Menstrual experiences of adolescent girls in schools: recommendations for menstrual health education in England

Not all people who menstruate identify as women or girls, for example transgender men and non-binary individuals. After careful thought and consideration, it was decided that this research project would focus on the menstrual experiences of cis-gender adolescent girls. Therefore, when presenting the results of this study, the authors refer to ‘girls’. However, throughout all other sections the use of ‘‘menstruating young people’ or ‘people who menstruate’ are used to encompass all people who menstruate, regardless of their gender identity. A qualitative study was conducted using focus group discussions (FGDs) with adolescent girls in a school setting. FGDs were selected as the method of data collection to allow for interactions between participants that would not be possible with one-to-one interviews. FGDs were considered a flexible method that allowed for enriching and thought-provoking discussion to take place. This study was guided by COREQ [ 41 ]. Qualitative content analysis was used as the underpinning methodological orientation for this study in order to identify common themes in relation to the lived experience of participants [ 42 ]. Ethics approval was provided by University College London Ethics Committee (9831/008). Parents/carers and the participants received written communication regarding the nature of the study and informed consent. In addition, participants were provided with a copy of the distress guidelines developed by the research team. As participants were under 18, parent/carer consent was obtained in each case in addition to participant consent. Participants were made aware that they could withdraw from the study at any time and were not obliged to answer any questions that they did not want to. Participants were encouraged to seek support if they needed it and to contact the researchers if they had any questions. Schools throughout Southeast England within reasonable travelling distance of University College London were directly approached and invited to participate via email. Schools in Wales, Northern Ireland and Scotland were not included in the study because (1) they were not within reasonable travel distance and (2) each of these countries have devolved powers and their own education and healthcare systems that needs to be explored separately. A representative from each school recruited individual participants by reaching out to eligible pupils and their parents/carers. Purposive sampling was used to select participants based on their age and sex [ 43 ]. Females had to be in year 10, which includes ages 14–15 years, and they had to have reached menarche. A semi-structured question guide was developed by the authors that consisted of four main questions (Table  1 ). Teachers from participating schools reviewed the question guide prior to FGDs. The open questions allowed for in depth discussion to take place amongst participants. Table 1 The four questions that were asked in each FGD FGD Questions 1. How do you feel about having a period? 2. How does your period affect your wellbeing? 3. How can we improve support around periods? 4. How can we improve education around periods? The four questions that were asked in each FGD Between May and June 2023 FGDs of 55 min were conducted face to face in private rooms at school during school hours. Four schools were visited and two FGDs were carried out in each, making a total of eight FGDs. Each focus group had between 6 and 10 participants. This sample size was deemed sufficient for this study as it allowed for a range of insights and experiences to be discussed, and saturation of data was reached by the end of FGDs. Saturation was determined when recurring points were being made and no new themes were emerging. FGDs were led by JH and attended by AB, audio-recorded and transcribed verbatim. Two schools had a teacher present in the room, but they were unobtrusive and not involved in the FGD. The names of participants were not used to protect identity. At the beginning of each FGD, the research team introduced themselves and explained the study to the participants. They explained how the FGDs would work and ensured the participants knew what to do if they felt distressed at any point. The researchers also checked throughout the sessions for signs of distress. A summary of each session was written to accurately encapsulate the discussion and tone and begin understanding initial thoughts and ideas. Upon completion of each FGD, written transcripts were developed and checked for accuracy. Transcripts were not returned to participants. Thematic analysis was performed using an inductive approach [ 44 , 45 ]. Themes and patterns were identified from the transcripts [ 46 ] without assigning specific codes to data segments. This allowed for a more flexible and dynamic approach to analysis, with an emphasis on understanding the data as a whole. Discussions were undertaken throughout the process to ensure agreement in selected themes and allow for adjustments and revisions. The analysis process began with familiarisation with the data. Transcripts were broken down by question and analysed individually. One researcher highlighted initial themes during the familiarisation process, attempting to cover the experiences and feelings of each individual participant. Data was then organised into themes. Repeated thoughts and particularly meaningful sentiments were noted alongside initial thoughts and ideas pertaining to the data. Themes were then reviewed against the overall data set to ensure that it was representative. Themes were refined iteratively by two researchers until it was determined that the overall narrative was adequately conveyed. The research team consisted of UK born cis-gender women of various ethnicities based in England and Scotland. Professor Joyce Harper (JH) is a professor of reproductive science at UCL’s Institute for Women’s Health who has several years of experience conducting qualitative research and FGDs in the field of reproductive health. Alice Brooks (AB) was an MSc student at the time of research and has lived experience of menstrual disorders. JH and AB obtained Disclosure and Barring Service checks prior to visiting schools. JM is a consultant gynaecologist specialising in menstrual disorders and a researcher at the University of Edinburgh. She was involved in the development of the research paper.

Demographic data of individual participants was not collected but the demographic data for each school can be found in Table  2 . In total there were 49 participants. Table 2 The demographic data of each school involved in the FGDs Local Authority School Type Ofsted Rating Status School 1 Merton Independent N/A Single Sex School 2 Essex Academy Converter Outstanding Co-ed School 3 Hertfordshire Academy Converter Outstanding Single Sex School 4 Essex Academy Converter Good Co-ed The demographic data of each school involved in the FGDs Participants were engaged in the FGDs and 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. Each participant had their own unique experiences of menstruation. Many described negative feelings towards menstruation, and others spoke about neutral thoughts and positive aspects. Three themes were identified for this question which explore the negative, neutral and positive domains of menstrual experiences. Feelings about menstruation were directly associated with the level of menstrual symptoms each participant experienced. A large proportion of participants had negative feelings about periods, describing them as ‘annoying’ and ‘horrible’. Participants reported resentment towards the fact that they have to have periods and others do not. “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.” (Co-ed-4-FG2) “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.” (Co-ed-4-FG2) Several participants noted the significant impact that periods had on their lives, affecting their mood, social life, sports and school. Some participants expressed an altered outlook on their day when menstruating and described periods as inconvenient. “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.” (Co-ed-2-FG1) “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.” (Co-ed-2-FG1) A few participants 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. “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!’” (Single-sex1-FG2) “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!’” (Single-sex1-FG2) One participant said that she saw periods as a blessing. She explained that in earlier years, periods were viewed as a curse, but as she got older, they became less significant and offered an opportunity to connect with others experiencing the same thing. “ 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 , (Single-sex-1-FG1) talk about it with people.” “ 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 , (Single-sex-1-FG1) talk about it with people.” Five themes were identified for this question that encompass the physical, emotional and mental symptoms related to menstruation, as well as its impact on school, socialising and sport. A significant number of participants reported a history of dysmenorrhea, ranging from mild to severe. Some said that dysmenorrhea prevented them from being able to go to school and spend time with friends. A number added that regular analgesics such as paracetamol did not ease their pain, so they had to just cope with it. “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.” (Co-ed-2-FG2) “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.” (Co-ed-2-FG2) In addition to dysmenorrhea, several said they experienced additional symptoms before and during menstruation such as fatigue, back pain, bloating, heavy menstrual bleeding and nausea. They described feeling ‘heavy’ and ‘exhausted,’ and said that this time in their cycle was ‘hell’. Some participants described not being able to leave the house as a result of physical symptoms. “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!” (Co-ed-4-FG1) “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!” (Co-ed-4-FG1) Many participants reported that they experienced emotional difficulties before and during menstruation such as mood swings, anxiety, anger, crying, irritability and low mood. They spoke about how these symptoms negatively affected their day-to-day life, their home environment, and their relationships with others. “I think I get really grumpy , and I experience my emotions more.” (Single-sex-3-FG1) “I think I get really grumpy , and I experience my emotions more.” (Single-sex-3-FG1) Some of the participants had mental health difficulties such as eating disorders, body image issues, anxiety and depression, which they said were worse during menstruation. Issues discussed included worsened body image, panic attacks, depressed mood, suicidal thoughts, and binge eating urges. “This is like really kinda personal , but I get like incredibly like , really , like , really badly depressed and suicidal , like on the week before.” (Single-sex-3-FG2) “This is like really kinda personal , but I get like incredibly like , really , like , really badly depressed and suicidal , like on the week before.” (Single-sex-3-FG2) Several participants reported having struggled to attend school because of their menstrual symptoms. A few said they had to take days off school, and others went to school but found it difficult to get through the day. They felt they missed out on classwork as well as time with their friends. “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.” (Single-sex-3-FG1) “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.” (Single-sex-3-FG1) Some participants reported that their period affected their concentration at school. They said that they did not have the same motivation as usual and that their menstrual symptoms made them unable to focus during lessons. A few reported that menstruation affected them during exam time by reducing their motivation and affecting their overall academic performance. They explained that they often ended up achieving lower grades than usual if they were on their period. “If I’m on my period during an exam , I tend to do worse than I usually do.” (Co-ed-2-FG1) “If I’m on my period during an exam , I tend to do worse than I usually do.” (Co-ed-2-FG1) Several participants reported not wanting to socialise or leave the house during menstruation. They said that they often want to stay in bed, but as a result felt sad about missing out on fun with their friends, which affected their mood. A few participants spoke about feeling guilty about having mood swings and feeling angry around their friends which often prevented them going out. “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!” (Co-ed-4-FG2) “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!” (Co-ed-4-FG2) Some participants 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.” (Single-sex-1-FG2) “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.” (Single-sex-1-FG2) Several participants regularly participated in sports such as rowing, dancing, football and running. They spoke about how their period affected their training and competitions because of dysmenorrhea, fatigue, and reduced motivation. They mentioned that the unpredictable nature of periods affected their sport, and that their overall performance was worse while menstruating. “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’.” (Co-ed-2-FG2) “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’.” (Co-ed-2-FG2) Several said that when menstruating they struggled with physical education lessons at school 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.” (Co-ed-2-FG1) “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.” (Co-ed-2-FG1) Participants reported varying levels of support. Factors such as family dynamics, school attended, and friendship groups were all identified as factors influencing the level of support each individual received. The three main themes identified around support were support in school, at home, and from peers. Overall, the support received at school was poor. Participants did not feel supported and felt as though there was a major lack of understanding and empathy from staff members. Often teachers told them to ‘just deal with it’ and that ‘everybody gets a period’. They felt that in general, teachers were more focused on education than on student wellbeing, which left them feeling unable to reach out for help. “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.” (Co-ed-2-FG2) “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.” (Co-ed-2-FG2) Participants reported a lack of support from the school nurse. Several participants said that when they attended the school nurse with menstrual symptoms, they were not allowed to go home and were sent back to class. They were frustrated that they were made to stay in school despite their symptoms and subsequent inability to focus in class. There were also reports of parents/carers fabricating a story about why their child needed to leave, as menstrual symptoms were never accepted as a reasonable excuse. “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.” (Co-ed-2- “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.” (Co-ed-2- At every school, participants said that more often than not teachers would not let them go to the toilet during class, even if they shared that they were on their period. They said that whether you would be allowed was inconsistent, with each teacher adopting their own set of rules. One participant expressed that not being allowed to go to the toilet at school was one of the reasons she did not want to come in while she was menstruating. “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.” (Co-ed-2- “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.” (Co-ed-2- Participants from all schools included reported issues with the toilets. They were frequently described as ‘disgusting’, and were reported to have been very busy, especially at breaktime. Participants from one school reported that blocks of toilets were regularly locked which reduced access, and that there were always teachers present in the bathrooms which made them feel uncomfortable. “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.” (Co-ed-2 “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.” (Co-ed-2 The access to period products varied between schools. One school had period products available in the toilets, but participants said that the box was usually empty. In another school they had to go to the administration office, which several participants reported feeling uncomfortable about. One school had a facility called ‘The Hive’ which provided a safe space as well as a free supply of period products. “I think they should be in the toilets because I’d feel awkward going to the office for stuff like that.” (Single-sex-3-FG2) “I think they should be in the toilets because I’d feel awkward going to the office for stuff like that.” (Single-sex-3-FG2) There were several solutions proposed by participants for how support could be improved at school. Participants expressed a need for having a designated person at school that they could talk to about periods. They also said that there needed to be more flexibility for those who have more severe symptoms to take time off school. All participants said they would like easier access to period products in the toilets and to be allowed to access the bathrooms freely. “I’d much prefer being able to quietly grab what I need instead of having to ask.” (Single-sex-3-FG2) “I’d much prefer being able to quietly grab what I need instead of having to ask.” (Single-sex-3-FG2) Each participant had their own unique experience of support at home, as well as varying family dynamics, relationships and living circumstances. Generally, most participants spoke positively about their relationship with their mother, expressing that they could talk freely with her and felt comfortable talking about menstruation. “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.” (Single-sex-1-FG1) “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.” (Single-sex-1-FG1) Several participants reported that whilst they had good intentions, their fathers could be awkward talking about menstruation. “I’m a lot more awkward talking to my dad about it because he doesn’t understand it as much.” (Single-sex-3-FG1) “I’m a lot more awkward talking to my dad about it because he doesn’t understand it as much.” (Single-sex-3-FG1) Having a supportive environment at home was not the case for all. Some participants felt that their parents/carers were not understanding and did not take their menstrual symptoms seriously. There were multiple reports of participants’ parents/carers telling them to ‘stop being dramatic’. “…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’.” (Single-sex-3-FG1) “…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’.” (Single-sex-3-FG1) Having separated parents was associated with more turbulent support depending on which parent they lived with. One participant said that when she first started her period, she would not stay at her father’s house because she felt too embarrassed. “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.” (Single-sex-3-FG2) “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.” (Single-sex-3-FG2) Participants 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 for menarche and didn’t carry as much shame around menstruation. “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.” (Single-sex-3-FG2) “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.” (Single-sex-3-FG2) Participants with brothers had more negative experiences compared to those with sisters. “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.” (Co-ed-2-FG2) “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.” (Co-ed-2-FG2) However, some participants had more supportive brothers who wanted to learn about periods. Overall, participants expressed the need for men and boys to be more educated about menstruation so that they could offer more support. Many participants spoke highly of the support they received from friends. They said their friends were supportive, communicative and non-judgemental. Several participants 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.” (Co-ed-4-FG2) “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.” (Co-ed-4-FG2) Participants did not have such positive experiences with boys. They said that most boys seemed disgusted by periods and would sometimes make hurtful comments or jokes towards them. Several participants explained that they thought boys behaved 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.” (Co-ed-2-FG1) “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.” (Co-ed-2-FG1) A few participants also mentioned some positive experiences where boys were interested in learning and were considerate about what kind of support they might have needed. “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.” (Co-ed-2-FG2) “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.” (Co-ed-2-FG2) There were reports of poor education in all four schools. Four themes were identified for this question, focussing on the level of education, content of education, teaching style and involvement of boys in menstrual education. Several participants shared that they had never had lessons about periods at secondary school, and a few of them said that they did not get taught about menstruation at primary school either. Those who did learn about periods in primary school said the lessons were very minimal. Some participants said their parents/carers told them a bit about periods, but they had to figure a lot of it out by themselves. Others shared that their parents/carers did not tell them about menstruation, 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.” (Co-ed-2-FG1) “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.” (Co-ed-2-FG1) Participants that had received menstrual education in schools said that the content was very scientific and avoided talking about social and emotional aspects. They said that the content of lessons only really explained the basics of how and why menstruation happens. They expressed a desire to be taught how to manage menstruation, about what kind of symptoms could occur, how much blood there should be and how long the bleeding should last. A few participants said they had learnt more on social media than they had from school or their parents/carers, and without this, they would not know what they do about menstruation. “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?” (Co-ed-2-FG2) “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?” (Co-ed-2-FG2) Further, several participants said that 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 like to learn about how each stage of the menstrual cycle impacts them. “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.” (Co-ed-4-FG1) “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.” (Co-ed-4-FG1) The majority of participants did not know how to recognise a normal versus abnormal period. They said they needed to be taught more about what normal menstruation should be like and when they should seek healthcare. They said that at school they were told that ‘everything is normal’, but that this resulted in further confusion. Participants with severe symptoms assumed that they had to just put up with their symptoms until they learned that they were not normal from social media. “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’.” (Single-sex-1-FG1) “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’.” (Single-sex-1-FG1) Many participants felt that they should have been taught about periods sooner than they were. Some of them reached menarche before they had learned about it, which meant that they did not know what was happening to them when they first bled. “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.” (Single-sex-1-FG2) “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.” (Single-sex-1-FG2) Participants reported that the person teaching them was an important factor contributing to the quality of the education they received. 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 participants 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 pupils 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.” (Single-sex-3-FG2) “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.” (Single-sex-3-FG2) Several participants said that boys needed to be better educated about periods. They explained that boys were immature when it came to periods, resulting in teasing and bullying. They said 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.” (Co-ed-2-FG2) “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.” (Co-ed-2-FG2) Many participants reported that they were separated from the boys in both primary and secondary school for lessons on menstruation. They said they felt that the separation of boys and girls promoted menstrual stigma and shame. They explained that separating 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. “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.” (Co-ed-4-FG2) “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.” (Co-ed-4-FG2) However, a few had mixed feelings about this and explained that they thought some girls may feel uncomfortable with boys being in the room. Though they did agree that at least some of menstrual education should be co-educational, especially as they got older.

The study offers key insights into the negative effects that menstruation has on the wellbeing of adolescent girls, as well as highlighting the negative attitudes around menstruation that exist in our society. We recommend improvements in education and support systems (Table  3 ); by providing training to teachers, implementing a school menstruation policy, improving the curriculum to cover all aspects of menstruation at an earlier age, including all genders in menstrual education, and ensuring appropriate support systems are in place with teachers to improve the wellbeing of all people who menstruate.

The purpose of this study was to explore how adolescent girls in schools across England felt about their periods, and how menstruation affected their physical, social, and emotional wellbeing. The study also aimed to understand how menstrual support and education can be improved. Most of the participants in the study reported that menstruation had a negative impact on their wellbeing. From this study, we have made recommendations for improving menstrual health education in UK schools (Table  3 ). Table 3 Recommendations for improving menstrual health education in UK schools Overarching Recommendation Suggestions for Implementation Improve menstrual health literacy and education with the provision of accurate and reliable information. >Mandatory reproductive health training should be provided for all teachers, including how to support those who menstruate. Offer further opportunities for professional development in this area. >The assignment of teachers with appropriate training in reproductive health who can deliver education and support, rather than the use of form tutors who are out of their comfort zone. >Menstrual Health education should be introduced in primary schools by Year 4 in a simple, age-appropriate way. >Improvements to the mandatory curriculum on menstrual health, ensuring a range of topics that cover all aspects of menstruation are included such as the menstrual cycle and HPO axis, menstrual hygiene, managing symptoms, contraception and when to seek medical help. >Ensure accessibility to educational resources both within and outside of school. >Collaborate with specialists (individuals and organisations) to ensure educational materials are accurate, reliable and up to date. Improve support in schools for people who menstruate. Address period related limitations to foster a more accessible environment. >Provide flexible and supportive arrangements for pupils who experience menstrual symptoms e.g. allowing time off and reasonable adjustments for exams. >Free and easy access to period products should be made available in all secondary schools. >When designing new school buildings, use single cubicle toilets that contain a sink as well as dark coloured furnishings that are easily wipeable. >Introduction of schoolwide policies that ensure appropriate toilet facilities and access. This should involve ensuring each school has a minimum number of toilets per student. >Implementation of dark coloured and comfortable uniforms. Normalise menstruation and reduce stigma and shame. >All genders should be given comprehensive education about periods and should not be separated for reproductive health education by default. >Encourage open discussions in the classroom about menstrual health, fostering an environment where pupils feel comfortable to ask questions and share their experiences. >Ensure menstrual health curriculum includes content on normalising menstruation and addressing stigma. Improve parent/carer support and involve parents/carers and the community in menstrual health initiatives. >Online reproductive health resources for parents/carers should be offered by the local council. >Initiatives driven by community organisations and healthcare providers to improve menstrual health support, awareness and services. >Improve at-home accessibility to menstrual products for people who menstruate who have difficulty accessing them, e.g. monthly deliveries of free products or community collection points. >Collaboration between schools and parents/carers to address any religious or cultural considerations related to menstrual health. Further research. >Investment in further research to explore the experiences of non-binary and transgender individuals and other minority groups. >A Priority Setting Partnership on menstrual health should be carried out by the appropriate parties to identify the priority areas of research as decided by a team of patients, healthcare professionals and academics. >Additional studies should focus on the experiences of healthcare amongst adolescent people who menstruate. Recommendations for improving menstrual health education in UK schools >Mandatory reproductive health training should be provided for all teachers, including how to support those who menstruate. Offer further opportunities for professional development in this area. >The assignment of teachers with appropriate training in reproductive health who can deliver education and support, rather than the use of form tutors who are out of their comfort zone. >Menstrual Health education should be introduced in primary schools by Year 4 in a simple, age-appropriate way. >Improvements to the mandatory curriculum on menstrual health, ensuring a range of topics that cover all aspects of menstruation are included such as the menstrual cycle and HPO axis, menstrual hygiene, managing symptoms, contraception and when to seek medical help. >Ensure accessibility to educational resources both within and outside of school. >Collaborate with specialists (individuals and organisations) to ensure educational materials are accurate, reliable and up to date. >Provide flexible and supportive arrangements for pupils who experience menstrual symptoms e.g. allowing time off and reasonable adjustments for exams. >Free and easy access to period products should be made available in all secondary schools. >When designing new school buildings, use single cubicle toilets that contain a sink as well as dark coloured furnishings that are easily wipeable. >Introduction of schoolwide policies that ensure appropriate toilet facilities and access. This should involve ensuring each school has a minimum number of toilets per student. >Implementation of dark coloured and comfortable uniforms. >All genders should be given comprehensive education about periods and should not be separated for reproductive health education by default. >Encourage open discussions in the classroom about menstrual health, fostering an environment where pupils feel comfortable to ask questions and share their experiences. >Ensure menstrual health curriculum includes content on normalising menstruation and addressing stigma. >Online reproductive health resources for parents/carers should be offered by the local council. >Initiatives driven by community organisations and healthcare providers to improve menstrual health support, awareness and services. >Improve at-home accessibility to menstrual products for people who menstruate who have difficulty accessing them, e.g. monthly deliveries of free products or community collection points. >Collaboration between schools and parents/carers to address any religious or cultural considerations related to menstrual health. >Investment in further research to explore the experiences of non-binary and transgender individuals and other minority groups. >A Priority Setting Partnership on menstrual health should be carried out by the appropriate parties to identify the priority areas of research as decided by a team of patients, healthcare professionals and academics. >Additional studies should focus on the experiences of healthcare amongst adolescent people who menstruate. In the study, many participants 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 [ 23 , 47 ] which is reflected in the frequent reports of menstrual difficulties in the study. Negative attitudes may also arise from the stigma and shame that is attached to periods [ 48 ], especially in those who started their periods earlier than others [ 49 ]. Several participants said that they did not know what was happening to them when they had their first period. This can be a traumatic event with effects that may persist throughout life, portraying periods as scary, negative experiences [ 50 ]. Our study examining the effects of menstruation on perimenopausal women ( n  = 31) found that they frequently referred back to what happened to them during puberty and said that the trauma of this has remained with them throughout their lives [ 9 ]. A few participants expressed more neutral and at times positive attitudes towards periods. Neutral and positive experiences applied more to those who had minimal symptoms and may be associated with advanced reproductive health literacy and a supportive home environment [ 19 ]. We also found some positive comments from the adult focus groups [ 40 ]. Therefore, improving education and menstrual support could contribute towards improving menstrual experiences and attitudes overall. Further research is required in this area to identify the specific factors that influence menstrual attitudes and to develop intervention strategies. The teenage years are often a turbulent time with the onset of puberty, body changes, and the first years of menstruation [ 51 ]; which can be particularly challenging due to the social and psychological challenges that come along with this milestone [ 51 , 52 ]. This sentiment was reflected in our research, with many participants reporting detrimental effects on their physical, emotional, and social wellbeing. Our partner studies on perimenopausal women [ 9 ] and women aged 18–40 [ 40 ] had similar results, with women reporting physical and emotional symptoms as well as impacts on their work, self-esteem, relationships, and social life. Many participants reported moderate-severe dysmenorrhea and heavy bleeding. Rates of dysmenorrhea and AUB are high in adolescent populations due to the immaturity of the HPO axis [ 4 , 53 ]. Plan International found that 79% of participants ( n  = 84) experienced symptoms that concerned them, but that they had not seen a doctor about it [ 11 ]. 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 as though they just have to ‘put up with it’; as well as social influences that stigmatise periods and encourage secrecy [ 19 , 20 , 22 , 23 ], [ 24 ] [ 25 ]. Periods impacting emotional and mental wellbeing was a common theme. One study found that 67% of participants had psychological problems related to their period, including changes in mood, irritability, and stress [ 12 ]. 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 [ 22 ]. Participants in the study also reported that during menstruation, they had increased severity of symptoms of existing disorders related to eating and body image. However, whilst there are some excellent pieces of research on this area [ 54 – 57 ] further research on the impact of menstruation on eating disorders, and in particular body dysmorphic disorder, is recommended. Poor education, lack of support, and menstrual stigma are factors which contribute towards making school a difficult environment for those who menstruate [ 11 ]. One study found that teachers in the UK felt that menstruation affected school attendance, participation in lessons, pupil confidence, and attitude and behaviour [ 27 ]. This aligns with our study, with reports of participants struggling to concentrate in class, attend school and perform well in exams because of their period. Participants 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. Several participants reported feeling unable to leave the house before and during menstruation, which was mainly due to physical and emotional symptoms, as well as anxiety around leaking. These findings are similar to a study in rural Tamil with girls attending school ( n  = 350) [ 58 ]. In addition to this, many participants reported a variety of negative effects on sport. Further research to identify barriers to physical exercise while menstruating and campaigns to tackle such barriers should be carried out in order to increase overall wellbeing. The study identified that having a solid support system at home and school is crucial for menstrual wellbeing. Unfortunately, our FGDs revealed that participants were not well supported at school. There were consistent reports of girls not being allowed to go to the toilet during class. Studies have found that typically, teachers do not want to let pupils go to the toilet during class to maintain order in the classroom and prevent pupils from purposefully missing class time [ 59 ]. Similarly, a qualitative study in Australia with 14–18 year old girls ( n  = 28) found that girls were concerned about having to ‘sit in a pool of blood’ at school [ 36 ]. 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. In England, there is a period product scheme which allows for state schools to access free period products [ 60 ]. 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 [ 61 ]. It was found that support from teachers is generally insufficient, which is consistent with the literature [ 11 , 62 , 63 ]. This may be due to a lack of training and/or personal perceptions and understanding of menstruation [ 27 ]. A study in Australia ( n  = 13) found that despite positive attitudes, teachers had poor ovulatory health knowledge and recognised a personal need for further training and professional development ([ 64 ]. Teachers could improve support by ensuring they are approachable for period conversations, allowing toilet access, supplying free period products and as suggested by a participant, undergoing reproductive health training for school staff (Table  3 ). 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 produced a report on menstruation, menstrual health and menopause in the workplace [ 65 ]. We recommend that this be extended to schools. Generally, the best support received was from peers, mothers and sisters. The support received from parents/carers varied widely, with several reports of fathers being sympathetic but having poor knowledge of menstruation [ 66 ]. A study by Roux found that most girls ( n  = 28) turn to their Mother’s for menstrual support, but due to their own lack of knowledge they cannot support them appropriately [ 36 ]. The need for improved menstrual health education was highlighted, with all participants reporting a lack of good quality menstrual health education at school. This finding aligns with Brown’s research, which found that menstrual cycle education in UK schools is ‘inconsistent and inadequate’ [ 27 ]. They found that teachers felt that they lacked the knowledge, confidence and time to approximately teach pupils on the subject. Further, a study in Australia gathered reflections from secondary school staff in relation to ovulatory menstrual (OM) health education, identifying a need for improved OM literacy; curricular alterations; teaching perspectives; school socio-economic environment; resourcing needs; and community engagement [ 67 ]. We therefore recommend that schools have designated teachers that are specially trained in menstrual and reproductive health education (Table  3 ). These teachers could also provide wellbeing support to pupils with menstrual concerns. In addition, we recommend that all teachers undergo reproductive health training as part of their qualified teacher status or postgraduate certificate in education. Participants reported that they needed more education on how to cope with periods rather than only the science of menstruation, which is of equal importance. This is reflected in the literature, with teachers in the UK having reported that less than 14% of lessons focused on the lived experience of periods [ 63 ]. Furthermore, a USA-based study found that participants reported inadequate educational content with a lack of focus on the practical aspects of managing periods [ 68 ]. It is fundamental that schools begin introducing a broader scope of content to menstrual education programmes that includes practical, emotional and social advice in addition to the essential science lessons (Table  3 ). Participants 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 [ 63 ]. Whilst the average age of menarche is 12 [ 5 ], it is not uncommon for menstruation to start as early as age 8 [ 69 ], and therefore the current curriculum means some girls will miss out on the essential education that they need before menarche. During the first few years post-menarche, the HPO axis is still immature, which can result in menstrual symptoms such as dysmenorrhea and AUB [ 5 ]. This is an incredibly important topic that is widely misunderstood. We therefore recommend that menstrual health education should be introduced at an earlier age, and that information about the HPO axis is appropriately structured into menstrual health education (Table  3 ). The findings of this study have highlighted that boys must receive menstrual Health education. Participants reported teasing and bullying as well as a lack of understanding and support from boys. Plan International found that 20% of girls have experienced bullying around their periods, with 67% of this taking place in schools [ 11 ]. In our study with women aged 18–40, many reported issues with their partners and male friends/colleagues not understanding menstruation which lead to frustration and lack of support [ 40 ]. We recommend improvements to the menstrual education that boys receive and consideration of integration of all genders together for some lessons on reproductive health (Table  3 ). A project lead by the senior author, the International Reproductive Health Education Collaboration (IRHEC) aims to educate the public and teachers by providing free, co-designed, evidence based educational resources, in various languages, on reproductive health. They have developed a reproductive health teaching resource for teachers and information leaflets on various reproductive health education topics including the menstrual cycle, endometriosis and PCOS, which was developed from studies lead by our group [ 30 , 31 , 33 ] and others [ 70 , 71 ] and are all freely available on the IRHEC web site [ 72 ]. The teacher’s resource was open for consultation in 2023 and was released in 2024, and it will hopefully address some of these issues on menstruation including the importance of educating boys and girls together, encourage open discussions, ensure education normalises menstruation but teaches when to seek medical help and where to access online further reading for certain topics, such as endometriosis. Work is currently underway to evaluate teachers use of the resource in different countries and to examine which curricula include reproductive health education globally. The senior author is also working with Wellbeing of Women to develop specific menstruation education in the UK. In Australia, Roux et al. [ 73 ] have used a mixed methods approach to evaluate their programme, My Vital Cycles ® , a holistic school-based ovulatory menstrual Health literacy program. The program was trailed with a Grade 9 cohort in a single-sex school in Western Australia, and its impact assessed through questionnaires and focus groups. The study found that the program improved functional, interactive, and critical menstrual cycle health literacy and had an unexpected finding of improving mood concerns. This intervention is being tested in a wider context. These programs are critical to ensure that we deliver effective, informative and supportive menstrual health education to all pupils globally and further research involving teachers and pupils is essential. A strength of the study is that the use of focus groups allowed those participating to express themselves more freely compared to other methods such as surveys [ 74 ]. Another strength is that the study included both co-educational 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. The analysis of data involved a multidisciplinary team of three researchers with different experiences, understandings and professions, which allowed for the data to be viewed from different perspectives, thus enhancing the analysis and interpretation of data. Furthermore, the use of direct quotes increases the credibility and transparency of the study. A limitation of this study is the use of qualitative content analysis. Content analysis is highly interpretive and therefore may lead to inaccuracies [ 75 ]. Parent/carer consent was required for participation in this study, which meant that the children of parents/carers who have more stringent beliefs about menstruation and hold a stigma around the topic could have been inadvertently excluded from this study. Indeed, the schools reported that some parents/carers did not consent. Furthermore, whilst there are several thousand secondary schools across England, only four were included in this study. Gender diverse individuals were not included, and LGBTQ populations were not determined. In addition to this, general demographic data was not collected for individual participants, which could provide invaluable information for the interpretation of results. Another limitation is the potential of 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, which could reduce the reliability of the data set representing the menstruating population as a whole. Furthermore, the views of teachers were not collected, and our recommendations will require their input for successful implementation which IRHEC are undertaking. An additional limitation is that in two out of four focus groups there were teachers present in the room, which may bias the student’s responses, but the researchers felt that the students in these groups were as open as those where a teacher had not been present. Finally, the participants 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. However, we feel this finding highlights the lack of prioritisation of menstrual education in the current school curriculum.

Menstruation, commonly referred to as a period, is a normal experience of reproductive-age females [ 1 ]. Menstruation occurs following regression of the corpus luteum in the late secretory phase and occurs every 24–38 days and is controlled by the hypothalamic-pituitary-ovarian (HPO) axis [ 2 ]. The menstrual cycle involves a series of highly regulated sequential events, with menstruation occurring approximately 14 days following ovulation if implantation does not occur [ 3 ]. Menarche, defined as the first menstrual cycle bleed, is usually anovulatory in nature [ 4 ], and occurs during adolescence, typically between the ages of 10 and 16 [ 5 ]. People who menstruated must learn to adjust to the physical, social and emotional changes at menarche. This requires appropriate, accessible education and support regarding menstruation and for family/carers to introduce menstruation as a normal experience, encouraging young people to communicate openly and seek healthcare when necessary. Menarche and menstruation can be unsettling experiences [ 6 – 9 ]. This is due to factors such as emotional and physical disturbances, lack of education, high levels of stigma and shame, lack of support and insufficient access to healthcare [ 10 – 12 ]. Participants in a United Kingdom (UK) based study described starting their periods as ‘scary’ and ‘horrible’, stating ‘I thought I was going to die’. This study also found that 14% of participants ( n  = 84) aged 9–24 admitted that they did not know what was happening when they had their first period [ 11 ]. The presence of abnormal menstrual symptoms such as dysmenorrhea, abnormal uterine bleeding (AUB), and premenstrual syndrome (PMS) can significantly impact overall quality of life (QoL) [ 12 , 13 ]. Dysmenorrhea is defined as pain during the menstrual cycle [ 13 ] and a systematic review and metanalysis of 38 studies including 21,573 women showed it affects 70–90% of people who menstruate [ 14 ]. AUB is characterised by changes to the volume, duration, regulation or frequency of bleeds [ 15 ] and is a condition that up to one third of women will experience during their life [ 16 ]. PMS is a collection of physical and emotional symptoms that occur one to two weeks before menstruation [ 17 ], affecting approximately 47.8% of people who menstruate [ 18 ]. In addition to the effects on QoL and overall health, these symptoms can impact a person’s ability to attend school or work and participate in social events, sports and hobbies [ 14 ]. Research has shown that the normalisation of menstrual abnormalities [ 19 , 20 ] and lack of proper menstrual education [ 21 ]. has resulted in women being unable to identify what is ‘normal’ versus ‘abnormal’, and not seeking healthcare when needed [ 19 , 20 , 22 ]. A recent study in Sweden found that those who experienced dysmenorrhea and AUB viewed their symptoms as ‘something they simply had to endure’ ( n  = 16) [ 23 ]. A 2020 study in Spain ( n  = 270) revealed that of 270 women who reported ‘normal’ menstruation, 67.4% had abnormal menstrual characteristics in terms of regularity, duration, blood flow and frequency [ 24 ], suggesting a significant knowledge gap. Stigma, shame and a lack of trust in healthcare professionals were identified as significant contributing factors to delayed presentation [ 25 ]. Menstrual health literacy is low in low/middle (LMIC) and high (HIC) income countries [ 19 ]. Young people are often misinformed about menstruation in LMICs, which results in higher levels of shame and poor menstrual hygiene practices [ 26 ]. In HICs such as Australia and the UK, there are several reports of poor education and support throughout schools and universities [ 14 , 27 ] and teachers generally do not have the training or confidence to teach menstrual health education [ 28 ]. Secondary schools in England have a curriculum for relationship and sex education that includes menstrual education [ 29 ] however, there appears to be a lack of focus on teaching about menstrual experiences, management, support and stigma [ 30 – 32 ]. Our previous studies show that young people do learn about the menstrual cycle at school, but very few are taught about issues such as endometriosis or polycystic ovary syndrome [ 33 ]. In LMICs such as Ethiopia, lack of support and good quality education around menstruation in schools leads to increased rates of school dropouts and low attendance [ 34 ] and may have a direct impact on overall wellbeing and QoL [ 22 ]. It has been shown that in the UK, 13% of schoolgirls ( n  = 84) miss at least one day of school per month which is higher than for coughs/colds and truancy [ 11 ]. In Australia, a menstrual education programme called My Vital Cycles (MVC) has been developed using evidence-based research to provide a robust and clinically effective programme. Several studies have found that MVC is effective in improving ovulatory-menstrual cycle literacy and improving wellbeing in adolescent girls [ 35 ]. Studies carried out by the MVC team have shown that students want to know more about their cycles [ 36 ]. Menstrual health encompasses not only physical but also mental, social and emotional wellbeing in relation to the menstrual cycle [ 23 ]. People who menstruate require access to adequate education, healthcare, support and freedom from discrimination and stigma across all areas of life [ 37 , 38 ]. Whilst menstrual health directly affects half of the population, there is limited qualitative research that explores the experiences of menstruation amongst adolescents in the UK. Understanding the lived experiences of menstruation in young people is critical for improving and promoting menstrual wellbeing, support and education [ 39 ]. Therefore, this study aimed to determine the impact of menstruation on the wellbeing of adolescent girls in schools in England and to understand how menstrual support and education can be improved. This study is part of a larger research project that involved women aged 18–25, 26–40 [ 40 ] and 40 to 55 years [ 9 ].

Supplementary Material 1. Supplementary Material 1.