Menstruation: Rhetoric, Research, Reality

What you are going to read here will challenge everything that we have thought, spoken, written and assumed about menstruation in the so-called developing countries. If possible, read this as if this is the first time you are reading something about this subject. Read with curiosity, read with kindness; so that we keep aside personal prejudice and work on what really matters.

The conflicting findings

Over the last 6 months, our team has had one-on-one conversations with 1058 adolescent girls and women from across 37 villages in rural Karnataka (South India) and urban Bangalore. Our findings in this process made us question all that we have read about this subject – be it the high prevalence of menstrual disorders in rural areas, the supposed low use of Sanitary Products in India and the stories about poor menstrual hygiene leading to Reproductive Tract Infections (RTI) and School Absenteeism.

So we began digging into what independent researchers have found to clarify our conflicting thoughts and findings. This write-up presents the findings from published studies that we were able to access. We have studied over a 100 papers for this exercise and cited 90 papers in this write-up. Here is what they reveal about the commonly made assumptions about menstruation.

Assumption #1. Developing countries have greater prevalence of menstrual disorders

The vast majority of work on Menstrual Health and Hygiene is happening in developing countries like India, Kenya, Nigeria, Nepal, Bangladesh, etc. However, the discourse and agenda is largely set by entities from developed nations. The comparative studies such as WHO’s multi-country study [30] usually compare data from developing countries, with hardly a mention of the prevalence of menstrual disorders in developed countries. The assumption that developing nations have a higher prevalence of menstrual disorders is generally not contested. The reasons cited are often the poor socio-economic status, illiteracy and simply the fact that we are a “developing” nation. Let’s revisit this assumption by looking at comparative data on menstrual disorders from India, other developing countries and the so-called developed countries.

Menstrual Disorders DataLet’s take a closer look at some of these studies on US, UK, Australia, Japan, Singapore and South Korea.

Heavy Menstrual Bleeding / Mennorhagia

(India prevalence: 1% to 23%)

  • An internet based study of 4506 participating women across 5 European countries showed that 27.2% have experienced two or more symptoms of Mennorhagia in the previous year. 304 (30.3%) of 1004 from France reported at least two heavy menstrual bleeding symptoms, compared with 245 (24.5%) of 1001 from Germany, 329 (32.9%) of 1000 from Spain, 222 (22.2%) of 1001 from the Netherlands, and 125 (25.0%) of 500 from Switzerland. Overall, 564 (46%) of the women with symptoms had never consulted a physician. [63] 
  • A postal self-reported study in England covering 1861 women over a period of 12 years, found that the baseline responses showed 52% women who reported symptoms of Mennorhagia. The 12-month cumulative incidence was found to be 25%. [62]
  • A London study of Elite and Non-Elite Athletes in 2015 covered 789 participants through an online survey and 1073 face to face interviews. Heavy Menstrual Bleeding was reported by half of those online (54%), and by more than a third of the marathon runners (36%). Surprisingly, HMB was also prevalent amongst elite athletes (37%). Overall, 32% of exercising females reported a history of anemia, and 50% had previously supplemented with iron. [65]

Hysterectomy (surgical removal of whole or part of the uterus)

(India prevalence: 4% to 6%) [83]

  • “In the UK, 20% of all women, and 30% in the USA, have a hysterectomy before the age of 60; Mennorhagia is the main presenting problem in at least 50-70%”. [71]
  • Approximately 600,000 hysterectomies are performed in the USA each year, and the procedure is the second most frequent performed major surgical procedure among reproductive-aged women [68]. The estimated proportion of hysterectomies performed for a primary diagnosis of dysfunctional uterine bleeding varies from 6% to 18% [69].
  • A community survey of 8,896 households was undertaken in the Hunter region of New South Wales (Australia) to assess women’s health status. The prevalence of hysterectomy in this sample was 16.9%, with 34.2% of women in their fifties having had a hysterectomy. Most hysterectomies (75%) were performed on women between the ages of 30 and 49 years.[70]

Menstrual Pain / Dysmenorrhoea among adolescent girls

(India prevalence: 11.3% to 72.6%)

  • The MDOT study in Australia surveyed 1051 adolescents between 16 – 18 years and found that 94% experienced menstrual pain, 96% had PMS, 58% reported clots in their menstrual blood (which could mean Mennorhagia) and 30.5% reported irregular periods. [78]
  • A questionnaire based study of girls in grades 11 and 12 in Western Australia showed that 80% suffered from Dysmennorhea [74]
  • A study of 1000 female students in Housten (Texas, U.S), showed that 85% reported Dysmenorrhoea [80]
  • A survey of girls ages 12 – 21 years in Washington D.C (U.S) found that Premenstrual syndrome (PMS) was the most prevalent reported menstrual disorder (84.3%) followed by Dysmenorrhea (65%), abnormal cycle lengths (13.2%), and excessive uterine bleeding (8.6%) [81]
  • A Singapore study of adolescent girls showed that 83.2% suffered from various degrees of Dysmennorhea [79]
  • A study of Japanese adolescents between ages 18 and 25 years found that 63.6% had heavy menstrual flow, 79% had menstrual pain and 63% had irregular cycles. [75]
  • A study of adolescents in South Korea showed that 43.35% reported bleeding quantity as large to very large amount, 74.5% complained of Dysmennorhea and 80% complained of irregular cycles [76]

Economic Implications

  • In U.S., menstrual bleeding has significant economic implications for women in the workplace: women who bleed heavily were estimated to work 6.9% or 3.6 weeks less every year. Work loss from increased blood flow is estimated to be $1692 annually per woman. [72]
  • Each year approximately £7 million are spent on primary care prescribing for Menorrhagia in the UK [67]

The data above raises serious questions about why the focus has been on developing nations, when in fact the developed countries have a greater prevalence of menstrual disorders, in spite of them following WASH’s Menstrual Hygiene formula.

Assumption #2. Use of Sanitary Napkins is only 12% in India

The most often quoted study on India is the one by A.C.Neilson and endorsed by Plan India in October 2010, which states that only 12% Indian women use Sanitary Napkins and the rest are using unsanitary methods of managing menstruation. This study titled “Sanitary Protection: Every Woman’s Health Right” is not available on any public domain; not even for a cost. This raises a big question mark around a study that is so widely used, even to the extent of justifying policy decisions. When we asked journalists who quoted this study, they admitted that they simply googled and copied what other articles wrote. We hope that this is at least a published study.

On the other hand, data from other published studies done in India (2010 onwards), indicate a relatively high usage of Sanitary Napkins. Reporting a similar trend, is a study of 138 papers on Menstrual Hygiene Management in India which stated that the usage of Sanitary Napkins among adolescents ranges between 32% in rural areas to 67% in urban areas [17]. The table below shows the usage of menstrual products across India.

Sanitary Pad usage

 

Assumption #3. Poor Menstrual Hygiene Management leads to Reproductive Tract Infection (RTI)

The A.C Neilson report also suggests that around 70% women in India are at risk for Reproductive Tract Infections (RTI) owing to usage of cloth and other unsanitary methods. Further, the entire movement around Menstrual Hygiene Management justifies its importance by connecting hygiene to reproductive tract infections.

But the fact is that there is no established evidence that links poor menstrual hygiene to prevalence of RTIs or menstrual disorders. A study by London School of Hygiene & Tropical Medicine which looked at 14 articles to understand possible correlations between MHM and RTI found that there was no association between confirmed bacterial vaginosis (typically characterised by excessive white discharge) and MHM. [18] It also mentions that

“The body of evidence to support the link between poor MHM and other health outcomes (secondary infertility, urinary tract infections and anaemia) is weak and contradictory.”

The study concludes by stating that

“It is plausible that MHM can affect the reproductive tract but the specific infections, the strength of effect, and the route of transmission, remain unclear.” [18]

Strangely, it has occurred to very few that Menstrual Disorders have nothing to do with hygiene or the product used. The most common menstrual disorders such as Dysmennorhea (period pain), Mennorhagia (heavy bleeding), Ammenorhea (no bleeding), Oligomenorhea (Menstrual cycles > 35 days) have no association with what product is used or how hygiene is maintained. The more serious disorders like Endometriosis or PCOS are even more cut-off from hygiene correlations. Some write-ups even associate poor menstrual hygiene with cervical cancer, for which there is even lesser evidence.

In our attempts to justify our work on Menstrual Hygiene, we seem to have lost our mind. It is unfortunate that we have missed out the important conversations and interventions around menstrual disorders in our pursuit of promoting menstrual products.

Assumption #4. Girls in developing countries are dropping out of school due to lack of menstrual products and toilets

Having functional toilets in schools is an absolute must, not just for girls. But, unnecessarily connecting it to menstrual hygiene seems more agenda driven than real. Let’s look at what existing studies reveal.

A comparison of data owing to school absenteeism during menstruation in developing nations shows that the percentage of girls who remain absent during menstruation is around 12.1% in China [21], 15.6% to 24.2% in Nigeria [19, 20], 24% in India [17] and 31% in Brazil [22].

If the current hypothesis – that school absenteeism is due to lack of toilets or Sanitary Napkins – is true, then surely developed countries must have little or no absenteeism. However, data indicates that it is no different in developed countries.

Studies indicate that 17% teenagers in Canada [23], 21% in Washington D.C [24], 24% in Singapore [25], 26% in Australia [26] and 38% in Texas [27] miss school owing to menstruation.

More interesting is that the reasons for missing school have nothing to do with Sanitary Pads or Toilets; in most cases, it has to do with Dysmenorrhea (pain during menses). A study of girls having Dysmennorhea in the U.S showed that 46% miss school due to period pain. [82]

The study by The London School of Hygiene & Tropical Medicine [18] which looked at 14 studies states:

“Despite the apparent acceptance in WASH policies that menstrual management affects attendance of adolescent girls at school there is very little high quality evidence associating school attendance or drop-out with menstrual management. The only published study identified found no association between provision of a menstrual cup and school attendance. An unpublished study by Scott et al found significant improvements of 9% to 14%. in recorded class attendance from access to sanitary napkins and/or MHM education but full details of the study methods and results were not available at the time of the review. A systematic review into the linkages between separate toilets for girls and school attendance was inconclusive. The data were analysed without taking account of age with respect to menstruation and MHM provisions in school may have been among the influencing factors. No studies were found which addressed provision of pain medication or other factors that may have a bearing on attendance or drop-out rates. We cannot therefore report that the current evidence indicates improved MHM improves attendance at school.”

Another important study was undertaken by American Economic Association [29] which conducted a randomized evaluation of Sanitary Products to school girls in Nepal. They collected daily data in Nepal on girls school attendance and menstrual calendars for up to a year. The study came up with two findings

“We report two findings. First, menstruation has a very small impact on school attendance: we estimate that girls miss a total of 0.4 days in a 180 day school year. Second, improved sanitary technology has no effect on reducing this (small) gap: girls who randomly received sanitary products were no less likely to miss school during their period. We can reject (at the 1% level) the claim that better menstruation products close the attendance gap. We conclude that policies to address this issue are unlikely to result in schooling gains.”

Why do developed countries have a greater prevalence of menstrual disorders?

The high prevalence of menstrual disorders in developed countries could be linked to lifestyle and food habits. A few studies have tried to establish the correlation between stress, late night shifts, obesity and menstrual irregularities. Here is what they found.

  • Studies on menstrual cycle irregularities among female workers in Japan [64] showed that menstrual cycle irregularities were related to stress, smell of cigarettes, age and smoking habits.
  • A study in Tehran comparing menstrual problems among day workers and shift workers indicated that Dysmennorhea was 44% among day workers and 66% among shift workers. Similarly, only 7% day workers had irregular periods, while 19.4% shift workers had irregularity in their period. [84]
  • Obesity has been closely linked with various menstrual disorders [85, 87]. 61.9% women in U.S, 57.2% women in U.K, 56.1% women in Australia have a BMI greater than 25; whereas, the percentage of obese women in Nigeria, India, Bangladesh and Nepal are 33.6%, 20.7%, 18.7% and 13% respectively. [86] The high rate of obesity among women in developed countries could be one of the reasons for the higher prevalence of menstrual disorder.

So how come the developing countries do not have these issues?

One big reason is probably the existence of cultural practices around menstruation which took care of the needed lifestyle and diet habits for maintaining a healthy menstrual cycle.

Practices that allow women to take the needed rest during menstruation, avoid physical exertion, along with specific diet restrictions, are not taboos. These are the means by which women in ancient societies took care of their health – by intelligently weaving science into culture and religion, so that large masses of women are benefited.

Whether it is India’s Ayurveda, China’s Acupuncture [90], or the indigenous science of the Caribbean islands [88, 89] – there is a far deeper understanding of the menstrual cycle than we have cared to investigate. This understanding shows in the menstrual health of the women from these countries. This is the area where research could go if we chose wellbeing instead of treatment and surgery, not to mention the effect prevention will have on health budgets.

Instead of attempting to investigate the practices or learn from indigenous societies, developed countries are proactively destroying the knowledge and wisdom that exists in such nations. Perhaps they do not realize that the price they pay is the health of their own women.

Why has the focus been on Menstrual Hygiene and not Menstrual Disorders, in spite of the research and evidence?

Over the last 4 years, we (Mythri Speaks Trust) have been approached by leading Sanitary Napkin Manufacturers with the same request camouflaged as CSR activity – help us enter the rural Indian market.

Almost every NGO in India that works on menstruation is selling a Menstrual Product or is supported by a Sanitary Napkin manufacturer. Yes, India is as an untapped market for manufacturers of hygiene products. But in order to sell, they have gone to the extent of systematically decimating an entire culture and making people feel ashamed about themselves by indicating that we lack hygiene and by calling our cultural practices as taboo.

Every entity working on menstruation in India quotes data without checking its validity or authenticity, and in the process, sells India. The media and NGOs involved, knowingly or unknowingly have become puppets in the hands of the few who control the market. The conditioning is so deep and ingrained that even when data points otherwise, they make the same old statements in TED talks and award speeches, of lack of hygiene and resulting problems. This is dangerous.

The reason for this focus on menstrual hygiene is best described in the report by The American Economic Association [29]:

“A number of NGOs and sanitary product manufacturers have begun campaigns to increase availability of sanitary products, with a stated goal of improving school attendance (Deutsch 2007, Callister 2008, Cooke 2006). The largest of these is a program by Proctor & Gamble*, which has pledged $5 million toward providing puberty education and sanitary products, with the goal of keeping girls in school (Deutsch 2007). The Clinton Global Initiative has pledged $2.8 million to aid businesses who provide inexpensive sanitary pads in Africa; again, the stated goal is improvement in school and work attendance. In addition to these large scale efforts, a number of smaller NGOs (UNICEF, FAWE, CARE) have undertaken similar programs (Cooke, 2006; Bharadwaj and Patkar, 2004). Despite the money being spent on this issue, and the seeming media consensus on its importance, there is little or no rigorous evidence quantifying the days of school lost during menstruation or the effect of modern sanitary products on this time missed. Existing evidence is largely from anecdotes and self-reported survey data.”

(*Proctor & Gamble is the manufacturer of Whisper Sanitary Napkins)

We all know that the forces which control the perceived needs of developing countries are driven by economic outcomes. Given the way they work, in another 5-7 years, don’t be surprised if nothing remained of the wisdom and knowledge that women possessed about their menstrual cycles. It has already happened with the vast knowledge India had about pregnancy and childbirth that now stands destroyed.

But for now, let us remember that as of 2016, it was not India, Gambia, Nigeria, Philippines or Nepal that had the most menstrual disorders; it was the United States, the United Kingdom and Australia –  the countries that are leading the Menstrual Hygiene Movement to “help” the developing nations.


 

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