Introduction/Purpose:

Across the globe, the onset of menstruation (menarche) marks the entry of adolescent girls into the reproductive years of her life. Menstruation is a natural, inevitable biological process that is nevertheless highly stigmatized, to the point of making a serious impact on menstrual health, education, freedom, intimacy, autonomy, and personal development. Adolescent girls with menstrual disorders, such as severe pain or heavy menstrual bleeding, can experience significant impairment in quality of life. With the simple and cost-effective provision of education, hygiene supplies, and treatment of menstrual disorders, adolescent girls can stay in school, avoid shame, and live more productive lives. This document is a call to action for policy makers and providers of care for adolescent girls globally to address the menstrual health needs of adolescent girls.

Care providers should use the menstrual cycle as a vital sign for adolescent health, and treat menstrual disorders to improve the quality of life in adolescents.

Menstruation is a vital sign—just like heart rate, respiratory rate, or temperature. A person’s menstrual history offers valuable information regarding their overall health, yet it is often made invisible like no other physiological function. The menstrualhistory should be a routine part of the medical history taken of adolescent girls. Menarche usually occurs around 12 years of age, but can vary regionally by about12 months. Girls beginning menses before age 10 or without onset of menses by age 15 years should be evaluated for precocious or delayed puberty. It should be noted that, among adolescents, 90% of post-menarche menstrual cycles span 21 to 45 days. Girls with shorter cycles than 21 days are at risk of anemia from blood loss and should be evaluated, as should girls with persistently longer menstrual cycles than every 3 months, especially after the first year after menarche.

Heavy menstrual bleeding leading to anemia is a most common emergency gynecological issue in adolescents. HMB causes great concern for adolescents and their families, with school accidents triggering discomfort, shame, and low self esteem, and contributing to a lower quality of life. In adolescents, the most common causes of heavy menstrual bleeding are anovulatory cycles and underlying bleeding disorders, unlike in adults, where heavy menstrual bleeding can be structural due to myomas or malignancies.

The most common cause of abnormal uterine bleeding in adolescents (95%) is anovulation due to an immature hypothalamic pituitary gonadal (HPG) axis. Bleeding is characteristically heavy, protracted and irregular. Sleep disturbances and increased major stressors may trigger anovulatory bleeding. Underlying conditions such as hypothyroidism should be ruled out, but are less common in adolescents than adults. When patients with heavy menstrual bleeding present with severe anemia or profuse bleeding,or have a family history of heavy menses, 20% or more are found to have underlying bleeding disorders, most commonly Von Willebrand Disease.

Heavy menstrual bleeding can be safely controlled using combined oral contraceptives, even in young adolescent patients. These are widely available and inexpensive. The medication reduces menstrual blood loss by stabilizing the endometrium and reducing endometrial thickness. It is also safe to use oral progesterone, levonorgestrel intrauterine devices, DepoMedroxyprogesterone, and the contraceptive implant in adolescents who have never been sexually active to control blood loss. These medications do not impair future fertility, do not encourage sexual activity, and do not increase cancer risk. Where hormonal medications are not available or accepted by families, tranexamic acid can be used to decrease menstrual blood loss.

Significant pain with menses, dysmenorrhea, can significantly affect quality of life. 15-20% of adolescents miss school every month due to menstrual pain. Simple heating pads have been shown to reduce menstrual pain. Non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen and naproxen as well as antispasmodics are effective in reducing the pain triggered by prostaglandins causing uterine contractions. Oral contraceptives also significantly reduce menstrual pain as well as blood loss. Adolescents with persistent pain not responding to these medications should be referred for specialty evaluation for uterine anomalies or endometriosis. Endometriosis has been found in up to 75% of adolescents with menstrual pain refractory to medical management.

Menstruation is a physiologic process, not a reflection of maturity or self-worth. Providers within cultures should advocate that girls should be protected from abuse or shame related to menses.

Menarche is a physiologic process that does not reflect readiness to engage in relationships or sexual activity, yet In some cultures, menarche is still perceived as a signal a girl is ready for arranged marriage and the onset of reproductive potential. This leaves girls exposed to forced child marriage and sexual abuse, especially in times of humanitarian crises. Menstruation is one indication of biological fertility but does not mean girls have reached physical, mental, psychological and emotional maturity.

When menstruation is not handled with dignity, related shame or teasing, as well as exclusion is common. Menstruation in some cultures is perceived as shameful or dirty. Not only does this view negatively affect individual self-esteem, it can also lead to restriction of access to religious spaces, school or extracurricular activities, and social gatherings, making women less able to participate in
public life due to common misconceptions. Conversely, adolescents who have delayed onset of menses can be disparaged as not real women and not be permitted to participate fully in society.

Providers and healthcare educators within cultures can help reduce the stigma and outsized societal role associated with menses.

Access to menstrual hygiene should be promoted to ensure the continued education of girls and to thereby reduce poverty.

In many areas of the world, menarche unfortunately marks the beginning of interrupted education due to lack of menstrual education, hygiene supplies, and facilities to cope with menstruation.

According to a study carried out by the World Bank and the United Nations Children’s Fund (UNICEF), out of the 1.8 billion menstruating people around the world, 500 million have no access to adequate facilities where they can fulfill their menstrual hygiene needs. It is estimated that, at the global level, 2 out of every 5 menstruating children miss 5 school days per month, on average, because of the lack of adequate infrastructure for menstrual hygiene.

In low- and middle- income countries, even adolescents with normal menses may struggle due to lack of access to menstrual management products,lack of adequate facilities for their private, acceptable handling, as well as the lack of safe water. In Latin America, 106 million people still lack an adequate restroom at home. This is compounded by the lack of education and guidance for menstruating children before their menarche, particularly in the more isolated, rural areas, as well as by cultural and religious factors that can create taboos that exacerbate the issue.

The high cost of menstrual management products leads to gender inequity. Girls with low socioeconomic status often rely on homemade, lower-quality dressings, owing to a scarcity of resources. When food or clothing drives are organized, or aid bags are given by the State, menstrual hygiene products should be included. Access to menstrual hygiene supplies such as sanitary towels or tampons should be provided in public restrooms.

Taxation of menstrual hygiene supplies creates a uniquely gendered barrier for poor families. In South America, Colombia passed in 2019 the VAT exemption of sanitary towels and tampons. In Argentina, several local and nationwide bills have been introduced to consider the provision of menstrual management products forfree at public establishments such as schools, hospitals, prisons, universities, and
shelters, among others, as well as the elimination of taxes on these kinds of items.In Peru, a bill was introduced in July proposing that menstrual management
products are recognized as basic necessities.

More and more countries are now beginning to address this issue, with the backdrop of feminist organizations’ campaigns such as “Free Period” in the United Kingdom, “Menstruación libre de impuestos” in Colombia and “MenstruAcción” in Argentina. Scotland has become the first country to legislate that free sanitary products are available to anyone who needs them.

Call to action:

1. Integrate scientific, gender-sensitive health education in school curriculum.
2. Encourage appropriate management of disabling menstrual symptoms such has heavy bleeding and severe pain so that girls can stay in school and have improved quality of life.
3. Support legislation and initiatives to provide funding for basic necessities
suchas clean water and private sanitary facilities to improve menstrual hygiene among adolescents
4. Advocate for a revisiting of cultural norms to end discriminatory and stigmatizing beliefs and practices surrounding menstruation that limit female adolescents from realizing their full potential in society.

FIGIJ, 10 January 2021

This advocacy statement has been endorsed by:
FIGO (International Federation of Gynecology and Obstetrics),
RCOG (Royal College of Obstetricians and Gynaecologists), and
EBPCGO (European Board and College of Gynaecology and Obstetrics).