Menstrual health and period poverty among young people who menstruate in the Barcelona metropolitan area (Spain): protocol of a mixed-methods study

INTRODUCTION

The importance of menstrual health has been historically neglected, mostly due to taboos and misconceptions around menstruation and androcentrism within health knowledge and health systems around the world. There has also been a lack of attention on 'period poverty', which refers to the financial, social, cultural and political barriers to access menstrual products and education. The main aim of this research is to explore menstrual health and experiences of period poverty among young people who menstruate (YPM).

METHODS AND ANALYSIS

This is a convergent mixed-methods study, which will combine a quantitative transversal study to identify the prevalence of period poverty among YPM (11-16 years old), and a qualitative study that will focus on exploring menstruation-related experiences of YPM and other groups (young people who do not menstruate (YNM); primary healthcare professionals; educators and policy-makers). The study will be conducted in the Barcelona metropolitan area between 2020 and 2021. Eighteen schools and 871 YPM will be recruited for the quantitative study. Sixty-five YPM will participate in the qualitative study. Forty-five YNM and 12 professionals will also be recruited to take part in the qualitative study. Socioeconomic and cultural diversity will be main vectors for recruitment, to ensure the findings are representative to the social and cultural context. Descriptive statistics will be performed for each variable to identify asymmetric distributions and differences among groups will be evaluated. Thematic analysis will be used for qualitative data analyses ETHICS AND DISSEMINATION: Several ethical issues have been considered, especially as this study includes the participation of underage participants. The study has received ethical approval by the IDIAPJGol Research Ethics Committee (19/178 P). Research findings will be disseminated to key audiences, such as YPM, YNM, parents/legal tutors, health professionals, educators, youth (and other relevant) organisations, general community members, stakeholders and policy-makers, and academia.

Monthly variation of hot flashes, night sweats, and trouble sleeping: effect of season and proximity to the final menstrual period (FMP) in the SWAN Menstrual Calendar substudy

OBJECTIVE

Although reproductive function is influenced by season, few studies have evaluated seasonal effects on menopausal symptoms. We assessed the impact of season and proximity to the final menstrual period (FMP) on frequency of symptom reporting.

METHODS

In all, 955 participants in the Study of Women's Health Across the Nation recorded whether or not they had experienced menopausal symptoms on a monthly menstrual calendar over a 10-year period. We modeled the log-odds of presence of a given symptom each month using a logistic mixed-effects model, assuming a third-order polynomial before the FMP and a different third-order polynomial after the FMP. We assumed sine and cosine functions for month of the year.

RESULTS

Five to 10 years before the FMP, ∼20% of women reported hot flashes and night sweats, whereas ∼40% reported trouble sleeping. Prevalence rose ∼4 years before the FMP with a sharp jump in hot flash (∼60%) and night sweats (∼40%) prevalence coincident with the FMP. Peaks in hot flashes and trouble sleeping were observed in July with troughs in January. The peak and trough in night sweats occurred about 1 month earlier. Odds of hot flashes, night sweats, and trouble sleeping were 66%, 50%, and 24% greater, respectively, at the seasonal peak versus the seasonal minimum.

CONCLUSION

Menopausal symptoms exhibit seasonal variation associated with the summer and winter equinoxes. Seasonal increases in night sweats precede increases in hot flashes. Prospectively recorded monthly symptom data demonstrate that hot flashes and night sweats increase notably coincident with the FMP. : Video Summary:http://links.lww.com/MENO/A476.

Women's and girls' experiences of menstruation in low- and middle-income countries: A systematic review and qualitative metasynthesis

BACKGROUND

Attention to women's and girls' menstrual needs is critical for global health and gender equality. The importance of this neglected experience has been elucidated by a growing body of qualitative research, which we systematically reviewed and synthesised.

METHODS AND FINDINGS

We undertook systematic searching to identify qualitative studies of women's and girls' experiences of menstruation in low- and middle-income countries (LMICs). Of 6,892 citations screened, 76 studies reported in 87 citations were included. Studies captured the experiences of over 6,000 participants from 35 countries. This included 45 studies from sub-Saharan Africa (with the greatest number of studies from Kenya [n = 7], Uganda [n = 6], and Ethiopia [n = 5]), 21 from South Asia (including India [n = 12] and Nepal [n = 5]), 8 from East Asia and the Pacific, 5 from Latin America and the Caribbean, 5 from the Middle East and North Africa, and 1 study from Europe and Central Asia. Through synthesis, we identified overarching themes and their relationships to develop a directional model of menstrual experience. This model maps distal and proximal antecedents of menstrual experience through to the impacts of this experience on health and well-being. The sociocultural context, including menstrual stigma and gender norms, influenced experiences by limiting knowledge about menstruation, limiting social support, and shaping internalised and externally enforced behavioural expectations. Resource limitations underlay inadequate physical infrastructure to support menstruation, as well as an economic environment restricting access to affordable menstrual materials. Menstrual experience included multiple themes: menstrual practices, perceptions of practices and environments, confidence, shame and distress, and containment of bleeding and odour. These components of experience were interlinked and contributed to negative impacts on women's and girls' lives. Impacts included harms to physical and psychological health as well as education and social engagement. Our review is limited by the available studies. Study quality was varied, with 18 studies rated as high, 35 medium, and 23 low trustworthiness. Sampling and analysis tended to be untrustworthy in lower-quality studies. Studies focused on the experiences of adolescent girls were most strongly represented, and we achieved early saturation for this group. Reflecting the focus of menstrual health research globally, there was an absence of studies focused on adult women and those from certain geographical areas.

CONCLUSIONS

Through synthesis of extant qualitative studies of menstrual experience, we highlight consistent challenges and developed an integrated model of menstrual experience. This model hypothesises directional pathways that could be tested by future studies and may serve as a framework for program and policy development by highlighting critical antecedents and pathways through which interventions could improve women's and girls' health and well-being.

REVIEW PROTOCOL REGISTRATION

The review protocol registration is PROSPERO: CRD42018089581.

Wealthy, urban, educated. Who is represented in population surveys of women's menstrual hygiene management?

Inadequate menstrual hygiene presents a barrier to women's dignity and health. Recent attention to this marginalised challenge has resulted in the first national assessments of menstrual practices. Intuitively, surveys require women to have had a recent menses to be eligible. This study seeks to determine if there are demographic differences between women who are eligible and ineligible to answer questions about their menstrual hygiene during these assessments. Secondary analyses were undertaken on nationally or state representative data collected by the Performance Monitoring and Accountability 2020 survey programme across eight countries (Burkina Faso, Ethiopia, Ghana, India, Kenya, Niger, Nigeria, and Uganda). Female respondents were included in the study and compared on whether they had a menstrual period within the past three months and thus were eligible to answer questions regarding menstrual practices. On average, 29% of surveyed women across samples were ineligible to be asked menstrual hygiene questions. Higher levels of education, wealth, and urban residence were associated with higher odds of eligibility. Young and unmarried women were also more likely to be eligible. Demographic differences between eligible and ineligible women were consistent across all countries. Wealthy, urban, and educated women are more likely to be eligible to answer survey questions about menstrual hygiene. While population surveys may be representative of menstruating women, proportions of menstrual hygiene practices reported underrepresent the experiences of more vulnerable groups. These groups are likely to have greater struggles with menstrual hygiene when they are menstruating.

Menstruation experiences of South African women belonging to the ama-Xhosa ethnic group

A growing body of research has emphasised the salience of cultural beliefs and traditional practices to women's experiences of menstruation. Relatively less research has, however, been undertaken in South Africa. This study explored the experience of menstruation among women from the ama-Xhosa ethnic group, one of the largest ethnic groups in the country. Among the ama-Xhosa, there are distinct cultural practices associated with menstruation, including the female rite of passage (intonjane) and virginity testing (inkciyo). However, few studies have explored the experience of menstruation for women from this cultural group. This study involved the synthesis of data from individual interviews and focus group discussions conducted among a sample of ama-Xhosa women. The data were analysed using thematic analysis. Distinctive findings included women's participation in traditional cultural practices of intonjane and inkciyo and the presence of cultural taboos associated with menstruation. Women's narratives revealed strong ambivalence regarding these practices. On the one hand, they wanted to adhere to traditional practices but experienced these customs as evoking discomfort and shame. The study confirmed the prevalence of negative constructions of menstruation. Positive appraisals of menstruation as evoking joy and happiness were also encountered.

Knowledge, Attitude, and Practice on Menstrual Hygiene Management among School Adolescents

BACKGROUND

Menstrual hygiene management remains a taboo in many communities in Nepal. Cultural beliefs about menstruation such as food taboos and untouchability have negative impact on dignity, health and education of adolescent girls. The objective of the study was to assess the current knowledge, attitude and practice of school adolescents on menstrual hygiene management in Doti District in Far-Western Nepal.

METHODS

This cross-sectional study was carried out from October to December 2016 at seven village development committees in Doti district, Nepal. This study was done among 276 students from grade seven and eight of 11 schools. Self-administered structured questionnaire was used to obtain information from school students. Descriptive analysis was done to analyse the knowledge, attitude and practice of school adolescents on menstrual hygiene management.

RESULTS

67.4% respondents had fair knowledge and 26.4% respondents had good knowledge on menstrual hygiene management. However, out of 141 female adolescent respondents, only 56 (40%) were engaged in good menstrual hygiene practices. Around half of the respondents had positive attitude towards menstrual hygiene management related issues.

CONCLUSIONS

Although knowledge on menstrual hygiene management among school adolescents is fair, still attitude and practice need to improve. Findings indicate the need of behavior change communication campaigns along with frequent reinforcement of school health education programs.

Negotiating Discourses of Shame, Secrecy, and Silence: Migrant and Refugee Women's Experiences of Sexual Embodiment

In Australia and Canada, the sexual health needs of migrant and refugee women have been of increasing concern, because of their underutilization of sexual health services and higher rate of sexual health problems. Previous research on migrant women's sexual health has focused on their higher risk of difficulties, or barriers to service use, rather than their construction or understanding of sexuality and sexual health, which may influence service use and outcomes. Further, few studies of migrant and refugee women pay attention to the overlapping role of culture, gender, class, and ethnicity in women's understanding of sexual health. This qualitative study used an intersectional framework to explore experiences and constructions of sexual embodiment among 169 migrant and refugee women recently resettled in Sydney, Australia and Vancouver, Canada, from Afghanistan, Iraq, Somalia, South Sudan, Sudan, Sri Lanka, India, and South America, utilizing a combination of individual interviews and focus groups. Across all of the cultural groups, participants described a discourse of shame, associated with silence and secrecy, as the dominant cultural and religious construction of women's sexual embodiment. This was evident in constructions of menarche and menstruation, the embodied experience that signifies the transformation of a girl into a sexual woman; constructions of sexuality, including sexual knowledge and communication, premarital virginity, sexual pain, desire, and consent; and absence of agency in fertility control and sexual health. Women were not passive in relation to a discourse of sexual shame; a number demonstrated active resistance and negotiation in order to achieve a degree of sexual agency, yet also maintain cultural and religious identity. Identifying migrant and refugee women's experiences and constructions of sexual embodiment are essential for understanding sexual subjectivity, and provision of culturally safe sexual health information in order to improve well-being and facilitate sexual agency.

Negotiating Discourses of Shame, Secrecy, and Silence: Migrant and Refugee Women's Experiences of Sexual Embodiment

In Australia and Canada, the sexual health needs of migrant and refugee women have been of increasing concern, because of their underutilization of sexual health services and higher rate of sexual health problems. Previous research on migrant women's sexual health has focused on their higher risk of difficulties, or barriers to service use, rather than their construction or understanding of sexuality and sexual health, which may influence service use and outcomes. Further, few studies of migrant and refugee women pay attention to the overlapping role of culture, gender, class, and ethnicity in women's understanding of sexual health. This qualitative study used an intersectional framework to explore experiences and constructions of sexual embodiment among 169 migrant and refugee women recently resettled in Sydney, Australia and Vancouver, Canada, from Afghanistan, Iraq, Somalia, South Sudan, Sudan, Sri Lanka, India, and South America, utilizing a combination of individual interviews and focus groups. Across all of the cultural groups, participants described a discourse of shame, associated with silence and secrecy, as the dominant cultural and religious construction of women's sexual embodiment. This was evident in constructions of menarche and menstruation, the embodied experience that signifies the transformation of a girl into a sexual woman; constructions of sexuality, including sexual knowledge and communication, premarital virginity, sexual pain, desire, and consent; and absence of agency in fertility control and sexual health. Women were not passive in relation to a discourse of sexual shame; a number demonstrated active resistance and negotiation in order to achieve a degree of sexual agency, yet also maintain cultural and religious identity. Identifying migrant and refugee women's experiences and constructions of sexual embodiment are essential for understanding sexual subjectivity, and provision of culturally safe sexual health information in order to improve well-being and facilitate sexual agency.

'This is a natural process': managing menstrual stigma in Nepal

Menstrual stigma has been demonstrated in many societies. However, there is little research on menstrual attitudes in South Asia, despite religiously-based menstrual restrictions imposed on women. To understand menstrual stigma in this context, we conducted qualitative research with women in Nepal. Nepali Hinduism forbids menstruating women to enter a temple or kitchen, share a bed with a husband or touch a male relative. During menstruation, women are 'untouchable'. There has been virtually no research on how Nepali women make meaning of these practices. The current study employed focus groups and individual interviews to understand how some Nepali women experience menarche and menstrual stigma. We explored how women describe their experiences and the strategies they adopt to manage age-old stigma in a rapidly modernising society where they have multiple roles as workers, wives and mothers. Participants reported they experienced menarche with little preparation, which caused distress, and were subjected to ongoing stigmatisation as menstruating women. They described coping strategies to reduce the effects of this stigma. This study provides a unique perspective on coping with menstrual stigma in South Asia.

A community-based study of menstrual hygiene practices and willingness to pay for sanitary napkins among women of a rural community in northern India

BACKGROUND

Hygiene-related practices of women during menstruation are of paramount importance. There is a lack of sizeable literature on menstrual practices from northern India. We documented the menstrual hygiene practices of rural women and assessed their willingness to pay for sanitary napkins.

METHODS

A cross-sectional study was done in villages under the Comprehensive Rural Health Services Project (CRHSP), situated in Ballabgarh, Haryana. The study participants were women in the age group of 15-45 years. Nine villages were selected randomly while the number of respondents in each selected village was decided through the probability propor-tionate to size sampling method. The households were selected using systematic sampling. One woman was interviewed in each household using a pre-tested questionnaire.

RESULTS

A total of 995 women were interviewed. A majority of them (62%) were unaware of the reason(s) for menstruation. The role of the health sector in providing information regarding menstruation was low as only a few women (1.5%) had got information from the auxiliary nurse midwife (ANM)/health worker (HW). For the majority of women, besides religious activities, other routine activities did not suffer during menstruation. Only 28.8% of women were using sanitary napkins and of those who did not use napkins, only one-fourth (25.3%) were willing to buy them. The mean (SD) price per napkin that these women were ready to pay was Rs. 0.54 (0.43), equivalent to US$ 0.01.

CONCLUSION

Women in the reproductive age group should be provided with appropriate information about menstruation, and they should be told about the advantages of using sanitary napkins. Health sector functionaries should play a proactive role in the delivery of such information.

Predicting the timeline to the final menstrual period: the study of women's health across the nation

CONTEXT

Predicting the final menstrual period (FMP) would help women know when their menopause transition will be completed. Additionally, biological changes, such as accelerated bone loss, precede the FMP by at least 1 year.

OBJECTIVE

Our objective was to assess whether FSH, estradiol, or urinary N-telopeptide predict where an individual is on her timeline to FMP.

METHODS

The sample was 554 women from the Study of Women's Health Across the Nation. We modeled the probability of having crossed specified landmarks: 2 years before, 1 year before, and the FMP. We also modeled the probability of being in narrower intervals: 2 to1 year before FMP, 2 years before FMP and FMP, or 1 year before FMP and FMP. We determined the candidate markers that best predicted having crossed each landmark, with the optimum defined as the greatest area under the receiver-operator curve; created formulas for the probability of having crossed each landmark; and calculated sensitivity and specificity.

RESULTS

Final models included current estradiol and FSH (each as a fraction of 1 previous reference measure), age, menopause transition stage, race/ethnicity, and whether serum was collected during the early follicular phase. Areas under the receiver-operator curves of final models that predicted the probability of a woman having crossed 2 years before, 1 year before, and the FMP itself were 0.902, 0.926, and 0.945, respectively. If we classified women as having crossed the 2 years before the FMP landmark when predicted probability exceeded 0.3, sensitivity was 85% and specificity 77%.

CONCLUSION

This model could help patients and researchers estimate the time to FMP.

Cultural and social practices regarding menstruation among adolescent girls

The study attempts to find out the existing social and cultural practices regarding menstruation, awareness levels, and the behavioral changes that come about in adolescent girls during menstruation, their perception about menarche, how do they treat it, and the various taboos, norms, and cultural practices associated with menarche. The study was conducted on 117 adolescent girls (age 11-20 years) and 41 mothers from various communities and classes in Ranchi comprising residential colonies and urban slums. The findings unfolds many practices: cultural and social restrictions associated with menstruation, myth, and misconception; the adaptability of the adolescent girls toward it; their reaction, reaction of the family; realization of the importance of menstruation; and the changes that have come in their life after menarche and their resistance to such changes. The article also suggests the strategies to improve menstrual health and hygiene among adolescent girls. The study concludes that cultural and social practices regarding menstruation depend on girls' education, attitude, family environment, culture, and belief.

Relationships between menstrual and menopausal attitudes and associated demographic and health characteristics: the Hilo Women's Health Study

The objective of this study was to examine the relation of menstrual attitudes to menopausal attitudes and the demographic and health characteristics associated with each. This cross-sectional study consisted of a randomly selected sample of 1,824 respondents aged 16 to 100 years in multi-ethnic Hilo, Hawai'i. Women completed questionnaires for demographic and health information, such as age, ethnicity, education, residency in Hawai'i, menopausal status, exercise, and attitudes toward menstruation and menopause. Women more often chose positive terms, such as "natural," to describe menstruation (60.8%) and menopause (59.4%). In bivariate analyses, post-menopausal women were significantly more likely to have positive menstrual and menopausal attitudes than pre-menopausal women. Factor analyses were used to cluster attitudes followed by linear regression to identify demographic characteristics associated with factor scores. Asian-American ethnicity, higher education, reporting more exercise, and growing up outside of Hawai'i were associated with positive menstrual attitudes. Higher education, older age, post-menopausal status, growing up outside of Hawai'i and having hot flashes were associated with positive menopausal attitudes. Bivariate correlation analyses suggested significant associations between factor scores for menstrual and menopausal attitudes. Both negative and positive menstrual attitudes were positively correlated with the anticipation of menopause, although negative attitudes toward menstruation were negatively correlated with menopause as a positive, natural life event. Demographic variables, specifically education and where one grows up, influenced women's attitudes toward menstruation and menopause and should be considered for inclusion in subsequent multi-ethnic studies. Further research is also warranted in assessing the relationship between menstrual and menopausal attitudes.

Observance of the laws of family purity in modern-orthodox Judaism

This research is a follow-up to a previous study measuring the observance of the ritually unclean period (Niddah) among Modern-Orthodox Jews. A total of 267 participants completed an online questionnaire comprised of a list of 16 "strict" and "lenient" forbidden behaviors. Participants reported whether they had engaged in these behaviors during Week 1 (the actual menstrual period) and during Week 2 (the "clean days" following the cessation of bleeding). Results showed that laws were being violated, with more transgressions during the second week than the first week. Additionally, more "lenient" laws were being broken than "strict" ones. Level of religious observance was significantly negatively correlated to the number of transgressions. However, there was no significant correlation between the number of transgressions and the age at marriage, sex, or how long one had been married.

Menstruation in Ulysses

This article investigates James Joyce's fascination with a wide variety of medical texts, sexual folklores, religious beliefs, and persistent superstitions about menstruation. That fascination finds its way into Ulysses, which draws upon a number of intertexts to inform a curiosity about the female body most strikingly articulated by Bloom, Molly, and Gerty MacDowell. These intertexts are not simply imported into the novel but are dismantled and interrogated, as Joyce exposes, rather than endorses, clichés of essential femininity.

[Women, bodies, and Hebrew medieval medical literature]

This essay explores different views on the female body articulated within Hebrew medieval texts on women's health care. It also investigates whether texts also integrate women's own perceptions of their bodies, and of their needs and care. I have analysed how this genre of Hebrew literature understood two key issues in the construction of sexed bodies: menstruation and cosmetics.

Taiwanese adolescents? gender differences in knowledge and attitudes towards menstruation

The purpose of the study was to explore gender differences in knowledge and attitudes towards menstruation among Taiwanese adolescents. This study was a secondary data analysis of a cross-sectional comparison study conducted in Taiwan. A total of 287 female and 269 male students at a junior high school participated in the study. The results showed that almost all the students had heard about menstruation and most of them had received menstrual information at school. However, their knowledge about menstruation was not accurate. Moreover, the male students expressed more negative attitudes towards menstruation than the female students. Taboos were heard by most students and, although many female students doubted the reality of the taboos they had heard, they observed them anyway. The study calls for an evaluation of sex education and suggests more open discussions about menstruation among young people in those education sessions. In addition, school nurses and obstetrical/gynecological nurses should be involved more in adolescents' sexual education.

Acceptability of contraceptive-induced amenorrhea in a racially diverse group of US women

OBJECTIVE

The study was conducted to determine women's preferences about menstrual bleeding patterns and their willingness to manipulate bleeding with contraception.

STUDY DESIGN

Women presenting for routine obstetric and gynecologic care at two US locations (Portland, OR, and Atlanta, GA) were offered a self-administered, anonymous survey. A validated survey tool was used.

RESULTS

Valid surveys from 292 women were obtained. Mean age was 27 years (SD 8.0). We were unable to separate geographic vs. racial differences in responses because race significantly differed between sites (p<.001). The populations surveyed were predominantly black in Georgia (88%, 58/66) and white in Oregon (83%, 142/172). Overall, the majority of women did not like their menstrual period (69%, 190/275) and preferred a menstrual frequency of every 3 months or never (58%, 164/281) with no differences between racial groups. When asked if they would consider using a birth control method that stopped their menstrual periods, 40% (111/278) reported yes, 28% (78/278) reported no and 32% (89/278) were undecided. However, significantly fewer black than white women would consider a birth control method to stop their menstrual periods (29% vs. 49%, p=.006).

CONCLUSIONS

Although the majority of US women surveyed dislike menstruation and prefer less frequent or no menstrual periods, black women were less accepting than white women of contraception that induces amenorrhea.

Comparison of gestational age classifications: date of last menstrual period vs. clinical estimate

PURPOSE

The purpose was to compare the two different measures of gestational age currently used on birth certificates (the duration of pregnancy based on the date of last menstrual period [LMP] and the clinical estimate [CE] as related to health status indicators. We contrasted these measures by race/ethnicity.

METHODS

NCHS natality files for 2000-2002 were used, selecting cases of single live birth to U.S. resident mothers with both LMP and CE gestational age information.

RESULTS

Approximately 75% of the records had valid LMP and CE values and for approximately one-half of these, the LMP and CE values did not exactly agree. Overall and for each race and ethnic group, the LMP measures resulted in higher proportions of very preterm, preterm, postterm and SGA births. CE value provided preterm rates of 7.9% and for LMP, 9.9%. The odds ratio of preterm birth for African-Americans using the CE measure was 1.78 [95% Cl 1.77-1.79]. The odds ratio using LMP was 1.93 [95% Cl 1.92-1.94]. Whites were the referent population.

CONCLUSIONS

Different measures of gestational age result in different overall and race-specific rates of very preterm, preterm, postterm, and SGA births. These findings indicate that substituting or combining these measures may have consequences.

Development of a New Scale to Measure Beliefs about and Attitudes Toward Menstruation (BATM): Data from Mexico and the United States

This article introduces the Beliefs about and Attitudes toward Menstruation Questionnaire (BATM). It is a 5-point Likert scale that was normed on 1,090 Mexican people of different ages and educational levels. In a second study data from 274 undergraduate students from Mexico and the United States were compared. Four factors emerged in both samples: secrecy, annoyance, proscriptions and prescriptions, and pleasant. Mexican students scored significantly higher than U.S. students on the Proscriptions and Prescriptions subscale. Men scored significantly higher on this subscale than women. Implications of these findings are discussed, as is the possible utility of the questionnaire for future research.

The distribution of consecutive closed birth intervals in females in Uttar Pradesh

Most studies of closed birth intervals are regarding their variation at specific orders among females. This paper attempts to study the nature of the distributions of consecutive closed birth intervals. Data from the Uttar Pradesh National Family Health Survey 1998-99 (NFHS-2) were analysed. It was found that, under certain assumptions, the postpartum amenorrhoea period and menstruating interval are negatively associated, indicating that socio-cultural factors are affecting the menstruating interval.

Follicular phase hormone levels and menstrual bleeding status in the approach to menopause

OBJECTIVE

(1) Characterize the relationship between follicular phase hormone levels and menstrual bleeding patterns in the approach to menopause; (2) identify racial differences in hormone levels; (3) determine independent contributions of menstrual status, race, age, BMI, and smoking to hormone levels.

DESIGN

Randomly identified, population-based cohort, stratified to obtain equal numbers of African American and Caucasian women, prospectively followed for 5 years.

SETTING

Women in Philadelphia County, PA, identified by random-digit telephone dialing.

PARTICIPANT(S)

Women aged 35 to 47 years with regular menstrual cycles at enrollment (N = 436).

DATA COLLECTION

Blood sampling twice in each of 7 assessment periods during days 1-6 of the cycle, menstrual dates identified through structured interview and daily symptom reports, anthropometric measures and standardized questionnaires at each assessment period.

MAIN OUTCOME MEASURE(S)

Serum levels of follicular E(2), FSH, inhibin B, and LH.

RESULT(S)

The mean levels of E(2), FSH, inhibin B, and LH were differentially associated with the 5 menstrual status groups defined by changes in bleeding patterns. Significant changes in hormone levels occurred prior to missed menstrual cycles for inhibin B, FSH, and LH. All hormones had a highly significant interaction between menstrual status and BMI. African American women had significantly lower levels of E(2) and LH compared to Caucasian women in univariate analyses. The interaction of race, menstrual status, and BMI was highly significant (P<.001) for E(2), with African American women having lower E(2) levels until postmenopause, when E(2) levels were higher in AA women with BMI > or =25 and BMI > or =30.

CONCLUSION(S)

Levels of E(2), FSH, LH, and inhibin B are significantly associated with menstrual bleeding patterns in late reproductive age women and differentiate the earliest stages of the menopausal transition. Racial differences in mean levels of E(2) appear strongly mediated by BMI.

Attitudes Toward and Experience with Menstruation in the US and India

Sixty-seven women students who were attending a university in southern India and 61 women students who were attending a liberal arts college in New England volunteered to participate in this study. The women supplied demographic information, information about their knowledge and levels of preparedness prior to menarche, and sources of their information about the menstrual cycle. They also completed the Menstrual Attitude Questionnaire (Indian version), the Menstrual Distress Questionnaire, and a test of knowledge about the menstrual cycle. American women scored significantly higher than Indian women on the knowledge test, and they also reported that they had better preparation for menarche than Indian women did. Indian women scored significantly higher than American women on the attitude subscales: Menstruation as a Natural Event and Denial of the Effects of Menstruation. Implications of these findings are discussed in light of cultural messages women receive.

Menstrual-related changes expected by premenarcheal girls living in rural and urban areas of Mexico

Most women experience changes surrounding the start of menstruation. These changes are influenced by sociocultural context. Consequently, certain changes are more pronounced in some cultures than in others. Girls enter menarche with a clear set of paramenstrual expectations that may alter their menstrual cycle-related experiences when they become postmenarcheal. This study explored expectations concerning the paramenstrual changes of 1,173 premenarcheal girls living in rural and urban areas of Mexico. In accordance with the findings of studies conducted in other countries, Mexican premenarcheal girls associate menstruation with a set of mostly negative expectations. A comparison of the results from urban and rural girls revealed that urban girls expected negative paramenstrual changes more, while rural ones expected positive changes more. These differences suggest that the cultures in which girls are brought up have an impact on their expectations. Urban girls are more exposed to media which present a picture of menses as a debilitating event, while rural girls link menses with health because it is associated with the ability to have children.

Menstruation: knowledge, attitude and practices of students in Ile-Ife, Nigeria

This study investigated students' knowledge of, beliefs, attitude to and practices during menstruation. Data was collected from a sample of 200 students from Ile-Ife using the multi-stage sampling technique. Only 5% of respondents could correctly define menstruation. Materials used to manage menstruation include sanitary pad, pieces of cloths, toilet rolls, cotton wool, tampon and shoulder pad foam. Practices vary on menstruating and non-menstruating days with 11(39.3%) of the 28 practices classified as healthy, 6(21.43%) as potentially harmful and 11(39.3%) as uncertain. Three (21.43%) of the listed 14 beliefs and taboos are potentially health-promoting, 5(35.71%) are potentially not health-promoting while 6(42.86%) are potentially harmless. Menstruation is associated with restrictions in diet and social interaction with 8%, 20.5% and 5% seeing menstruation as abnormal, dirty and a disease respectively. Findings from this study would be helpful in planning educational programmes to correct misinformation and promote healthy practices among women during menstruation.

Menstrual madness: women's health and well-being in urban Burma

Women's health in peri-urban Burma is conceived of in terms of blood, strength, and the relationship between the body, the body politic, and the local environment. The regulation and volume of blood at menstruation and childbirth are the fundamental indicators of health and well-being. Well-being is contingent on harmony in and between the body and the universe. Blood flow is a key symbol through which women's beliefs and practices concerning their health and well-being can be understood at the levels of pathophysiology, interpersonal relations, the local environment, and the wider political and moral economies of urban Burma.

Health beliefs and practices among Arab women

The purpose of this article is to describe the healthcare beliefs and practices of Arab American women, specifically those regarding menstruation, pregnancy, childbirth, and family planning. The information in this paper is derived from the author's experience as a researcher, as an Arab healthcare provider, and from the literature. Guidelines for nurses who provide care to Arab American women are also presented.

Blood and milk: constructions of female bodily fluids in Western society

This paper explores ways in which these essentially 'female' bodily fluids are constructed in Western societies. It first reviews the context of menstruation and lactation in modern Western societies. It next considers menstruation and breastfeeding as affirmations of womanhood, and then the extent to which breast milk and menstrual blood are considered 'good,' 'different' to other milk and blood, sexual and disgusting. Finally, it discusses pressures which arise from the marketing of related products. The paper suggests that women's belief in their ability to nourish their infant from their own body may be undermined by negative constructions of women's bodily fluids which 'product'-based promotion of breast milk may fail to address.

Indigenous practices of Saudi girls in Riyadh during their menstrual period

The objective of this study was to identify the indigenous menstrual hygiene practice of Saudi girls in Riyadh. A total of 600 girls aged from 11 years to 18 years were selected from outpatient clinics at three different hospitals in Riyadh. Data were collected using a structured interview. The results revealed that nearly two-thirds of the girls avoided certain foods, drinks and activities, including showering and performing perineal care, and practised several indigenous rituals during the period. Mother, religious books and sisters were the main sources of the girls' infomation. The study suggests that nurses and health care providers should use all available opportunities to educate young girls about menstruation.

Self-defined menopausal status in a multi-ethnic sample of midlife women

OBJECTIVES

This study aimed to identify factors associated with women's perceived menopausal status and to evaluate agreement between women's self-designation and a menstrually-based classification in a multi-ethnic sample of women.

METHODS

A cross-sectional survey was conducted as part of a large, seven-site, multi-ethnic study, the Study of Women's Health Across the Nation (SWAN). All variables were assessed by self-report in 13952 women aged 40-55 years. Multiple linear regression was used to assess determinants of self-defined menopausal status, stratifying by race/ethnicity within three anatomical/hormone use strata. Kappa statistics were used to evaluate agreement between the self-defined and menstrually-based classifications.

RESULTS

For women with an intact uterus, at least one ovary and not using hormones, menstrual patterns explained about half the variance in self-defined menopause status with older women classifying themselves later in the transition. Disagreement between menstrually-based and self-defined menopausal status was 39, 38, 36, 32 and 29% for Hispanic, African-American, Japanese, Caucasian, and Chinese women, respectively (kappa statistics=0.46, 0.41, 0.40, 0.53 and 0.58). Women with vasomotor symptoms tended to self-designate themselves as being in transition regardless of their menstrual patterns. Age and 12 months of amenorrhea explained about 40% of the variance in self-categorization among women using hormones with an intact uterus. Bilateral oophorectomy, age and time since surgery explained about 20% of the variance among post-surgical women.

CONCLUSIONS

Menstrual characteristics are strong predictors of women's self-perceived menopausal status. However, additional factors, including symptoms and cultural differences in the meaning of specific bleeding patterns, are also relevant and require further investigation.

Idealised versus tainted femininity: discourses of the menstrual experience in Australian magazines that target young women

Information and messages concerning health-related issues are not confined to material provided by official figures or sources. Much information exists in the community and comes from a variety of sources. One such source is the media. This paper reports the findings of a study conducted over a 12-month period of advertisements for menstrual products in a selection of four monthly Australian magazines (n = 48) directed towards young women. The study examined the way in which menstruation and the menstrual experience were depicted in terms of page space, textual content and visual images. Findings revealed that advertisements for menstrual products provided confusing, conflicting and paradoxical messages. These included stressing the normality of menstruation while also emphasising the importance of keeping it hidden and secret. Menstruation was depicted as being a state of tainted (idealised) femininity because of the potential for the menstrual silence to be shattered by people finding out. Protection failure was depicted as being the ultimate in tainted femininity and a result of a woman's incorrect choice of product. Choosing menstrual-care products was depicted as simple but, paradoxically, complex and confusing. Women were depicted as liberated and sophisticated but images and language related to infancy were used. Freedom and liberation were conferred by the use of the advertised product. Overall, in common with previous studies, menstruation was depicted as a crisis of hygiene that is a risk to femininity. Advertisements for pantyliners suggest that femininity itself poses a threat to (idealised) femininity. This study demonstrates the crucial role of the media as a source of health information for young women.

Prospective assessment of menstrual and premenstrual experiences of Icelandic women

In the only Icelandic study on premenstrual symptoms, a retrospective one conducted in 1991, investigators found 30% of the sample to have severe premenstrual changes. In light of critique that retrospective data primarily reflect socioculturally held beliefs about menstruation, the present study was undertaken in order to assess prospectively Icelandic women's premenstrual and menstrual symptoms and experiences. A total of 211 menstrual cycles were recorded by 83 women using a daily health diary. A symptom pattern was defined for each woman. A small majority of the women (51.8%) displayed a low symptom pattern. Two women (2.4%) demonstrated a premenstrual syndrome pattern, and 5 women (6.0%) exhibited a premenstrual magnification pattern. The remaining women displayed mixed symptom patterns indicating wide variability in women's experiences. These findings differ from the Icelandic retrospective study and from a USA study using prospective data. Therefore, it is concluded that menstrual socialization influences symptoms expectation and reporting.

Menstrual and premenstrual experiences of women in a developing country

The menstrual and premenstrual experiences of black Zimbabwean women were examined. Twenty-five professional women and twenty-five domestic workers were interviewed using semistructured, open-ended interviews designed to explore their experiences. An analysis of consensual data indicated a number of predominant themes, including secrecy associated with menstruation, the negativity surrounding menarche, the breakdown of the traditional family network that passes on information about menstruation, and the acceptance of menstrual cycle experiences by the women. The main differences between the two groups concerned explanations of the functions and purpose of menstruation and the reporting of physical and affective symptoms. These differences are suggestive of the impact of educational level on experiences of menstruation.

Women's hidden transcripts about abortion in Brazil

Two folk medical conditions, "delayed" (atrasada) and "suspended" (suspendida) menstruation, are described as perceived by poor Brazilian women in Northeast Brazil. Culturally prescribed methods to "regulate" these conditions and provoke menstrual bleeding are also described, including ingesting herbal remedies, patent drugs, and modern pharmaceuticals. The ingestion of such self-administered remedies is facilitated by the cognitive ambiguity, euphemisms, folklore, etc., which surround conception and gestation. The authors argue that the ethnomedical conditions of "delayed" and "suspended" menstruation and subsequent menstrual regulation are part of the "hidden reproductive transcript" of poor and powerless Brazilian women. Through popular culture, they voice their collective dissent to the official, public opinion about the illegality and immorality of induced abortion and the chronic lack of family planning services in Northeast Brazil. While many health professionals consider women's explanations of menstrual regulation as a "cover-up" for self-induced abortions, such popular justifications may represent either an unconscious or artful manipulation of hegemonic, anti-abortion ideology expressed in prudent, unobtrusive and veiled ways. The development of safer abortion alternatives should consider women's hidden reproductive transcripts.

Effects of a randomized health education intervention on aspects of reproductive health knowledge and reported behaviour among adolescents in Zimbabwe

Unwanted teenage pregnancy and the attendant morbidity and mortality necessitate an understanding of the factors influencing adolescent sexuality and the implementation of programmes designed to improve their knowledge and reproductive behaviour. A randomized controlled study on reproductive health knowledge and behaviour was undertaken among adolescent pupils drawn from a multi-stage random cluster sample. A self-administered questionnaire was used to assess aspects of reproductive health knowledge and behaviour at baseline followed by a health education intervention, except for control schools. Results are based on 1689 responses made up of 1159 intervention and 530 control respondents. There was a significant increase in correct knowledge about aspects of menstruation in intervention as compared with control schools [odds ratio (OR) = 4.5, 95% confidence interval (CI) = 3.4-6.1). Significantly, (OR = 2.0, 95%CI = 1.1-3.9) more pupils from intervention than control schools scored correctly on practice relating to menstruation. Pupils from intervention schools were more likely (P < 0.001) to know that a boy experiencing wet dreams could make a girl pregnant and that a girl could get pregnant at her first sexual intercourse (OR = 1.4, 95%CI = 1.1-1.9). Knowledge of family planning was low in both groups at baseline but was high at five months follow-up in the intervention schools. The findings point to the need for early school-based reproductive health education programmes, incorporating correct information on reproductive biology and the subsequent prevention of reproductive ill health.

Menopausal experiences of Thai women. Part 2: The cultural context

This paper describes the cultural context of middle-aged Thai women who took part in a survey of symptoms and attitudes to menopause. The women lived in Nonthaburi province, adjacent to Bangkok, which has undergone a transition from rural to urban. Household structure often includes three generations. There have been changing opportunities for women in areas of education, occupation and family size and women's power increases with age. Thai women perceive menstruation as an indicator of health and take special care during menstruation. There is a special idiom in Thai 'leod cha pai-lom cha ma' (the blood will go--the wind will come) used to describe changes in a woman's behaviour, emotions and well-being during the menopause. These changes are expected to happen occasionally, not in every woman. Some women looked forward to menopause, while others were found to be ambivalent towards it.

Ethnic differences in the duration and amount of menstrual bleeding during the postmenarcheal period

In 1989, 125 African-American and 123 European-American girls aged 12-14 years living in Durham, North Carolina, were enrolled in a 2-year study in which they maintained a menstrual calendar, recording the date and amount of menstrual bleeding. Weight, exercise, and stress during the previous week were recorded at the start of the menstrual cycle. Ethnicity was the strongest determinant of the duration of menstrual bleeding and of the probability of heavy bleeding. The mean duration of bleeding was 5.1 days for African-American girls and 5.6 days for European-American girls. Low body mass index, high stress, and dieting also influenced bleed duration, but the effects of low body mass index and stress were modified by ethnicity. european-American girls were less likely to have an episode of heavy bleeding (odds ratio = 0.48) than were African-American girls, while high stress increased the risk of having heavy bleeding episode (odds ratio = 1.51). Further investigation of potential ethnic differences in menstrual bleeding characteristics and of the role of stress in provoking heavy bleeding is warranted.

Menstrual bleeding patterns in Chinese women using the Norplant subdermal implant

An analysis of the menstrual diary records of 306 cases of Norplant users over 5 years is reported. The results indicate that the disturbances of menstrual cycles during Norplant use were mainly caused by changes in the total number of vaginal bleeding days. Menstrual patterns were irregular and prolonged. Disturbances of the menstrual pattern were improved after 6-12 months of use, mainly showing a decrease in the number of spotting days. About 30-40% of users may regain their normal menstrual pattern after 1 year of use. There was a proportion of cases with an abnormal menstrual pattern throughout the 5 years of use, but the gross cumulative termination rate for menstrual problems was only 13.0%. Norplant users are susceptible to an increase in the number of spotting days and irregular bleeding. The main reason for termination of contraceptive use was prolonged bleeding for a long time. This is important information that should be provided in counselling potential Norplant acceptors, especially the changes in menstrual pattern. We also have a responsibility to try to find a treatment for prolonged bleeding.

Eskimo women and a menstrual cycle study: some ethnographic notes

This article examines ethnographic data collected from indigenous Alaskan women who participated in a menstrual cycle study conducted by The Tremin Trust Research Program, initially known as the Menstruation and Reproductive History Program (MRH). In the 1960s, the MRH program was expanded to Alaska to study non-Caucasian women's menstrual cycles. In addition, an ethnographer collected data through participation observation from some 345 women who participated in the MRH study. These data were recorded in field notebooks during site visits to Alaskan villages. Major themes and contextual information were identified in the data that described the daily lives of the women and their experiences as research participants. Eskimo women described the cultural conflicts that arose during the conduct of the menstrual studies and problems encountered when the investigators failed to account for the traditional gender roles in Eskimo society. Cultural differences were apparent when the women described the culturally inappropriate health education provided by the research team. The goals of the menstrual cycle study emphasized research progress rather than the health needs of the research participants; this emphasis accentuated the severity of health problems and the lack of health services experienced by Eskimo women.

Perceptions of menopause in northeast Thailand: contested meaning and practice

This paper draws on data collected from village-based ethnographic research conducted in northeast Thailand in 1990-1991 and highlights the polarities and contradictions of perceptions of menopause that exist between village women and health personnel with whom these women interact. For village women until recently, the menopause has been regarded as a simple and natural biological event; for health professionals, it is consistently represented as a 'medical problem' indicating treatment. The paper highlights women's construction of menopause, and their recognition and management of its physical symptoms. It draws attention too to differences among women and to the dynamic nature of their understandings and consequent health-seeking behaviour. The paper also describes the way in which health providers, through their own training and reading of professional and popular journals, increasingly represent the menopause as a pathological process and treatable condition. Through the exploration of conflicting perceptions of the menopause among contemporary Thai women, the paper draws attention to the heterogeneity and fluidity in understandings of biological processes that are related to and reflect the wider social and economic changes to which they are subject.