Menstrual health without stigma

nature medicine Volume 29 | May 2023 | 1029 | 1029 https://doi.org/10.1038/s41591-023-02386-5 Editorial Menstrual health without stigma From menarche to menopause, menstrual health is intrinsically linked to general health and must find regular attention in clinical practice. M enstrual Hygiene Day , com - memorated annually on 28 May, aims to end the stigma surrounding menstruation. The day serves to raise aware- ness of global challenges to accessing men - strual hygiene products and to normalize menstruation as a part of regular life. Menstrual hygiene — the ability of women, girls and other people who menstruate (which can include transgender men and non-binary people) to care for their bodies during menstruation — is a fundamental prerequisite for menstrual health, defined as a state of complete physical, mental and social well-being throughout the menstrual cycle 1. From menarche to meno - pause, people’s menstrual health is intricately linked to their general health and must find regular attention in clinical practice. A menstrual cycle that is medically considered in the normal range can last 24–38 days, with up to 8 days of bleeding2. There can be a disconnect between what a person feels is a healthy men- strual cycle for them and what medical guide- lines consider to be normal. Part of the problem is the lack of discourse and of education of the public and healthcare providers around what to expect from a healthy menstrual cycle. Irregular cycles (even those within the medically defined normal range) and heavy periods can negatively affect quality of life for many people. The same is true for premenstrual syndrome, which up to 77% of women experience3, with symptoms such as menstrual pain and emotional dysregulation4. The discomfort and social embarrassment asso- ciated with menstrual pain and unpredictable bleeding can prevent people from engaging in daily activities4. When it comes to menstrual symptoms that are considered normal, but in reality interfere with general health — a fun- damental human right — societal framing and the discourse in medical settings must change. With approximately 400 menstrual cycles in a person’s lifetime, the regular experience of any of the symptoms noted above can be crip- pling. For people who struggle with these symp- toms, it can be challenging to recognize their hardship and need for help. That is also because the societal attitudes around menstruation are loaded with stigma and shame. Moodiness and irritability during ‘that time of the month’ is a trope used to devalue women’s contributions at home, in the workplace and in other settings, and the association of menstruation with being unclean culminates in the exclusion of women from public life in some regions. Having to men- struate in secret because of these constraints is not only disempowering and misogynistic, it is deeply inhumane. Stigmatization and normalization of uncom- fortable menstrual symptoms can also mask pathological conditions, as well as being bar- riers to seeking and receiving proper medical care4. Such is the case for women with endo- metriosis (a chronic systemic disease with symptoms that include severe pelvic pain, infertility and adverse mental health) and premenstrual dysphoric disorder (PMDD) (a chronic neuroendocrine condition with symp- toms that include severe emotional dysregu- lation, depression and anxiety, as well being associated with an increased risk for suicide), according to the UK All Party Parliamentary Group report on endometriosis and a 2018 global survey of premenstrual disorders. Many women face unacceptable, decade-long wait- ing times to achieve accurate diagnoses for these and other serious medical conditions. A lack of physician sensitivity toward and awareness of these and other related condi - tions can lead women to hesitate to seek medical help in the first place and increases the number of appointments needed to achieve accurate diagnoses. Although 5–10% of women struggle with endometriosis5 and 5.5% of women struggle with PMDD 6, there are no validated screening tools or screening programs for either. Formal diagnoses require additional burdens; for example, surgery for endometriosis, and 2–3 months of tracking of symptoms for PMDD. Efforts to increase education about menstrual health and related disorders need to be ramped up in the public, as well as in medical communities. Ultimately, healthcare providers and patients need to feel confident in acknowledging, discussing and recognizing symptoms that require treatment. Beyond hormonal contraception, which can also carry problematic side effects such as depression, there are limited treatment options for people who struggle with potentially pathological menstrual symptoms. Research efforts for effective screening strategies and non-invasive and swift diagnoses, as well as availability of effective treatment options, must increase. Making menstrual health checks routine in clinical practice also would help to remove the stigma and improve general good health for people who menstruate. Medical interventions can also interfere with the menstrual cycle. Studies have shown that mRNA vaccines against COVID-19 can induce changes in menstrual cycle length7. This obser- vation was missed initially because potential adverse events related to or reflected in the menstrual cycle are generally not recorded in clinical trials, which raises questions about the mechanisms for the safeguarding of men- strual health before drugs and biologicals enter the market. The lack of consideration of menstrual health in disease etiology and treat- ment speaks to a disregard of how menstrual cycles can fundamentally affect and/or be reflective of health for those who menstruate. If menstrual health parameters were routinely measured in clinical research and practice, these data would ensure increased safety, as well as exposing potential links between the menstrual cycle and disease states. Patient-centered, standardized menstrual health outcomes need to be recorded by default in clinical work, as well as in research. Women, girls and other people who menstru- ate need to be involved in design of clinical studies in which they are being asked to partic- ipate. Open, stigma-free discourse in health- care settings is essential for the generation of evidence-based knowledge on menstrual health and setting the course for a truly com- prehensive approach to health. Published online: 15 May 2023 References 1. Hennegan, J. et al. Sex. Reprod. Health Matters 29, 31–38 (2021). 2. Munro, M. G. et al. Int. J. Gynaecol. Obstet. 143, 393–408 (2018). 3. Schoep, M. E. et al. Am. J. Obstet. Gynecol. 220, 569. e1–569.e7 (2019). 4. Critchley, H. O. D. et al. Am. J. Obstet. Gynecol. 223, 624–664 (2020). 5. Taylor, H. S. et al. Lancet 397, 839–852 (2021). 6. Gehlert, S. et al. Psychol. Med. 39, 129–136 (2009). 7. Edelman, A. et al. BMJ Med. https://doi.org/10.1136/ bmjmed-2022-000297? (2022). Check for updates