Sociocultural context.

Across cultures, menstruation was stigmatised, constructed as something that was ‘dirty’ or ‘impure’ and shrouded in silence. Menstrual stigma was a pervasive influence on women and girls. It meant that menstrual topics were not openly discussed, making it difficult to access accurate information or seek support. Negative attitudes to menstruation were internalised and manifested across multiple themes represented in the model, including as self-imposed expectations to keep menstrual status hidden, and shame and distress at the potential of having menses exposed.

Restrictive gender norms also underlay the knowledge, behavioural expectations, and social support that influenced experiences of menstruation. Expectations of female propriety and the roles of women and girls over the life course as daughters, wives, and mothers restricted resource access and proscribed care-giving tasks and movement outside the home, interacting with more immediate contributors to menstrual experience.

Proximal antecedents of menstrual experience of knowledge, social support, and behavioural expectations are described below, with supporting quotations presented in Box 1 and contributing citations highlighted in Table 3.

Knowledge.

All studies reported an influence of knowledge about menstruation on women’s and girls’ experiences. Multiple domains of knowledge were discussed across studies, including the basic biology of menstruation, reproduction and the links between menstruation and pregnancy, practical management of menses and pain, and interpreting the accuracy of local taboos around menstruation.

Many authors stated that most of their study population had deficits in knowledge of menstrual biology [37, 44, 47, 55, 57, 68, 69, 71, 73, 77, 83], with some noting that only healthcare providers and biology teachers had a comprehensive understanding [95, 100]. In some studies, knowledge was more varied, with those who had attended secondary education or schools with more comprehensive reproductive health education having adequate knowledge [62–64, 83]. Knowledge deficits varied in content. In some studies, younger girls were unaware of their reproductive organs and that menstrual bleeding originated from this system, rather than elsewhere such as the digestive tract [9, 41]. In others, girls’ post menarche and older women linked menstruation with reproduction but had other lingering questions such as why menstrual bleeding occurred [11, 15, 44, 72, 73] or whether it was needed to rid the body of ‘dirty blood’ [10, 14, 34, 71, 72, 77, 84]. Near universally across studies, women and girls recalled experiences of intense distress and confusion if they were unaware of menstruation at menarche, with many participants reporting they thought they were sick or dying. In contrast, girls who had received information before menarche described more positive experiences. Where investigated, women and girls also lacked clarity on what constituted normal and abnormal (i.e., disordered) menstruation [47, 73, 85, 105, 109].

Even when aware of menstruation, participants often had insufficient information to understand the relationship between menstruation and reproduction. At menarche, many girls were told they were now fertile and to avoid males; however, this information was often provided without clarifying how or when girls were vulnerable to pregnancy [9, 32, 41, 58, 59, 64, 77, 84, 88]. Beliefs that menarche indicated sexual initiation prompted girls to hide their status for fear of punishment, reported in studies from Ethiopia [89, 100], Ghana [88], and Mali [95].

Girls expressed a strong desire for more practical information, including managing menses or pain relief [3, 8, 41, 57, 72, 73, 83, 88, 89, 93, 95, 103]. Practical knowledge about menstruation influenced the practices undertaken as well as individuals’ perceptions of their practices, with a lack of clarity around what was required for ‘hygiene’ causing concern.

Deficits in knowledge created confusion around the accuracy of cultural restrictions and taboos, creating distress and impacting confidence. Girls in many studies sought clarity on the accuracy of taboos such as appropriate foods or practices during menstruation. Several studies noted distress resulting from conflicting advice from different sources (e.g., parents, teachers, nongovernmental organisations [NGOs]) [3, 9, 44, 71, 73].

Social support.

Social support, or lack thereof, strongly dictated menstrual experiences. Parents, siblings, peers, partners, and teachers were sources of information, resources, comfort, or assistance to accomplish menstrual tasks. Manifestation of mother–daughter communication was context dependent. In many settings, mothers served as the primary support and source of information for girls, whereas in others such as Ghana [4], Malawi [79], South Africa [84], and Tanzania [3], they were sometimes considered culturally inappropriate, and other female relatives such as aunts or grandmothers were expected to serve in this role. However, individuals’ access to support sources often varied more according to personal circumstances than country. Partners’ perceptions of menses contributed to women’s self-conceptualisation, resource availability, and the impact of menses on daily activities.

Friends and peers were critical: in school settings, they checked for stains, accompanied others to changing facilities, or provided emergency supplies. Teasing or harassment by female, but especially male, peers was highly distressing for adolescent girls. They reported great distress at males being aware of their menstrual status and bullying behaviours such as males teasing them if their status was revealed.

Healthcare providers such as nurses or community health workers were mentioned in only a few studies, and always as unsupportive [3, 84, 87, 101, 103, 109]. In studies of those with dysmenorrhea or menstrual disorders, some participants were embarrassed to seek help. Others reported pursuing multiple avenues such as doctors and herbalists or community healers in attempts to receive effective treatment for their pain [103–105, 109].

Teachers provided mixed support to girls during menstruation. Some were sensitive to girls’ needs and provided information or support such as emergency supplies, while others were uncomfortable or punitive if girls soiled themselves at school. Girls often felt more comfortable with female teachers than male teachers, who were viewed as less understanding and presented threats of sexual advances.

Behavioural expectations.

Across studies, menstrual experience was impacted by internally and externally enforced behavioural expectations, i.e., expectations women and girls placed on themselves or those enforced by others.

Externally enforced behavioural expectations included explicit cultural or religious expectations of menstruating women as well as more implicit ideals of propriety and cleanliness placed on menstruating bodies. Explicit cultural restrictions varied across and within countries according to region, religion, caste, and individual family expectations. So too did the extent to which such restrictions directly impacted women’s and girls’ social participation. In the most severe cases, subpopulations in Nepal practiced Chhaupadi, ritual seclusion from the community and home during menstruation [36, 101]. In Zambia, Lahme and colleagues reported that participants experienced a single instance of seclusion during their first period that many girls found embarrassing and distressing [68]. In many settings, menstrual blood—and by extension, menstruating women—were considered ritually impure or polluting [10, 14, 16, 34, 37, 41, 43, 47, 60, 62–64, 68, 72, 77, 100, 101]. Such beliefs translated into restrictions on women’s behaviour, including not interacting or sitting with males; touching or cooking food; having contact with crops, livestock, or farming; or having sex. Adolescent girls reported distress at these changes to expected behaviour and fears that they would cause harm to themselves or others. In many religions, women and girls were banned from touching religious texts, praying, or entering places of worship during menstruation. Beliefs about the impurity or power of menstrual blood influenced management practices. Women and girls took steps to ensure that others could not see or access their disposed menstrual blood such as washing materials prior to disposal, eschewing single-use disposable sanitary pads, or wrapping used absorbents to prevent detection.

Other behavioural expectations stemmed from beliefs that different foods or activities would negatively impact women’s and girls’ health during menstruation. Hot or cold foods were feared to influence blood flow or clotting, and foods of various colour or flavour groups were feared to exacerbate menstrual pain, smell, acne, or cause illness.

Expectations were enforced by others, such as teachers or family, through instruction, discipline, or teasing. Family members enforcement of behavioural expectations such as religious or culturally proscribed menstrual restrictions greatly influenced the extent to which these were adhered to and thus women’s and girls’ menstrual experience. Less explicit taboos such as expectations of cleanliness, female propriety, and secrecy around menstruation were ‘enforced by adults in the community through signals and gestures’ [33]. Participants expressed fear of judgement from others should they fail to comply.

Women and girls internalised menstrual restrictions and stigma and sought to regulate their behaviour accordingly. This impacted confidence to engage in other activities during menstruation and added to experiences of shame because a failure to hide menses was viewed as a personal failure to maintain feminine standards or menstrual etiquette.

Physical environment.

Many studies focused on the relationships between menstruation and infrastructure, in particular, water and sanitation facilities. Women and girls reported requiring spaces to undertake a range of menstrual tasks, including changing menstrual materials, washing and drying menstrual materials, and cleaning their hands and bodies. Such spaces were often unavailable or poorly supported female needs.

Availability and characteristics of sanitation facilities and infrastructure varied across the locations frequented by participants, such as home, school, work, or public areas. Available facilities shaped experiences. An absence of sanitation facilities or safe spaces outside the home meant managing menstruation in these locations was more challenging, reducing confidence to travel outside the home and increasing distress and fear of shame. Characteristics of the infrastructure such as the distance to or availability of soap and water, as well as the presence of locks or lights, influenced the menstrual practices that could safely be undertaken. The availability of a bin or incinerators or community waste disposal or the use of pit latrines influenced disposal choices. There were mixed perspectives on disposal options. For women and girls, the priority was perceived privacy, with concerns that materials would attract pests. Teachers and authors expressed concerns about blockages to sanitation systems.

The way that women and girls perceived the available environments for menstrual management was an integral part of their experience, expanded upon below. This represented a combination of what was available with personal needs and expectations for cleanliness, privacy, and ‘appropriate’ behaviours. In schools, gender-separate latrines and locks on doors were frequently discussed as compromising privacy, as was a lack of water to wash hands and remove evidence of menstrual blood from latrines.

Environmental considerations were noted in studies across varied geographies. Wet seasons and weather presented challenges for thoroughly and discretely drying reusable menstrual materials [16, 79]. Water scarcity altered behaviours where this resource was limited and was therefore conserved during washing absorbents or cleaning blood from hands or latrines [88, 89, 100]. Two studies undertaken in a cold climates found that latrines were too cold to be used during winter months [35, 77].

Economic environment.

Lack of funds to purchase menstrual items or pain relief, and lack of affordable cloth or commercial menstrual products, was a frequent study finding. Many women and girls struggled to afford their choice of material, some studies noting that the household frequently lacked money for basic necessities and that commercial sanitary pads were considered an unaffordable luxury [5, 10, 15, 41, 43, 51, 64, 68]. Adolescent girls in poor households noted that requesting money for menstrual needs could cause friction in the household [10, 11]. Girls regularly undertook paid employment to generate funds. Two studies from Kenya and one in Ghana noted concerns that girls engaged in transactional sex to meet menstrual and other personal funding needs [4, 11, 64]; authors of a study in Ethiopia noted that this was not reported in their population [100]. In some studies, authors noted that teachers and NGOs provided menstrual materials, but that this was unreliable [44, 58]. Similarly, in humanitarian contexts, participants expressed that material provision was inconsistent [15, 35, 83]. Stock shortages and inflated pricing of menstrual products due to remote locations, retailer mark-up, and taxes were noted in some studies [5, 62, 63, 104]. In humanitarian contexts, changed access to materials was salient in women’s experiences as they adapted to new management practices or were unable continue their past preferred behaviours [40, 83].

Menstrual practices.

The behaviours undertaken to manage menstrual bleeding were a central component of the experiences reported. While studies differed in the extent to which they explored these practices, together they provided a comprehensive picture of the range of practices women and girls undertake to manage menses (S2 Table). These included accessing and using materials to absorb menses, changing materials and disposing of them, washing hands before or after changing materials, washing genitals, and washing and drying reusable materials. Transportation of clean and used materials, as well as their storage between menses, were highlighted in a smaller number of studies. Practices were strongly linked to participants’ experiences of physical health symptoms, with suggestions that unhygienic practices directly cause irritation and infection [9–11, 41, 44, 51, 56, 68, 72, 75]. Participants frequently interpreted genital irritation as resulting from properties of their menstrual materials. Many studies highlighted inadequate access to preferred, comfortable materials to absorb menses as problematic. The materials used, and the resources to undertake menstrual practices such as washing hands, were associated with women’s and girls’ levels of confidence to manage menstruation and their confidence to engage in other activities.

Perception of practices and environments.

A critical distinction emerged between reported menstrual practices and women’s and girls’ perceptions of them, i.e., if women were able to use their preferred practices and if these were perceived as reliable and comfortable (S2 Table). Perceptions were heavily influenced by women’s and girls’ understanding of menstruation and their internalised expectations of optimal practices. Similarly, while the physical environment impacted on menstrual experience, perceptions of the environments’ cleanliness, privacy, and safety were an integral component of experience. The stigmatised nature of menstruation, taboos against the visibility of menstrual blood, and threat of sexual advances or teasing by males all contributed to women’s and girls’ perceptions of the adequacy of different environments. For example, in some cultures, even if disposal bins were available within latrines, taboos around others seeing menstrual blood meant that these were perceived as inadequate because they left women and girls feeling vulnerable to embarrassment or physical harm through witchcraft [14, 72, 84].

Participants described different levels of satisfaction with the same practices or environments. In some studies, this manifested in generational tensions between mothers and daughters, where mothers felt that daughters already had greater access to materials or knowledge than they had experienced [5, 97]. In humanitarian contexts, maintaining expected standards of cleanliness and menstrual etiquette was challenged when practices and environments had changed [35, 40]. Perceptions reflected an interaction between resources and behavioural expectations and were often more salient to confidence, shame, and psychological, and social consequences than the menstrual practices themselves.

Containment.

Containment was fundamental to participants across populations and included leakage, keeping materials in place, and minimising detectable odour. Authors conceptualised containment challenges differently, with some viewing soiling or odour as failures of resources to meet females’ basic needs causing frustration, while others viewed concerns about visible menstrual blood as symptoms of the stigmatised nature of menstruation and enforced need for concealment. Direct quotations from participants supported both discourses. They expressed fear at stigma or bullying invoked by revealed menstrual status; at the same time, they expressed frustration at the need to clean limited supplies of cloths or linens or at the experience of odour. Similarly, cloths falling out of underwear was viewed as both embarrassing and a frustrating restriction of activities. The now-dirty materials needed to be cleaned and re-affixed. Internalised expectations of menstrual etiquette, keeping clean and discrete, meant that failures to contain menstrual blood or odour were viewed as personal failings imbued with embarrassment and distress.

Confidence.

Women and girls reported varying levels of assurance that they were able to manage their menstruation and could undertake other activities during menstruation. These closely related subthemes were a salient part of menstrual experience. In our integrated scheme, this is titled as confidence but includes concepts of self-efficacy and perceived agency.

Women’s and girls’ confidence that they could execute the necessary tasks to manage their menses pervaded reports of menstrual experiences although was rarely identified by authors as an independent theme. Reading across studies, authors consistently noted improved confidence to manage menstruation when participants had access to preferred materials and environments, greater knowledge, and access to social support [10, 15, 34, 38, 41, 51, 56, 58, 64, 70, 72, 75, 79, 84, 95, 103, 104]. One study identified and defined this construct as menstrual self-efficacy [51]. Studies with greater interpretive depth noted that a lack of confidence to manage menses influenced how women and girls perceived themselves and their bodies, internalising a sense that ‘their bodies are beyond their control’ [5, 16, 47]. Conversely, greater confidence positively impacted outcomes.

Throughout studies, authors also reported varied levels of confidence to engage in other activities while menstruating. This was influenced by women’s and girls’ confidence that they could manage menstruation and past experiences of failed containment, as well as by the support available. In some studies, this confidence was expressed as women’s and girls’ sense of ‘freedom’ or empowerment during menstruation, that they could freely participate in social activities or travel outside the home without preoccupation with their menstruation [10, 43, 44]. Confidence to undertake other activities during menstruation was frequently the mechanism through which poorly perceived menstrual practices and shame translated into impacts on social participation and well-being.

Shame and distress.

Across settings and studies, menstruation was overwhelmingly associated with feelings of shame and distress. Internalised menstrual stigma and expectations of silence on the topic resulted in negative attitudes and intense fears of shame should menstrual status be exposed. In most studies, some participants reported experiences of intense distress recalling incidents when menstrual status was revealed. Distress—including worry and fear—associated with menstruation were highlighted by authors as significant burdens in the lives of women and girls and as indicative of the need for more attention to the topic [3, 10, 11, 16, 40, 43, 44, 51, 68, 72, 81, 83, 84, 88, 90].

In some studies, authors noted that participants, typically a small minority, expressed a positive sentiment regarding their menstruation as affirmation of their womanhood and fertility [5, 8, 32, 43, 47, 51, 52, 55, 60, 71, 78, 85, 109]. For these women and girls, menstruation was viewed as a healthy bodily function, and the stress of management was tempered by pride in being a woman and the potential of joy of motherhood.

Individual menstrual factors.

Physical symptoms during menstruation—particularly menstrual pain such as cramping of the abdomen, back, and legs—was a prominent part of women’s and girls’ experiences. Participants also reported fatigue, headache, nausea, vomiting, breast tenderness, skin blemishing, and irritability. Menstrual symptoms and the presence of abnormalities or disorders moderated individuals’ experiences, exacerbating shame and reducing confidence if participants felt that their experience was abnormal and making it more difficult to conceal menses. Pain directly restricted school, work, and social participation. In some studies, girls expressed a desire for a safe place to rest at school to manage menstrual cramping [8, 88]. Awareness of, and access to, pain relief methods varied. In some studies, participants reported used strategies such as paracetamol or local herbal remedies, hot water, or rest to combat menstrual pain. Individual menstrual variations, such as the extent of bleeding, influenced perceptions of adequate practices and environments. Despite being the focus of very few studies, antecedents of menstrual experience, including knowledge, social support, behavioural expectations, and the resource environment, were all relevant to managing pain and other symptoms [103–109]. Few women accessed healthcare, and the economic environment restricted access to pharmaceutical pain relief. In 3 studies, authors reported myths that pharmaceutical pain relief would result in health detriments or infertility [62, 70, 79].

Physical health.

Women and girls reported genital discomfort, irritation, rashes, and bruising during menses stemming from the properties of menstrual materials or inadequate frequency of change [9–11, 15, 37, 41, 44, 51, 56, 57, 68, 69, 72, 75]. Authors linked these reports to reproductive tract infections, supported by key informants such as healthcare providers. In many settings, participants emphasised the importance of ‘keeping clean’ during menstruation to prevent disease and were anxious to maintain this standard. However, beliefs about the practices required for cleanliness or the associated health consequences varied. In some settings, women and girls expressed a need to wash genitals many times per day to maintain hygiene, while in others, washing during menstruation was thought to impact blood flow. In some studies, authors reported a mix of experiences of symptoms such as irritation, as well as participants’ perceived health risks. Participants reported fears of infertility or cancer resulting from unhygienic menstrual management [11, 44, 97]. In others, women and girls were concerned that they could contract genital infections or viruses from using unclean sanitation facilities [16, 56, 81, 84]. Authors identified health impacts resulting from adherence to taboos such as dietary restrictions on the consumption of common foods, linked to fatigue, or withholding urination for fear of others observing menstrual blood in latrines [16, 41, 56, 57].

Psychological health.

Reading within and across studies, our integrated model separated the negative menstrual experiences of poor confidence to manage menstrual bleeding or shame and distress associated with menstruation, from the impacts of this experience on broader psychosocial well-being and mental health, i.e., impacts on anxiety, depression, and well-being beyond the immediate menstrual experience. Studies noted the potential for negative menstrual experiences to have broader psychological impacts [9, 10, 43, 44, 47, 68, 89, 93, 107]. Authors noted the erosion of self-esteem due to menstrual experiences, the contribution of stress during menstruation to anxiety, and depression linked to reduced social participation or experiences of stigma. Studies of those with menstrual disorders highlighted feelings of powerlessness in addressing dysmenorrhea or associated symptoms that may negatively impact psychological outcomes for these individuals [60, 103–105].

Education and employment.

Many studies that focused on girls of school age reported consequences for education [3–5, 8–11, 15, 37, 39, 41, 44, 51, 56–59, 62–64, 67–70, 72, 75, 77, 79, 85, 87–89, 91, 93, 94, 100, 101, 104, 106, 107]. Some highlighted full- or part-day absences, and others detailed disengagement from class when girls were present. Reduced participation was triangulated with reports from teachers. Multiple aspects of menstrual experience contributed. Poorly perceived menstrual practices such as unreliable absorbents that girls felt were liable to leak or expose odour reduced attendance and engagement [8, 9, 11, 37, 39, 41, 56–59, 64, 68, 69, 72, 75, 79, 80, 85, 91, 93, 94, 100, 101]. Girls lacking knowledge and confidence to manage menstruation were reluctant to be around others [3–5, 8, 39, 70, 75, 77, 89]. Unsupportive infrastructure was problematic. In many schools, girls reported that they had no adequate location to change absorbents, feared others seeing menstrual blood in latrines, or lacked facilities to dispose or clean absorbents [4, 5, 9, 10, 15, 41, 51, 56–58, 64, 70, 72, 74, 79, 87, 88]. This meant travelling home to change menstrual materials, often resulting in part-day absences. Menstrual pain made school attendance challenging. Some studies reported that teachers would send girls home from school, or punish them, if they detected odour or soiled outer garments, directly linking enforced behavioural expectations to education [41, 43, 81]. Where menstrual restrictions forbade girls from travelling outside the home or being around males, these also directly impacted school attendance.

Fewer studies attended to the experiences of adult women, and most explored sanitation infrastructure and menstrual experiences at home rather than at work. Some studies linked social exclusion, restriction of travel, and infrastructure deficits to impacts on formal or informal employment [39, 62, 63, 98].

Social participation.

Women and girls reported altering movement and participation outside the household during menses, as well as restricting activities such as running or playing sports [9, 14, 15, 35, 36, 38, 41, 43, 44, 47, 51, 59, 62–64, 70, 74, 77, 85, 97, 98, 100, 103–105, 107, 109]. Many motivations echoed those restricting school attendance, with women and girls experiencing pain or afraid their menstrual status would be exposed, that others would detect odour, or that menstrual materials or blood would fall out of place. Behavioural expectations in many settings also restricted interactions with males, food preparation, or participation in religious gatherings or activities. As noted above, women expressed varied adherence to and frustrations with explicit restrictions on activities during menstruation, some appreciating rest and others disliking being excluded. Some restrictions were interconnected with expectations of propriety placed upon girls as they sexually matured, to protect from sexual advances, as they could now become pregnant.