The National Association of Nurse Practitioners in Women’s Health (NPWH) asserts that all individuals who menstruate should have adequate access to appropriate menstrual products and to facilities that support privacy, safety, hygiene, and sanitation for changing menstrual products, washing body and hands, and cleaning or disposing of used materials. As well, all individuals who experience menstruation should have access to accurate, timely, and age-appropriate information about the menstrual cycle, expected changes that occur from puberty through menopause, and related self-care and hygiene practices. Access to healthcare for timely diagnosis and care for discomforts and disorders related to the menstrual cycle is important for menstrual health (MH), which extends beyond physical wellbeing to include mental and social wellbeing. Menstruation should be free from stigma and psychological distress so that individuals can confidently care for their bodies, make informed decisions about self-care, and participate in daily activities without menstrual-related discrimination or exclusion.

Menstrual equity frames MH as a public health issue, a gender equality issue, and as part of reproductive justice.¹ Advocacy groups in a variety of arenas are using this framework to address the issues regarding equitable access to information and menstrual products; support for privacy, safety, hygiene, and sanitation in self-care during menstruation; and freedom from social stigma, discrimination, and exclusion based on menstrual status. This growing advocacy movement has led to a number of policies enacted in the United States to address the needs of vulnerable populations and to support MH that encompasses physical, mental, and social wellbeing. NPWH champions initiatives at global, national, state, and local levels that advance MH and equity.

NPWH recognizes women’s health nurse practitioners (WHNPs) as the intentional leaders to promote MH and ensure menstrual equity. The breadth and depth of WHNP program curricula prepare the WHNP with distinct competencies to provide gynecologic, sexual, and reproductive healthcare in a holistic and client-centered manner.² This knowledge affords them with expertise that can be used to lead and/or provide consultation in initiatives, advocacy activities, research, and policy making regarding MH and menstrual equity.

Background

When individuals cannot afford or obtain sufficient, appropriate, and preferred menstrual products, they may suffer the health and psychological impact of using products for longer than indicated, resorting to using substitutes such as toilet paper or rags, or not using any products at all. They may be compelled to miss school, work, or other activities because they are ashamed of appearing unhygienic or unkempt.^3,4 The lack of menstrual products to manage menstrual hygiene may increase susceptibility to genitourinary infections.⁵ People living in poverty including school-age individuals, those who are homeless, and those who are incarcerated are among the most affected by a lack of access to menstrual products.^1,6

Menstrual hygiene products are a health-related necessity, yet persons with low or no income face the inability to obtain such products. They may be able to receive assistance in purchasing food products through public benefits programs such as the Supplemental Nutrition Program for Women, Infants, and Children. However, these programs do not cover any household items or grooming products and thus exclude menstrual hygiene products.⁴ Individuals with limited transportation may have extra cost burdens if they have to use local convenience stores where prices may be inflated and are unable to buy less expensively in bulk because they do not readily have the money at hand.^4,6 Further, the majority of states apply regular sales tax on menstrual products ranging from 4% to 10%.¹ This tax is referred to as the tampon tax. Faced with the growing voices of advocates and legislators, there are an increasing number of states that have or are considering eliminating this tax.^1,6

Menstrual hygiene supplies are not typically stocked in schools. Even when schools have menstrual products available on a student’s request, embarrassment and shame may deter their asking. Instead, students who are otherwise unable to secure menstrual products may stay home from school or have to endure or fear humiliating menstrual bleeding accidents. The issue of access to menstrual hygiene supplies is even more complicated for students who are transgender males. Even if supplies are available in female-designated bathrooms, if there are no gender-neutral bathrooms, transgender boys likely will not find menstrual hygiene products in the bathroom appropriate for their gender identity.⁴ Access to menstrual hygiene products in schools is important for students’ attendance, productivity, and sense of self-esteem. Some states and cities have passed or proposed legislation to ensure that menstrual products are readily available at no cost in all school bathrooms. Currently, no federal legislative proposals explicitly address menstrual equity in schools.⁶

Individuals experiencing homelessness encounter both the challenge of access to menstrual products and safe, private, hygienic facilities where they can change products, wash their hands, and dispose of used materials. Without adequate supplies they risk leaking and may not be able to readily clean blood-stained clothes. The lack of hygienic facilities exacerbates anxiety and stress during menstruation and increases vulnerability. Physical and emotional health are compromised.³ Some homeless shelters do distribute menstrual products to their residents, but they rely on public donations to maintain supplies.¹ Although legislation has passed that allows government-funded shelters to use federal grant money to purchase menstrual supplies, this is subject to local board approval that is not guaranteed.^1,6

People who are incarcerated rely entirely on prison or jail staff to meet their medical and hygiene needs. They may not be able to afford the purchase of menstrual products at the facility commissary.⁷ They often have to ask correctional officers for needed menstrual products and may not have a choice between pad and tampon, or both, to meet their individual needs. They face humiliation and health concerns when they use a product longer than the intended time and when they have to wear blood-soaked or -stained clothing while waiting for laundry day.^1,6 The Dignity for Incarcerated Women Act, first introduced in 2017, included the requirement for federal prisons to provide female inmates with menstrual products free of charge and in a quantity that meets the healthcare needs of each prisoner.⁶ Although this act did not pass in 2017, the requirement was included as part of a larger criminal justice package, the First Step Act, which did pass in 2018.⁸ The First Step Act covers federal prisons, but if a woman is housed in a state or local prison or jail, the cost of menstrual products is left to the discretion of that jurisdiction’s legislative body or Department of Corrections. At least 12 state and local jurisdictions have introduced or passed legislation to provide free menstrual products to female inmates and detainees in recent years.^1,6

Menstrual equity also is advanced by providing open communication to dispel misconceptions and taboos surrounding menstruation. Misconceptions and taboos promote stigma and menstrual restrictions that limit individuals’ social interactions and everyday productivity as active members of society. Access to emotionally supportive and culturally aware information about menstruation, self-care, and hygiene products facilitates the ability of menstruators to have periods free of shame, embarrassment, anxiety, and undue discomfort.^9–11 Recent studies indicate that even in high-income countries (eg, United States, Canada, Australia) menstruators face menstrual-related restrictions, have gaps in knowledge, desire conversations that normalize menstruation, and want practical information about such topics as menstrual hygiene products and managing period pain.^10,11

Gaps in knowledge and silence can impede the ability of young people to navigate menarche and menstruation as expected and acceptable events. Timely, supportive communication, however, can equip them with knowledge about the physiology of menstruation, available menstrual hygiene products and correct use, how to track menstrual cycles, what parameters and symptoms are expected, how to manage menstrual pain, and what symptoms suggest the need to see a healthcare provider.¹⁰ Significant menstrual pain and/or heavy bleeding may cause school absences with each cycle. Unfortunately, the diagnosis and treatment for menstrual health disorders such as dysmenorrhea and endometriosis are frequently delayed in part because young menstruators lack appropriate knowledge, are embarrassed to discuss symptoms with healthcare providers, or have normalized their pain and do not want to appear melodramatic.^12,13

Some individuals may face additional challenges in managing menstruation. Among them are transgender and nonbinary persons with natal female anatomy, individuals with disabilities, those who are recent migrants or refugees, and active-duty military. Although the challenges may differ across and within these populations, biases and discrimination and lack of supportive and appropriate information about menstruation can compound experiences of stigma, restrictions, and lack of self-esteem.

Menstruation can be a source of gender dysphoria (ie, significant stress or impaired functioning related to a discrepancy between gender identity and natal sex) among transgender males and some nonbinary persons.^14,15 Changing menstrual hygiene products can be difficult to manage at school, work, or other public places for safety and identity reasons.¹⁶ Creating a healthcare environment that affirms each person’s gender identity is important so that patient-centered discussions about menstruation and goals in regard to continuing or suppressing menstruation can occur. As with all individuals who menstruate, information about what parameters for menses are normal, how to manage menstrual pain, and what symptoms suggest the need to see a healthcare provider are important. For patients who are taking testosterone, information is needed on when to expect cessation of menses and what constitutes abnormal bleeding that needs attention.^14,15

Some individuals with disabilities are at least partially dependent on others for their hygiene needs during menstruation, but it should not be assumed that they are incapable of managing self-care.^17–20 Healthcare should be patient centered, maintain dignity, maximize autonomy, avoid harm, and address knowledge needed about puberty, menstruation, and sexuality for the patient and caregiver.^20,21 In particular for adolescents with intellectual disabilities, conversations with the healthcare provider prior to puberty and menarche are important. This allows time for the patient and caregiver to address concerns and expectations and to receive anticipatory guidance.^18,21,22 Understanding an individual’s ability to describe location and severity of pain and the use of appropriate pain assessment tools can facilitate pain management and recognition of the need for evaluation of potential menstrual disorders.^17,20,21 Decisions about regulating or suppressing menstruation should be individualized to each patient’s needs and desires.^18,21,22

Migrant and refugee individuals often have limited or no knowledge about menstruation prior to resettlement in the US. They may have not had the opportunity to learn about MH due to poor access to health services and lack of information provided in school settings. Cultural and religious factors often intersect with lack of knowledge to shape their experience of menarche and menstruation. Their culture of origin may position menstruation as shameful, something that is taboo to discuss, and even dirty. Strict prohibitions may be in place for the individual while menstruating.^23,24 Recent migrant and refugee individuals are often transitioning between two different cultures in which the construct of menarche and menstruation is conflicting. Inadequate knowledge and silence around menstruation are associated with reports of traumatic experiences of menarche described as frightening and shocking.^23,24 Addressing menstrual issues with a healthcare provider may be difficult and avoided because of these past experiences. In one qualitative study of migrant and refugee women, however, the participants reported desiring information so that they could be more open with their daughters about menarche and menstruation.²⁵ To reach migrant and refugee populations outside of healthcare settings, culturally appropriate community initiatives on sexual and reproductive health promotion need to be accessible and offered in a range of modalities to meet their diverse needs.²³

As the number of women in the military increases, there is growing recognition of some of the unique structural and social barriers to menstrual health and hygiene that they encounter. This is most apparent when the individual is in field training or combat environments. Lack of latrines and showers in these settings affects the ability to privately change and dispose of menstrual products and to wash body and hands.^10,26,27 Traditional male norms and attitudes within the military can create social stigma around menstruation and menstrual hygiene needs.²⁶ Access to counseling on and availability of hormonal contraception for menstrual regulation and suppression if desired and adequate training of healthcare providers on women’s health issues vary across military services.^26,27 The 2020 Defense Health Board’s report on active-duty women’s healthcare addressed reproductive and urogenital health. The report noted that substantial improvements overall in active-duty women’s health can only be realized by identifying, standardizing, and deploying best practices across all military services.²⁶

Menstrual health and menstrual equity are global issues. The barriers to menstrual health and menstrual equity for people living in low-and middle-income countries are significant. Poverty; lack of access to healthcare, education, menstrual hygiene products, and clean water; activity restrictions based on taboos and misconceptions; and gender-based discrimination are among the challenges to overcome. The World Health Organization and the United Nations Children’s Emergency Fund (UNICEF) define menstrual hygiene management as being able to use clean sanitary products to absorb or collect menstrual blood and the privacy to change sanitary products as often as necessary; the ability to use soap and water for washing the body and having access to safe facilities to dispose of used menstrual hygiene products; having access to basic information regarding their menstrual cycle; and how to manage their menstruation with dignity and without discomfort or fear.²⁸ UNICEF has made a commitment to menstrual health and hygiene as one of its five interlinked priorities for empowering adolescent girls in their Gender Action Plan 2018–2021.²⁸ The United Nations includes menstrual health and hygiene as important for the fulfillment of girls and women’s rights, a key objective of its Sustainable Development Goals.²⁸

Implications for women’s and gender-related health and healthcare

WHNPs and other advanced practice registered nurses (APRNs) who provide women’s and gender-related healthcare have the opportunity to provide accurate MH information in a supportive manner. An assessment of social/structural determinants that may affect each individual’s ability to access and use menstrual hygiene products and to go about their usual activities during menstruation in a confident manner is important. Information and educational materials need to be appropriate to developmental stage, language, culture, and health literacy.

The achievement of MH and menstrual equity goes beyond the healthcare setting. WHNPs and other APRNs who provide women’s and gender-related healthcare can identify community resources that provide menstrual hygiene products to those in need. They can lead and collaborate with others to ensure these resources are available. Additionally, they can advocate for public health policies and legislation at local, state, national, and global levels that facilitate each individual’s right and ability to care for their bodies during menstruation without shame or embarrassment. Research is needed to fill several gaps in knowledge. Through research we can improve our ability to identify populations that are vulnerable to menstrual inequities, understand specific physical and mental health consequences associated with inadequate menstrual hygiene, and evaluate strategies to reduce inequities and improve menstrual health.

NPWH leadership

NPWH will provide leadership to ensure:

• Continuing education (CE) programs and resources are available to support WHNPs and other APRNs who provide women’s and gender-related healthcare in delivering MH education to a variety of populations.
• CE programs and resources are available to support WHNPs and other APRNs in acting as change agents and advocates to promote MH and menstrual equity in their communities.
• Research progresses to understand and address the causes and consequences of menstrual inequities among vulnerable populations.

References

1. ACLU National Prison Project Period Equity. Menstrual equity: A legislative toolkit. December 2019. 121119-sj-periodequitytoolkit.pdf.
2. National Association of Nurse Practitioners in Women’s Health. Women’s Health Nurse Practitioner: Guidelines for Practice and Education, 8th ed. Washington DC: National Association of Nurse Practitioners in Women’s Health; 2020.
3. Vora S. The realities of period poverty: how homelessness shapes women’s lived experiences of menstruation. In: Bobel C, Winkler IT, Fahs B, et al, eds. The Palgrave Handbook of Critical Menstruation Studies. Singapore: Palgrave Macmillan; 2020.
4. Kuhlmann AS, Bergquist EP, Danjoint D, Wall LL. Unmet menstrual hygiene needs among low-income women. Obstet Gynecol. 2019;133(2):238-244.
5. Sumpter C, Torondel B. A systematic review of  the health and social effects of  menstrual hygiene management. PLoS One. 2013;8(4):e62004.
6. Bringing Resources to Aid Women’s Shelters and the Legislation Clinic at the University of the District of Columbia David A. Clarke School of Law. Periods, poverty, and the need for policy: a report on menstrual inequity in the United States. May 2018.
7. Roberts TA. Bleeding in jail: objectification, self-objectification, and menstrual injustice. In: Bobel C, Winkler IT, Fahs B, et al, eds. The Palgrave Handbook of Critical Menstruation Studies. Singapore: Palgrave Macmillan; 2020.
8. Federal Bureau of  Prisons. An overview of the First Step Act.
9. Casola AR, Kunes B, Jefferson K, Riley AH. Menstrual health stigma in the United States: communication complexities and implications for theory and practice. J Midwifery Womens Health. 2021;0(0):1-4.
10. Riley AH, Slifer L, Hughes J, Ramaiya A. Results from a literature review of  menstruation-related restrictions in the United States and Canada. Sex Reprod Healthc. 2020;25:1-6.
11. Rubinsky V, Gunning JN, Cooke-Jackson A. “I thought I was dying:” (un)supportive communication surrounding early menstruation experiences. Health Commun. 2020;35(2):242-252.
12. American College of Obstetricians and Gynecologists. Committee opinion no. 651: menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Obstet Gynecol. 2015;126(6):e143-e146.
13. Holmes K, Curry C, Ferfolja TF, et al. Adolescent menstrual health literacy in low, middle and high-income countries: a narrative review. Int J Environ Res Public Health. 2021;18(5):2260.
14. Mehringer J, Dowshen NL. Sexual and reproductive health considerations among transgender and gender-expansive youth. Curr Probl Pediatr Adolesc Health Care. 2019;49(9):100684.
15. Schwartz AR, Russell K, Gray BA. Approaches to vaginal bleeding and contraceptive counseling in transgender and gender nonbinary patients. Obstet Gynecol. 2019;134(1):81-90.
16. Chrisler JC, Gorman JA, Manion J, et al. Queer periods: attitudes and experiences with menstruation in the masculine of centre and transgender community. Cult Health Sex.2016;18(11):1238-1250.
17. Li AD, Bellis EK, Girling JE, et al. Unmet needs and experiences of  adolescent girls with heavy menstrual bleeding and dysmenorrhea: a qualitative study. J Pediatr Adolesc Gynecol. 2020;33(3):278-284.
18. Quint EH, O’Brien RF, Committee on Adolescence; North American Society for Pediatric and Adolescent Gynecology. Menstrual management for adolescents with disabilities. Pediatrics. 2016;138(1):e20160295.
19. Steele L, Goldblatt B. The human rights of  women and girls with disabilities: sterilization and other coercive responses to menstruation. In: Bobel C, Winkler IT, Fahs B, et al, eds. The Palgrave Handbook of Critical Menstruation Studies. Singapore: Palgrave Macmillan; 2020.
20. Wilbur J, Torondel B, Hameed S, et al. Systematic review of  menstrual hygiene management requirements: its barriers and strategies for disabled people. PLoS One. 2019;14(2):e0210974.
21. American College of Obstetricians and Gynecologists. Committee opinion no. 668. Menstrual manipulation for adolescents with physical and developmental disabilities. Obstet Gynecol. 2016;128(2):e20-e25.
22. Hopkins CS, Fasolino T. Menstrual suppression in girls with disabilities. J Am Assoc Nurse Pract. 2020;00:1-6.
23. Hawkey AJ, Ussher JM, Perz J, Metusela C. Experiences and constructions of  menarche and menstruation among migrant and refugee women. Qual Health Res. 2017;27(10):1473-1490.
24. Metusela C, Ussher J, Perz J, et al. “In my culture, we don’t know anything about that”: sexual and reproductive health of migrant and refugee women. Int J Behav Med.2017;24(6):836-845.
25. Hawkey AJ, Ussher JM, Perz J. “I treat my daughters not like my mother treated me”: migrant and refugee women’s constructions and experiences of menarche and menstruation. In: Bobel C, Winkler IT, Fahs B, et al, eds. The Palgrave Handbook of  Critical Menstruation Studies. Singapore: Palgrave Macmillan; 2020.
26. Defense Health Board Report: Active Duty Women’s Health Care Services, November 5, 2020.
27. Eagan SM. Menstrual suppression for military women: barriers to care in the United States. Obstet Gynecol. 2019;134(1):72-76.
28. United Nations Children’s Emergency Fund (UNICEF). UNICEF for Every Child. Guidance on Menstrual Health and Hygiene. New York, NY: UNICEF; 2019.

Approved by NPWH Board of Directors: September 15, 2021