From both a global and domestic perspective, reproductive health providers should focus on menstrual health issues with women as part of their overall reproductive wellness and healthcare, according to the authors of a new paper on sexual and reproductive healthcare and rights.1

Menstruation should be thought of as a vital sign, particularly for adolescents, says Lucy C. Wilson, MPH, independent consultant with Rising Outcomes in Hillsborough, NC.

“Ask about menstruation as a potential indicator of other health problems, particularly in girls and adolescents,” she advises.

In 2006, the American Academy of Pediatrics Committee on Adolescence and the American College of Obstetricians and Gynecologists (ACOG) Committee on Adolescent Health Care said the menstrual cycle should be used as a vital sign for girls and adolescents. In 2015, ACOG reaffirmed this in a committee opinion.2,3

Clinicians learn what is clinically relevant in family planning and reproductive health, but they tend to forget their personal experience when speaking with patients in a professional setting, Wilson says. For example, Wilson recently spoke with a man who ran a program providing reproductive healthcare to adolescents. He also was a father of an adolescent girl.

“He said, ‘I’m taking my daughter to the gynecologist next week; she’s 13 and started her period, and it’s really painful, so we’ll take her to the doctor to get her on contraceptives to make it less painful,’” Wilson recalls. “He only thought about this from the perspective of his daughter, and it didn’t translate for him to the work he was doing professionally, partly because menstruation is not talked about openly.”

Once this dichotomy is brought to providers’ perspective, they can think about how their patients’ decisions about contraception might be affected by menstruation. “Taboos around menstruation make it more challenging for someone in a reproductive health program to address it,” Wilson notes.

There is no one way to expect people to view their menstruation and its effect on their contraception decisions. For many people, using a contraceptive that reduces or ends monthly bleeding and menstrual pain is a positive. But for others, menstruation means something different.

“Some people see bleeding as a positive, and without the monthly reminder, they worry about whether or not they’re pregnant,” Wilson says. “Others feel menstruation makes them feel like a woman; others like it because it allows them to not have sex that week.”

Menstruation and bleeding changes also can affect women’s decisions to discontinue a particular contraceptive method. Some people might view the sporadic bleeding and spotting that occurs when switching to a progesterone-only contraceptive as an adverse effect instead of a potential benefit, Wilson says. Or, patients may want a particular contraceptive because it will stop their bleeding eventually, but some providers only note the expected change in menstruation and do not frame it as a potential benefit.

Women in the United States and in other countries often lack the financial resources to afford menstrual health products, or they do not want to be inconvenienced with them. For them, contraceptives that stop their monthly bleeding could be attractive options.

“Contraception can be seen as an option for managing menstruation, but it can’t be seen as the only solution, as in, ‘We’ll use contraception, and you won’t need another menstrual health product,’” Wilson explains.

Clinicians also can open discussion about menstruation to assess patients’ pain and other symptoms. This could be an opportunity to educate patients and assess whether their experience is normal or if their pain could be the result of a problem.

For instance, clinicians could ask patients about these menstrual issues:

• Menstrual pain. “Several menstrual disorders or disorders of reproductive organs can contribute to more painful periods,” Wilson says. “These include endometriosis, uterine fibroids, and adenomyosis.”

When a patient says that menstruation is painful, rather than suggest an ibuprofen, the clinician can ask questions to learn more about the type of pain, which could be a sign of other health issues.

• Menstrual flow. “There’s not a lot of research out there on menstrual flow and anemia, but there is some research around heavy menstrual bleeding, and some contraceptive methods are potential treatments for heavy menstrual bleeding,” Wilson explains. “The hormonal IUD [intrauterine device] is marketed for heavy menstrual bleeding and has been used off-label for endometriosis.”4

• Premenstrual syndrome (PMS) symptoms. “Some classic PMS symptoms can be alleviated with contraceptive methods,” Wilson says. “Hormonal methods will affect the symptoms that women feel during that cycle.”

For instance, the original birth control pill was marketed initially as a treatment for menstrual bleeding and pain. “That was a way to get it approved before it was approved for contraception,” Wilson says.

Discussing menstruation with patients also provides an opportunity to determine which contraceptive method will fit with a woman’s lifestyle. For example, women who experience problematically heavy periods may not want a copper IUD, which could increase menstrual flow volume.

“I think asking about menstruation and explaining why you’re asking about it would be an important step to overcoming the taboo — at least in the doctor’s office setting,” Wilson says. “Having that conversation with your provider is important, not only to identify whether or not menstruation is problematic or that it underlies potential health problems, but to also help them identify a contraceptive method.”

“Providers should recognize that people have distinctly different views about their menstruation,” she adds. “Providers may think of it as the curse, but for some it may be an important part of who they are, and they really want to continue menstruating on a regular cycle.”

REFERENCES

  1. Wilson LC, Rademacher KH, Rosenbaum J, et al. Seeking synergies: Understanding the evidence that links menstrual health and sexual and reproductive health and rights. Sex Reprod Health Matters 2021;29:1882791.
  2. Diaz A, Laufer MR, Breech LL. Menstruation in girls and adolescents: Using the menstrual cycle as a vital sign. Pediatrics 2006;118:2245-2250.
  3. ACOG Committee Opinion No. 651: Menstruation in girls and adolescents: Using the menstrual cycle as a vital sign. Obstet Gynecol 2015;126:e143-e146.
  4. Stacey D, Shur M. Mirena IUD for the treatment of heavy periods. Verywell Health. Updated Nov. 22, 2019. https://www.verywellhealth.com/does-mirena-iud-help-treat-heavy-periods-906764