based on measurements of body weight and menstruation. A good outcome is indicated by maintenance of a body weight, within 15% of the average body weight, with regular menstrual cycles, an intermediate outcome would be indicated by the same weight gain which has either not been sustained, or where there were continuing menstrual disturbances. The fourth question in this subscale relates to “attitude to menstruation”, where a patient being “pleased that menstruation has returned” is seen as a good outcome, whereas an “active dislike” of menstruation is considered a sign of ‘sexual maladjustment’. This is assessed alongside a patient’s interest in marriage and reproducing, denial of libido, and aversion to heterosexual contact [ 15 ]. The inclusion of this question as part of assessment of ‘sexual dysfunction’ appears to position ‘attitude towards menstruation’ as indicative of wider attitudes towards fertility and traditional gender roles in relationships, motherhood, and reproduction. In addition to being problematic in its overt pathologizing of homosexuality and asexuality, this illustrates how menstruation may be viewed in close proximity to its relationship to fertility – perhaps, not (only) as an indicator of health, but as an indicator of potential reproductive capacities. Resumption of menstruation is an important aim in the treatment of functional hypothalamic amenorrhea in eating disorder patients and should be considered alongside other measures such as hormone levels [ 5 ]. However, the present study highlighted that the way services emphasised menstruation as a marker of health had adverse impacts for patients, including furthering negative associations with menstruation; especially as the emotional challenges of this were not addressed. This finding is consistent with wider research which reflects how patients feel that eating disorder services place focus on markers of health, such as weight, at the expense of recognising the emotional experience of these conditions [ 25 , 35 ]. This is especially concerning where this scrutiny of the physical body fuels invasive (and unnecessary) practices, such as forcing patients to show staff period products or underwear to prove they have menstruated. Whilst resumption of menstruation may represent a reassuring moment in eating disorder treatment from the staff perspective, this was described as creating distress amongst patients where menstruation was equated with feeling “fat” or “dirty”. One participant described fearing that they wouldn’t be seen as “ill enough” due to not experiencing amenorrhoea. This highlights the complex meanings that the presence, or absence, of menstruation – and the health it may be viewed as symbolising – can hold through the lens of an eating disorder. Indeed, research has illustrated the role that (the absence of) menstruation may play in the construction of anorexic identities, with the loss of menstruation signifying ‘achieving’ anorexia [ 9 , 32 ]. These experiences must also be understood within wider cultural contexts and entrenched menstrual taboo, which shape menstrual attitudes [ 4 ]. Although it is vital to monitor health markers, these must also be understood within the context of patients’ psychological wellbeing; the social and cultural factors which shape these experiences; and with caution to not further hyperfocus on the body and its metrics. Whilst the absence of menstruation is an indicator of poor health, menstruation itself is not an assurance of health; especially where this is associated with painful and disruptive experiences and disorder. Lived experience participants reported receiving little discussion about menstruation, or the health impacts of amenorrhea, beyond scrutiny of the presence/absence of menstruation. One participant reported receiving insufficient support for suspected endometriosis. Her pain, and how it impacted her, was misinterpreted as related to her eating disorder; the emotional connections between her eating disorder, menstrual cycle, and endometriosis were unaddressed. Although findings vary, several studies have reported an increased incidence of eating disorders, and disordered eating, in individuals with endometriosis [ 12 , 18 ]. Further research is needed to develop understanding of the complex relationships between gynaecological and menstrual conditions, eating disorders, and their aitiology and treatments. However, for eating disorder patients with gynaecological conditions, including problematic menstrual symptoms, there is a need to consider how these relates to their eating disorder and their health holistically. This speaks to the broader need for eating disorder services to take a more holistic approach to patient care, recognising the role of the body and co-occurring conditions in the development and maintenance of eating disorders [ 7 ]. Furthermore, participants received a lack of emotional support in dealing with the resumption of menstruation, although this experience was reported to be challenging. There is limited research considering the emotional experiences of menstruation for people with eating disorders. Psychodynamic theories of anorexia have suggested that a desire to supress menstruation may be factor in the development of anorexia due to a fear of womanhood, as symbolised by menarche [ 27 ], a desire to deny adult sexuality [ 27 ], or due to menstruation presenting a trigger in the context of experiences of childhood sexual abuse [ 28 ]. Additionally, in a study by Avila and colleagues [ 3 ] transgender youth (assigned female at birth) with restrictive eating disorders, reported a desire to lose weight in order to suppress menstruation, and alleviate the gender dysphoria associated with it. Eating disorders are complex, and generalisations should not be made about the causes of these. Nevertheless, the present study, and wider research, highlight the need to explore support and treatment options for those with extreme difficulties with menstruation. However, participants in the present study reported receiving a lack of support related to the emotional challenges menstruation posed – a finding which was consistent across hospital types and not specific to eating disorder units. Following the initial research phases, guidelines were developed to provide concrete actions for mental health services to improve patients’ experiences. These guidelines were co-authored by individuals with lived experience of menstruation and psychiatric inpatient treatment, with input from charities, regulatory bodies, and policy stakeholders [ 24 ]. These guidelines outline actions that can be taken in order for psychiatric inpatient settings, including eating disorder units, to provide greater support for patients related to their menstrual health as well as a need for staff training and increased information provision for patients. The study outlined in this article did not specifically examine experiences of menstruation in eating disorder units. Although the findings of this subgroup analysis are important as a subsection of the main study, further research will be required to develop a greater understanding of how eating disorder units support patients in relation to their menstrual cycles – including understanding current practice and considering how services can best support those in their care. Service provision may differ across child and adolescent and adult eating disorder units, and services beyond England. This study focused on experiences of treatment, therefore, there is a need for further research to understand the menstrual experiences of people with eating disorders more broadly; this should consider experience of menopause transition, and the differences in experiences across eating disorder diagnoses.

Functional hypothalamic amenorrhea (FHA)–the absence of menstrual periods due to inhibition of the hypothalamic-pituitary-ovarian axis–can be triggered by weight loss, stress, exercise, or a combination of these factors [ 6 ]. Eating disorders, such as anorexia nervosa, can put significant stress on the body and can disrupt menstrual functioning [ 30 ]. Menstrual disruptions can occur across eating disorder subtypes, including anorexia nervosa, binge-eating disorder and bulimia [ 1 , 13 , 14 , 20 , 29 ]. However, some patients may continue to menstruate despite having a very low weight or may resume menstruation at a weight which would not otherwise be considered an ideal physiological environment [ 5 ]. Until 2013, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) included amenorrhea as a diagnostic criterion for anorexia nervosa; those with otherwise equivalent symptoms, but continued menstruation, would be diagnosed with an ‘eating disorder not otherwise specified’ (EDNOS). Although no longer considered within the diagnostic criteria, it remains important to address menstrual status amongst people who would otherwise menstruate 1 with eating disorders due to the negative health outcomes associated with amenorrhea. The impact of eating disorders on the menstrual cycle is documented in biomedical and epidemiological studies, however, there is limited qualitative research examining patient experiences of amenorrhea, and its treatment in healthcare settings. In 2023, I conducted a qualitative study examining experiences of menstrual health in psychiatric inpatient settings 2 ; this involved interviews and open-text questionnaires with people with lived experience of treatment in inpatient settings and questionnaires with staff working in inpatient settings [ 21 , 22 ]. Four main themes were identified: the lack of privacy when menstruating in psychiatric inpatient settings; (restrictions in) access to menstrual materials in psychiatric inpatient settings; attitudes and approaches to menstruation; and menstrual support needs and care provision [ 21 , 22 ]. These were categorised as relating to institutional and interpersonal settings, where patients’ experiences were influenced by the (over)use of restrictive practices, as well as by the interactions they had with staff members. Staff were often reported to express stigmatising attitudes towards menstruation and provide inadequate support with patients’ physical and emotional needs related to problematic menstrual experiences. The study revealed that patients’ needs surrounding their menstrual health were largely unsupported, with many participants reporting experiences which may amount to neglect. Restrictions were placed on access to menstrual products and materials (including hot water bottles, medications, toiletries and clothing). The institutional environment and restrictive practices, such as enhanced observations, infringed upon patients’ privacy, making their menstruation visible to staff and those around them. While those who reported experiencing treatment in eating disorder units described the same issues as other participants, some of the restrictions reported were specific to eating disorder services. Given the unique challenges and negative experiences of eating disorder inpatient units [ 19 , 26 , 33 ] and the relationship between eating disorders and menstrual disruptions (e.g. [ 30 ], it is important to understand experiences of the menstrual cycle and inpatient eating disorder treatment. Therefore, to better understand the unique experiences of menstruation for individuals with an eating disorder, a qualitative subgroup analysis was conducted to analyse the data from staff and patients with experience relating to eating disorder inpatient services.

Lived experience participants discussed the way that eating disorders intersected with their menstrual health – particularly in the context of the loss and resumption of menstruation (amenorrhea). Menstruation was reported to be closely monitored by staff, who used the presence or absence of menstruation as part of assessments and to inform treatment plans. An interview participant described a shift in the focus of the staff once she had resumed menstruation, at this point, her meal plan was altered and the team began planning for her discharge from the service, although she continued to struggle emotionally. “It… really reinforced the like… ‘oh, I must be like better now’ […] everyone was so like, focused on […] ‘we can change like what you’re eating’ [and plan for] discharge. So I think it maybe kind of stuck with me that they were so focused on like menstrual health as like an indicator of like, how you’re actually feeling […] when everyone around you is telling you that it is, like it’s quite difficult to see past that.” – Interview participant 1, experience of adult eating disorder unit “It… really reinforced the like… ‘oh, I must be like better now’ […] everyone was so like, focused on […] ‘we can change like what you’re eating’ [and plan for] discharge. So I think it maybe kind of stuck with me that they were so focused on like menstrual health as like an indicator of like, how you’re actually feeling […] when everyone around you is telling you that it is, like it’s quite difficult to see past that.” – Interview participant 1, experience of adult eating disorder unit As is highlighted in the quotation above, the emphasis placed on menstruation was experienced for some lived experience participants as, not only unhelpful, but having a lasting impact on how they viewed their menstrual cycle and its significance. Additionally, multiple participants reported that they were forced to show staff members the blood on their underwear or menstrual products to provide evidence that they were being honest about the return of their menstrual cycles. “If you started your period again you had to show a member of staff to prove it, so they would adjust what weight you needed to gain to. This is part of the reason I didn’t want to come off the pill, as I was mortified about this prospect. I still get mortified and feel disgusting on my period and I do believe a lot of this shame and negative associations with getting my period was internalised from my time inpatient.” – Questionnaire participant 3, experience of CAMHS and adult eating disorder units “On eating disorder units especially, like… it’d be like ‘you need to show us your pad like to prove that you’re not like faking it [menstruation]’ […] like it still feels really… like no one trusts you.”- Interview participant 2, experience of CAMHS eating disorder unit and adult acute ward “If you started your period again you had to show a member of staff to prove it, so they would adjust what weight you needed to gain to. This is part of the reason I didn’t want to come off the pill, as I was mortified about this prospect. I still get mortified and feel disgusting on my period and I do believe a lot of this shame and negative associations with getting my period was internalised from my time inpatient.” – Questionnaire participant 3, experience of CAMHS and adult eating disorder units “On eating disorder units especially, like… it’d be like ‘you need to show us your pad like to prove that you’re not like faking it [menstruation]’ […] like it still feels really… like no one trusts you.”- Interview participant 2, experience of CAMHS eating disorder unit and adult acute ward Furthermore, some lived experience participants described how resuming menstruation, or continuing to have periods throughout their illness, was a challenging experience. Menstruation was positioned as a sign of health which, in the context of their eating disorder, had negative associations. “It just made me feel dirty and it made me feel like, you know, my body was healthy and I couldn’t really cope with that. And even though I’m having a period and it’s a good sign as I’ve got osteoporosis […] It just made me feel like I weighed too much.” – Interview participant 1, experience of adult eating disorder unit “I was afraid that if any other patient knew I was able to menstruate, they would see me as fat and not ‘ill enough’ to be on an eating disorders ward. I had my own internalised stigma around this, believing that I couldn’t really be ill or in need of treatment if my periods hadn’t stopped.” – Questionnaire participant 5, experience of adult eating disorder unit “It just made me feel dirty and it made me feel like, you know, my body was healthy and I couldn’t really cope with that. And even though I’m having a period and it’s a good sign as I’ve got osteoporosis […] It just made me feel like I weighed too much.” – Interview participant 1, experience of adult eating disorder unit “I was afraid that if any other patient knew I was able to menstruate, they would see me as fat and not ‘ill enough’ to be on an eating disorders ward. I had my own internalised stigma around this, believing that I couldn’t really be ill or in need of treatment if my periods hadn’t stopped.” – Questionnaire participant 5, experience of adult eating disorder unit The above quotes emphasis that, although both staff and patients spoke of menstruation being conceptualised as a sign of health, perhaps shaped by ill-driven driven thinking, the emotional significance of menstruation, and the health it may be seen to symbolise, differed from the patient perspective.