by Maria Carmen Punzi, Menstrual Health Focal Point, PSI Europe @mcarmenpunzi
What do a new mother, a pre-teen girl and an adolescent taking a hormonal contraceptive have in common? They are all most likely experiencing heavier, lighter or less predictable bleeding than what is considered “average menstruation.” The reproductive cycle is a continuum, unique for every woman, and while the bleeding experience starts with menarche, it continues when she becomes sexually active and changes throughout the course of her life.
When global health NGOs implement sexual and reproductive health and rights (SRHR) programs, we often work with girls and women who have already started menstruating. However, it is important not to assume they possess sufficient—if any— knowledge of the menstrual cycle. Typically, girls know how to manage their period, often limited to correct use of pads and hygiene practices. This is far from comprehensive. Understanding contraception, fertility and pregnancy can be a challenge in itself, but it becomes even more so when girls and entire communities believe myths about menstruation and restrict their daily activities because of them.
Considering all of the above, how can menstrual health help strengthen and provide new insights for our SRHR programs?
- Improving counseling for contraceptive continuation. Recent work conducted by PSI Europe, in partnership with the funding collaborative The Case for Her, has confirmed what previous studies1 have found: a common reason women discontinue hormonal contraceptives is their impact on menstruation. Hormonal and intrauterine device (IUD) contraceptives can cause bleeding to stop altogether (hormonal IUD), provoke heavier flow (copper IUD) or lead to spotting (Depo-Provera shot). Health workers must be aware of how concerning it is for women to see their bleeding patterns change as a result of contraception, and how important it is for women to feel normal and healthy. Counselors should use informative tools like the job aid NORMAL2 to inform and reassure their clients.
- Validating women’s individual experiences of menstruation. Some women view contraceptive induced amenorrhea (absence of menstruation) as positive, convenient and liberating from problems associated with menstruation, like painful periods. Others view regular menstruation as a marker of health and fertility and find it reassures them that they’re not pregnant, and so they don’t feel comfortable with not having a period3. Each woman has a unique menstrual experience, and to truly serve her, we need to listen to her concerns, understand her preferences and dispel myths. Since women’s decisions about contraception are determined by their perceptions of the method’s impacts on fertility and cycle irregularity,4 and their beliefs and desires about motherhood,5 all of these elements must be taken into account, when providing comprehensive information about the menstrual cycle, what changes are normal and when it’s important to speak to a doctor.
- Menstrual health as self-care. Menstruation is a valuable indicator and predictor of health. When girls and women learn to track their cycle, they gain important insights about their health, like getting to know what a “normal” period is for them in terms of cycle length, bleeding, as well as cramps and other symptoms. The introduction of period tracking apps to help record this data is an opportunity for women and girls all around the world to get more in touch with their cycle, spot anomalies early and become their own best health advocates.
- Menstruation and the future of diagnostics. The diagnostic field is buzzing with innovations to bring care closer to consumers and to help communities and individuals take control of their health. Research from the United States’ National Institutes of Health (NIH),6 as well as projects like QuraSense7 and NextGenJane,8 are showing that menstrual blood contains a vast range of unique health data that permits early diagnoses and disease management without the need of an invasive blood test. Menstrual blood samples will also soon be used to test for HIV, and cervical cancer and other sexually transmitted diseases and infections, and even potentially diagnose menstrual morbidities like endometriosis, which can affect fertility.
Menstrual health has the power to revolutionize the way we deliver SRHR interventions. It is essential that the global health community of practice acknowledges this and works to integrate menstrual health into existing interventions, further enabling women and girls to become powerful experts for their own bodies and health.
Banner Image: © PSI Nepal/Davendra Lal Shrestha
1. Rademacher, K. H., Sergison, J., Glish, L., Maldonado, L. Y., Mackenzie, A., Nanda, G., & Yacobson, I. (2018). Menstrual bleeding changes are NORMAL: Proposed counseling tool to address common reasons for non-use and discontinuation of contraception. Global Health: Science and Practice, 6(3), 603-610.
2. NORMAL job aid. Retreived from https://www.fhi360.org/sites/default/files/media/documents/resource-normal-counseling-job-aid.pdf
3. Polis, C., Hussain, R., & Berry, A. (2018). There might be blood: A scoping review on women’s responses to contraceptive-induced menstrual bleeding changes. Contraception, 98(4), 348.
4. Danna, K., Jackson, A., Mann C., & Harris, D. (2019). Lessons learned from the introduction of the levonorgestrel intrauterine system in Zambia and Madagascar. Retrieved from http://www.wcgcares.org/wp-content/uploads/2019/04/EECO-LNG-IUS-Case-Study.pdf
5. Findings from PSI’s Adolescents 360 Project. Retreived from https://staging.psi-2017.flywheelsites.com/2018/09/in-tanzania-long-acting-methods-are-for-girls-with-a-plan/
6. Menstruation as a Diagnostic Tool for Women’s Health https://www.nichd.nih.gov/newsroom/news/121218-menstruation-podcast
7. NextGenJane https://www.nextgenjane.com/
8. QuraSense https://qurasense.com/#site/home
Hear more from Maria Carmen about menstrual health at the Women Deliver 2019 concurrent sessions, “Power in Her Hands: Why Menstrual Health Matters for Sexual and Reproductive Health” on Monday, June 3, 6:30pm at The Case for Her booth and “Let’s Talk About It-Period!” on Tuesday, June 4, at 3:00pm (VCC West, room 118).
This article appears in PSI’s Impact magazine, released in tandem with Women Deliver 2019, as part of an ongoing conversation about putting #PowerInHerHands.