Menstrual health and endometriosis: costs incurred by women, health systems and society

The costs of women’s gynaecological health, as exemplified by menstrual health and endometriosis, can be substantial for women, health systems and society. The true economic burden associated with menstrual health and endometriosis is likely underestimated, and existing data is not compre- hensive for several reasons. First, existing economic evidence regarding the costs of women’s gynaecological health includes almost entirely non-dis- abled, cis-gender, heterosexual women. Research targeting speci fics u b - populations would likelyreveal higher costs. Second, most data come from high-income countries where the average ability of women to afford out-of- pocket costs is greater, averting further financial or health consequences. Available data, particularly for endometriosis, is somewhat homogenous and not representative of the diverseexperiences for most women across the world. Third, most of the literature regarding menstrual health, its impacts on education and employment, and the associated economic costs considers the average experience of uncomplicated menstruation. These studies do not explicitly include or account for the costs (to the individual or the health system) of challenges associated with menstruation, such as dysmenor- rhoea, heavy menstrual bleeding resulting in iron-deficiency anaemia, or abnormal menstrual bleeding. Fourth, while some economic studies of both menstrual health and endometriosis include indirect costs such as loss of productivity, many closely related, short- and long-term health and well-being outcomes (and their relevant additional costs) are not considered in existing evaluations. For example, when women do not have access to needed health services, they must often accept negative, multi-dimensional consequences such as pain and poor individual health, social exclusion or isolation and lower economic power 57,58 that result in poor mental health outcomes and/or negative impacts on family and co mmunity relationships. The con- sequential costs of these outcomes (including out-of-pocket expenditures borne by women and health system costs) are not systematically captured. Economic evaluations pertaining t o gynaecological health needs must therefore also consider the pain and losses in well-being and opportunity that result from an inability to access services due to individual or national financial constraints. In addition, and as is the case in many health areas, evaluations tend to remain siloed across sectors. Investments in water, sanitation and hygiene (WASH) co uld lead to large improvements in menstrual health 59. Not only are studies quantifying the economic benefits of WASH interventions lacking, but studies to date have tended to measure few health outcomes, potentially missing positive externalities within health that could imply even greater cost-effectiveness of interventions. This includes, for example, accounting for the impact of improved menstrual health on the incidence of bacterial vaginosis and sexually transmitted infections (STIs) 60,61. Further, some gynaecological events have a cumulative effect over time. Evaluation of these long-term and complex impacts is crucial62, but they are rarely taken into account in economic evaluations. For instance, dropping out of school due to lack of access to appropriate toilets and other menstruation-related challenges in school can result in diminished eco- nomic opportunities for girls co mpared to boys, as well as reduced knowledge about SRHR. They may, consequently, be at increased risk of unintended pregnancies, STIs, early marriage and gender-based violence, further compromising their health and well-being 63. Life course approaches have been used to better capture the complexities of cumulative health needs over time, particularly as life expectancy increases3, and could be used more explicitly to guide or structure economic evaluations. A life course approach might additionally facilitate greater attention to women ’s gynaecological health beyond reproduction, including peri-menopause and menopause, for which services are often lacking64. To inform a more efficient, equitable, people-centred allocation of health resources, further research on both the breadth and magnitude of economic costs related to women ’sS R H Ri s needed. In order to better understand the hidden costs related to poor gynae- cological health that many women fa ce globally, a programme of future research needs to include: (a) a thorough mapping of sexual and reproductive health and well-being issues that women face across their life course; (b) the development of a more fulsome framework for evaluating the economic impacts related to women’s SRHR that captures women in all their diversity as well as downstream health impacts; (c) a greater exploration of out-of-pocket costs borne by women in accessing these ser- vices and in their ability to self-care; (d) systematic surveying of women’s sexual and reproductive health services included in, and excluded from, health benefit packages and social insurance programmes across countries; and (e) a broader and more inclusive approach to measuring disease burden of women’s health, in addition to greater quanti fication of consequences beyond the health sector. Future research should also explore integrated interventions that address menstrual health as both a public health priority and an economic development issue, recognizing its multidimensional impact on education, labour, and gender equity. Health system andfinan- cing policies that include explicit protection for and link benefits to women’s needs, includingfinancial incentives for health and care workers to promote gender-responsive care, could help progress women’s SRHR. There are some limitations to our analysis. First, we did not conduct a full systematic review. We limited ou r search to manuscripts written in English in only one database, PubMed, and prioritized manuscripts for which the full text was readily available. However, PubMed is the largest database of its kind, we reviewed a large proportion of relevant articles retrieved in the search, and there was a great deal of coherence across studies included in the review, allowing us to characterize the likely economic burden of menstrual health and endometriosis on women, health systems and society (as well as associated gaps). Second, we draw on this subset of available evidence of the costs associated with menstrual health and endo- metriosis to highlight under-recognized SRHR needs and priorities of women and to call for further research. It is possible that studies of other aspects of women ’s gynaecological health h a v em o r ec o m p r e h e n s i v e l y described the associated costs. Third, while we attempted to include data from a wide range of settings and did not restrict our search by geography or country income level, most publish ed studies come from high-income countries. Economic costs may be higher in these settings because of greater earning potential and heightened costs of medical care, but the absolute health and well-being impacts may be most acute in lower-income settings, including for women who go without quality health care that isfinancially unattainable. Finally, while economic analyses help to draw attention to women’s health issues, economics is not the sole lens through which these issues should be evaluated. The notion that a physiological process requires medical management amounts to medi calization, and raising concerns regarding productivity losses to help justify greater attention to women’s empowerment and well-being is a capitalistic argument 65,66. Women deserve autonomy, time to rest and the freedomto prioritize their health and well- being without being reduced to the sum of their economic contributions. Policies should strive to balance economic arguments with holistic health perspectives 67,68.

Menstrual health and endometriosis incur substantial costs to individual women, health systems and society that are underestimated. Further, the financial, physical and emotional burden of poor gynaecological health on women is not well understood or quantified. Menstrual health is an aspect of health that can signi ficantly impact the overall health and well-being of women, but which has received insuf ficient attention in public health responses 69. Addressing the multifaceted and substantive costs associated with menstrual health, endometriosis, and other sexual and reproductive health issues that accrue to women, their families, communities, and societies requires comprehensive healthcare strategies, including preven- tion, early intervention, and support for affected women to mitigate the overall economic burden. We intentionally situated women’s gynaecological health outcomes within the context and complexities of the structural and social determi- nants of health, reinforcing the linkages between women’s economic status and their ability to realize the highest attainable state of SRHR. As such, https://doi.org/10.1038/s44294-025-00094-8 Perspective npj Women's Health | (2025) 3:54 4 future research and priority-setting regarding women’sS R H Ra n dw e l l - being must prioritize equity and centre the communities rendered vulner- able in their specific social, cultural, and political context(s). There is a need for researchers to engage in - and for donors to fund - research that advances the economic case for realizing SRHR with explicit attention to populations who have been excluded from economi c evaluations to date and where evidence of impact is currently lacking. Such a programme of research could influence intervention targeting and resource prioritization on the road towards improving health and well-being of women and universal health coverage. Data availability No datasets were generated or analysed during the current study. Received: 18 March 2025; Accepted: 23 July 2025;

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M.N., J.J.K.R. and S.T.R. were major contributors in writing the manuscript. M.R., C.K., M.B.Q., P.A. and G.O. provided critical review. All authors reviewed and contributed to the manuscript. Competing interests The authors declare no competing interests. Additional information Correspondenceand requests for materials should be addressed to Manjulaa Narasimhan. 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