Once only discussed in hushed voices with euphemisms such as “the curse,” “that time of the month,” or “Aunt Flo,” the monthly period, as a topic, is becoming less taboo. Menstruation should not be a cause for embarrassment or shame, advocates say.
To that end, Pantone, the color registry company, and the Swedish feminine product brand Intimina launched a marketing partnership last year to promote a shade of crimson called “period red,” as a way to destigmatize what is an entirely natural process.
Here in the United States, conversations are getting louder with both women and men rallying around the idea of “menstrual equity.” Plans and proposals range from seeking tax-free status to pushing for health insurance coverage of period products, to advocating for their free distribution in schools, shelters, and prisons.
There’s also a movement to embrace environmentally friendly reusable period products like silicone cups and discs, and/or specialized menstrual underwear—and some women even advocate the practice of what’s called “free bleeding," not using any products at all.
“The biggest misconception is that girls or women should suffer silently and not talk about their periods,” says Linda Fan, MD, chief of Yale Medicine Gynecologic Specialties. “There are women in their 40s who still don’t want to talk about their periods. But what if something serious is going on?” A heavy period could be endometriosis, for example.
Eliminating the stigma
Yale Medicine specialists in women’s health applaud these efforts to bring greater openness to discussions about periods. But several obstetrician–gynecologists report being surprised to learn about the inequalities that exist on this subject.
Lubna Pal, MBBS, MS, director of Yale Medicine’s Polycystic Ovary Syndrome and Menopause programs, says that she became attentive to “our culpability in our collective silence on a very normal phenomenon” when she was invited to a National Period Day Rally in New Haven, Conn., in 2019. The rally was organized by PERIOD, a global, youth-run nonprofit based in Oregon that works to provide and celebrate menstrual hygiene through education, service, and advocacy.
Sanitary products should be free, safe, comfortable, and aesthetic. They should be appealing to the customer, and companies shouldn’t be making money off the biologic needs of women. Lubna Pal, MBBS, MS, director of Yale Medicine’s Polycystic Ovary Syndrome and Menopause programs
“It was a phenomenal event that was spearheaded by inspirational youth. It was equally heartening to see males of all ages coming out in support of their daughters, wives, friends, and mothers. I think we should be having a much broader conversation about all of this,” Dr. Pal says. “As a daughter of a gynecologist, and then as a gynecologist and reproductive endocrinologist, I have approached menses as a ‘vital sign,’ a phenomenon whose regularity or irregularity can provide meaningful insights into the overall health of a woman of reproductive age.”
Dr. Pal believes that she and other health care providers have been myopic about period health. “Our focus has been on how regular it is, as well as on how much bleeding and how much pain there is,” she says. “Until attending the rally, I had not focused on important social aspects relating to periods. Are our educational institutions supporting girls who need sanitary products? Is it fair that you have to pay to get a tampon, but condoms are available for free? What resources are available to those who are incarcerated or others who are marginalized?”
Meanwhile, organizations in third-world countries are working to put a stop to such practices as isolating women who are menstruating, and ensuring that young girls aren’t missing school due to lack of access to feminine products. One company in India is offering employees paid sick time during their period.
Reusable period products
Another realization Dr. Pal came to at the rally was the environmental harm from soiled products that are used once and then disposed. “About 51% of the population is women, and for at least 30 years in an average woman’s lifetime, her contributions to the daily environmental waste get upped for a few days each month,” Dr. Pal says. “Shouldn’t we be thinking more about increasing access to biodegradable options that are less burdensome on the environment?”
Environmental impact can be reduced by switching to reusable sanitary pads, which are becoming more popular, or to a menstrual cup or disc. Made of silicone, rubber, or latex, these are inserted into the vagina during a woman's period, similar to a tampon. Blood is collected in the receptacle, which should be emptied every four to 12 hours. (It’s recommended that menstrual cups and discs be sterilized after each cycle; properly cared for, they can last for up to 10 years.) Women can also purchase disposable, single-use menstrual versions, though these are not as environmentally friendly.
“Reusable cups are safe, but there’s an art to using them; women have to learn how to insert and remove them correctly,” Dr. Pal says.
They can also be convenient and cost-effective, Dr. Fan points out. “An advantage of the menstrual cup is that it can absorb more than most tampons or pads. However, cups typically cost $30 or $40,” she says.
Expense should be a part of the conversation about period health, Dr. Pal adds. She believes menstrual products should be provided free of cost, at least to school-age and college students. “Sanitary products should be free, safe, comfortable, and aesthetic,” she says. “They should be appealing to the customer, and companies shouldn’t be making money off the biologic needs of women.”
Providers can do more around period health
Dr. Fan has recently started to think about how health care providers could do more to educate patients about menstrual health—and products.
“When you look at news articles and magazines, there is a ton of talk about the tampon tax and legislating that schools and jails need to have period products available, but information about these topics in the medical literature has been sparse,” she says.
That is starting to change. A recent report published in Obstetrics & Gynecology surveyed low-income women and found that nearly two-thirds of them can’t always afford to purchase menstrual products and often need to rely on diapers, rags, or paper towels.
Dr. Fan says the problem is of even greater concern now, since unemployment is so high. Many women suffer silently, she says, because the stigma around menstruation remains despite the recent openness surrounding period health. In order to alter the culture around the discussion, the varied influences in a women’s life—home, school, media, and medical providers—will need to evolve, she says.
“Physicians primarily speak with patients about periods when something is wrong,” she says. “When we need to make a diagnosis because there is a problem, we are there. But we don’t otherwise spend time talking to girls about when their period first comes, or talking to all ages about what to do if it’s heavy or painful.”
Dr. Fan, along with several colleagues and medical school residents, has explored how physicians and patients discuss menstrual health with the goal of identifying potential gaps. For a study, providers and patients were surveyed at three low-income clinics in New Haven.
Only 7% of providers reported consistently asking their patients about menstrual product use—despite the fact that 54% had either known or suspected that their patients could not afford menstrual products. Meanwhile, 53% of patients reported never having discussed menstrual products with their health care provider, and 45% said they had missed work or school during their period.
“We are not doing very well here,” Dr. Fan says, adding that physician knowledge of reusable products is low, despite the fact that patients showed a desire to learn more about such options.
Start the conversation young
As Dr. Fan conducted her research, she realized the adolescent population should not be left out of the conversation.
“The idea is that we can intervene sooner and in a more 'well thought out' way,” Dr. Fan says. “We hope to set up better education on this matter. If we—the experts on this—don’t break the silence, then who will?”
To that end, Alla Vash-Margita, MD, chief of Yale Medicine Pediatric & Adolescent Gynecology, has been collecting similar data among younger girls. So far, there are similar gaps when it comes to how providers counsel adolescent patients about menstrual products, she says. “It can be a lack of time or of willingness or desire,” she adds.
Most adolescents start off using menstrual pads, she says. Sometimes the girls aren’t comfortable with the idea of using a tampon (not to mention a cup), but the discomfort can also come from the adults in their lives.
“There is this myth that these are not good for young girls, so they are not offered to or bought for them,” Dr. Vash-Margita says. Athletes, in particular, may prefer products worn internally because they allow them to comfortably participate in all activities. Plus, she notes, “pads are notorious for causing vulvar irritation. It’s best to use hypoallergenic products if there are issues.”
Dr. Fan agrees. “Some are scented and people can have allergic reactions to that,” she says.
Sometimes, girls may need a little coaching on how to properly use a tampon, Dr. Vash-Margita adds. “I use a diagram of a female pelvis to do a demonstration in the office. I show that the vagina is a closed space at the top and that the tampon will not be lost in their body,” she says. “I use it as an opportunity to teach anatomy and physiology and what happens with the uterus lining and why it sheds. If a girl finds it uncomfortable to insert a tampon, I suggest using a lubricant for the first time to help.”
“It’s important to set up a lifelong expectation that women can and should discuss any menstrual issues they have with their health care providers,” says Dr. Fan. "Girls should learn to pay attention to what’s normal for them—regular or irregular, short or long, light or heavy—and alert the doctor if they have concerns."
It’s OK to not get your period—sometimes
With all this talk about menstrual products, Drs. Pal, Fan, and Vash-Margita always like to remind women that, when on certain types of birth control, you may have fewer periods or none at all—and that’s not unhealthy.
For any girl or woman who is not on any form of hormone-based birth control (e.g., pill, patch, ring, injection, implant, or intrauterine device), Dr. Pal explains that a change in the timing or pattern of her period might indicate something is amiss. But the scenario is very different if those who reliably use hormonal birth control experience a change in their periods. Missing your period is not uncommon with certain types of hormonal birth control products, she says.
“Physiologically, the norm for female biology is regular cycles,” she explains. “Yours could be 24 or 28 days, but it reflects a normal function of your reproductive clock. If it doesn’t work right, something may have messed up your clock, such as a problem with the timing of ovulation.”
Hormonal birth control products establish a different normal, Dr. Pal says, noting that there are several types. “For some patients, we use a traditional pill with 21 days of hormones and seven days of no hormones, or “placebo” pills. When a woman starts the week of placebo pills, her hormone blood levels drop, allowing the lining of the uterus to go through a 'withdrawal' bleeding,” which we call a period, she says.
She adds that there are no health consequences that go along with not getting your period. “The only thing to be vigilant about is to know that being on birth control continuously can thin out the endometrial lining, and, for some women, that can mean breakthrough bleeding. If that happens, they can take a break and take a placebo pill for a few days,” Dr. Pal says.
This is very different from missed periods in those who are not on any hormones, which could be caused by health-related conditions or pregnancy. “For any woman who may have missed an occasional pill, whose missed period is new and who is also sexually active, a pregnancy test is a way to make sure that the missed period is not because of pregnancy,” says Dr. Pal.
Dr. Fan adds that some women like getting their period just to reassure them that they aren’t pregnant. “That’s fine, of course, but other women are debilitated by their period, either from bleeding or pain, and it’s not bad to suppress it,” she says. “It doesn’t hurt their uterus. Some people may worry about increased rates of blood clots or breast cancer from birth control pills. There is a slight increased risk of blood clots and stroke, but that is usually with people who have a higher risk at baseline, and this is something you would talk to your practitioner about first.”
The key, she emphasizes, is to discuss any and all concerns about menstrual health with your health care provider.