Women and Menstruation in the EU

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A personal issue with societal significance

Menstruation is a natural part of women’s lives and signals good reproductive health.  However, many women are affected by menstrual symptoms—heavy bleeding and pain are the most common reasons for seeking help.  An estimated 20% of women suffer pain severe enough to interfere with daily activities (dysmenorrhea), and one in four experience heavy menstrual bleeding.[i] [ii] Strategies used by women to manage these conditions have societal as well as individual impacts, but to date, menstrual matters have been noticeably absent from public discussion and policy.

The basics

Menstruation is the discharge of blood and tissue that occurs as part of a woman’s menstrual cycle  On average, it lasts for three to five days within a 28-day cycle.  However, menstruation varying in length from between two and seven days within a cycle of 21 to 35 days is also considered normal.  Menstruation is part of a women’s life for around forty years, commencing at menarche (first menstruation) and concluding at menopause and directly affects around 130 million women in Europe.[iii]  The number of menstrual cycles experienced by women in Europe is increasing due to several factors, including early menarche and fewer years spent pregnant as well as breastfeeding.

The average blood loss during menstruation is 30-40ml; heavy menstrual bleeding (HMB) is defined as blood loss of 80ml or more per cycle.  HMB can be caused by abnormal blood clotting, disruption of normal hormonal regulation or other disorders, such as fibroids, polyps, endometriosis and adenomyosis.  It can cause health issues, including as anaemia and fatigue. Heavy flow is more common in adolescence, perimenopause and in those of any age with high oestrogen levels and ovulatory disturbances.[iv]

Dysmenorrhea is defined as the presence of crampy pelvic pain beginning shortly before or at the onset of menstruation and lasts one to three days. Primary dysmenorrhea (PD) is menstrual pain experienced by women with normal pelvic anatomy and is most common amongst young women.  Secondary dysmenorrhea is associated with underlying pathology in the reproductive system, including endometriosis, adenomyosis and uterine fibroids. Risk factors associated with PD, include earlier age at menarche, heavy menstrual flow, smoking, family history of dysmenorrhea, obesity, and alcohol consumption.[v]

Impacts on daily activities

Women use a variety of coping mechanisms to manage HMB and dysmenorrhea; for many women this includes reducing and restricting daily activities.

Severe menstrual pain can have a significant impact on academic and employment participation.  Studies show that about 30-50% of young women miss school or work at least once per cycle due to PD.  Even when school or work is attended, the presence of pain can affect concentration leading to poor performance and productivity.  PD can also reduce participation in other daily activities; women with PD are less likely to engage in voluntary physical activity, including sports as well as social and recreational pursuits.[vi] [vii]

Women with heavy menstrual blood loss experience similar restrictions. Fatigue associated with untreated or prolonged bleeding as well as practical issues around managing heavy blood loss can adversely affect work, social activities and sports participation.[viii] [ix]

Some studies look beyond a single menstrual disorder to consider the broader experience of menstruation—severe menstrual pain with HMB has a more significant impact across all aspects of women’s lives than HMB or dysmenorrhea alone.[x

In addition to severity of symptoms, a range of social factors influence the extent to which menstrual disorders impact everyday life, including employment status, type of work, extent of domestic responsibilities and level of support.  Moreover, individual personality and coping strategies influence how women perceive and manage the menstrual process.  Menstruation can be viewed as a positive and natural part of life, but also as bothersome and related to negative feelings.[xi]

Costs of restricting activities

Reducing and adapting daily activities during menstruation can adversely affect quality of life for individuals and can impact the wider social and economic environment.

Women who experience adverse menstrual symptoms report having a significantly lower quality of life than the general female population.[xii]  Studies show that HMB and dysmenorrhea that disrupt the usual routine is perceived as having a major impact on quality of life.[xiii] [xiv]

The effects of lost productivity and academic achievement extend beyond individual costs.  Workplaces incur significant costs from reported rates of absenteeism and reduced performance due to menstrual symptoms.  Absenteeism due to HMB is estimated to annually costs US$12 billion, though this may be an underestimate as the costs of presenteeism were excluded from calculations.[xv] Reduced female participation in education and the workplace is also of concern from a gender equality perspective.[xvi]

Menstrual taboo

While menstruation is not as stigmatised in Western societies as it is in some traditional cultures, it is still widely considered a taboo subject. These social and cultural prejudices play a central role in menstrual knowledge, attitudes and beliefs.

Menstruation is generally understood as a private and intimate matter that one should keep hidden from others, reinforcing the idea that menstruation is a secretive female process.[xvii] This belief can adversely affect women’s mental and emotional health; societal rules requiring secrecy can be a source of ongoing stress, especially when factors such as heavy menstrual bleeding and severe pain impede concealment.[xviii]  In addition, women report employing coping strategies not only for their own comfort, but also to avoid appearing unreliable, particularly in the workplace where women already combat obstacles due to their sex/gender.[xix]

A culture of secrecy and shame can also restrict access to information on menstruation and menstrual problems.  Women’s perceptions of what is normal with regard to menstruation depends largely upon their understanding of it.  Adverse aspects—such as pain and heavy bleeding—may be tolerated where they are perceived to be a normal part of the menstrual cycle.  In addition, many women are unaware that treatment is available for menstrual symptoms, which has implications for their health.[xx] [xxi]

Appropriate healthcare

Culture-bound values also shape the medical management of menstrual disorders. Menstruation is frequently presented in the medical literature as a one-dimensional biological and pathological aspect of women’s health.  However, menstrual pain is a subjective experience classified by the personal meaning to the individual.   Moreover, heavy menstrual blood loss can have different impacts on women depending on their personal circumstances. A medical model approach that fails to take into account impacts on the quality of life may result in over-treatment for some women and under-treatment of others.[xxii]  Thus, patient experience should be considered in conjunction with objective measurements.[xxiii] For example, medically defined definition of HMB is 80ml or more per cycle, but this amount is commonly interpreted as excessive menstrual blood loss that interferes with quality of life.[xxiv]  In addition, the European-wide Standards for Gynaecology Services include specific standards for menstrual bleeding disorders and chronic pelvic pain that emphasise a patient-focused approach.[xxv

Menstrual health in relevant policy

Menstrual health impacts across a broad range of policy areas including education, economic activity, justice/equality and public health.  These policy areas provide opportunities for its inclusion where it has been specifically named or sufficiently addressed.

Workplace health

The goal of greater female employment across EU Member States as set out in the Europe 2020 strategy underlines the need to more effectively address health and safety issues that affect women.[xxvi]  Around two thirds of working age women are currently employed.  The majority of these women are likely to be pre-menopausal, so menstrual health is important for a significant percentage of the workforce.[xxvii]  However, the majority of occupational health research on women’s reproductive health focuses on maternity issues, so other areas, including menstrual disorders, have received little attention.[xxviii]

The debate on how menstrual health impacts the workplace has increased recently due in part to the proposal in Italy to introduce a menstrual leave policy. While such policies have been in existence in several Asian countries for many years, this would be the first EU country to enact one.  Proponents of menstrual leave compare its role to that of maternity leave and support it from a gender equity perspective.  However, it has been argued that a ‘blanket’ menstrual leave policy brands everyone who menstruates as ill and perpetuates sexism. Others argue against the introduction of a specific menstrual leave policy as it could increase the bias in hiring and promoting women.   Informal evidence indicates a high degree of support for more flexible working policies that benefit all workers; however, some argue this fails to address the stigma associated with menstrual problems.

Gender equality and women’s health

The Strategy on women’s health and wellbeing in the European Region is based on the twin objectives of gender equality and good health and wellbeing.  The Strategy acknowledges that gender is a determinant of health and identifies gender mainstreaming as a mechanism to achieve gender equity. Four priority areas for action are identified all of which are relevant for progressing action on menstrual health:

  • Strengthening governance for women’s health and well-being, with women at the centre
  • Eliminating discriminatory values, norms and practices that affect the health and well-being of girls and women
  • Tackling the impact of gender and social, economic, cultural and environmental determinants on women’s health and wellbeing
  • Improving health system responses to women’s health and well-being.[xxix]

Human rights approach to menstrual health

Inadequate access to menstrual hygiene is recognised as a violation of human rights in developing countries.  In developed countries, social activists frequently use a rights-based approach on issues such as taxation of sanitary products.  Human rights are core values that the EU promotes both within its borders and around the world and this is reflected in the Action Plan on Human Rights and Democracy 2015-2019. While menstruation is not specifically identified within this high-level plan, several action areas are relevant to the issue including:

  • Empowering civil society organisations defending the rights of women and girls and;
  • Promoting gender equality, women’s rights, empowerment and participation of women and girls.[xxx]

Similarly, the World Health Organisation’s Action Plan on Sexual and Reproductive Health has three goals relevant to the issue of menstruation:

  • Enable all people to make informed decisions about their sexual and reproductive health and ensure that their human rights are respected, protected and fulfilled.
  • Ensure that all people can enjoy the highest attainable standard of sexual and reproductive health and well-being
  • Guarantee universal access to sexual and reproductive health and eliminate inequities.[xxxi]

Data on women’s health

Despite its sizeable impact on women’s health, menstruation is not included in Data and Information on Women’s Health in the European Union. [xxxii] [xxxiii] This may be due in part to a narrow focus on reproductive health in datasets, for example fertility rates are derived solely from the number of live births as opposed to considering potential to conceive.

STEPS FOR ACTION

1. Address the silence surrounding menstruation and menstrual disorders to improve women’s health and wellbeing. 

Member States and the EU should engage and collaborate with civil society, government officials, authorities, healthcare professionals, educators, professional organisations, NGOs, patient organisations, industry and other key stakeholders to increase awareness of menstruation and menstrual disorders.  Social activism and health education have helped to reduce stigma and normalise the concept of menstruation.   However, the conversation must be changed to one of empowerment rather than shame. The menstrual cycle must be framed as an asset.  Efforts must be made to increase the understanding of how the natural monthly cycle of energy flow can be maximised in women’s personal and professional lives.  Policy makers and key stakeholders should support action that addresses menstrual disorders through efforts like the establishment of task forces to bring the conversation into schools or workplaces.    

2. Support the development of policies, programme and practice across Europe that enable women to minimise risk factors for menstrual disorders, recognise abnormal symptoms and seek healthcare at an early stage. 

Menstrual disorders are widely misunderstood.  There is a lack of population-level interventions that increase awareness and facilitate easy access to care. Policymakers and stakeholders should promote the integration of menstrual management into public health campaigns as advocated by the WHO Action Plan on Sexual and Reproductive Health.   For example, eating a balanced diet, maintaining an active lifestyle, and not smoking can significantly reduce menstrual pain for many women as well as contributing to general health and wellbeing.  Efforts should be made to integrate women’s health issues like menstruation into employment and economic policies to adequately address the issues. Member States should work together to share best practice in health, employment and socioeconomic policies to employ a holistic approach to improving women’s health and wellbeing.   

3. Empower healthcare professionals and women themselves with the necessary skills, tools and knowledge for prevention, early detection and appropriate management to improve women’s health and wellbeing and to support women both in the workplace and at home.

A narrow medical understanding of the menstrual process can serve as a barrier to appropriate care. Policymakers and stakeholders should support a broader understanding and the adoption of standards and guidelines to promote appropriate medical management of menstrual disorders. Healthcare professional education should tackle the health and socioeconomic implications of menstruation and menstrual disorders.  Women themselves should be empowered through health literacy and workplace rights efforts. 

4. Improve data collection on menstruation within and across countries in Europe, disaggregating by factors like age.

Support research on effective menstruation and menstrual disorders multi-disciplinary and multi-sectorial policy, programming and practice.  There is a lack of data on menstruation and menstrual disorders within and across the EU Member States.  Efforts must be made to improve data collection to better understand the issues and trends as well as develop and track more effective interventions.  In addition, despite the prevalence of dysmenorrhea and heavy menstrual bleeding, there are significant gaps in knowledge about the disorders. Research into menstrual health is generally considered an emerging field, as until recently it was ignored or dismissed by medical researchers. Lack of evidence makes it difficult to promote recommendations as well as failing to support affected women. Policymakers and stakeholders should support research on menstrual disorders from both ethical and equity perspectives.    

 

5. Encourage Member States to implement effective policies that reduce the burden that menstruation and menstrual disorders pose to women.

Best practice on supporting women during menstruation and with menstrual disorders should be shared across Member States. Member States should explore efforts like the abolition of tampon and pad taxes.  Intervention should be explored for women with HMB, such as funding for pads, in order reduce the fiscal and health burdens that the condition places on them.   

 

6. Support efforts that counteract menstrual discrimination in the workplace.

Given the impacts of menstrual symptoms on women’s participation in the workplace and the debate surrounding menstrual leave policies, there is an opportunity to highlight this topic and tackle the issues.  Policymakers and stakeholders should facilitate an open debate on the management of menstruation in the workplace.   

 

7. Develop a comprehensive report on women and menstruation in Europe to raise awareness and encourage European action.

Review the existing evidence base and research to compile a thorough literature review.  Examine menstruation across the lifespan, including its link to other health conditions and other inequities.  Explore the biological, physiological, social, employment and economic factors in relation to menstruation and menstrual disorders.  Highlight current challenges and give examples of best practice.  Propose concrete policy, programming and practice solutions.  Foster collaboration with relevant stakeholders.     

A special thank you to PregLem SA for an unrestricted educational grant that supported the generation of the “Women and Menstruation in the EU” policy brief.


A warm thank you to our expert reviewer:

Dr. Katrín Fjeldsted, Past President of CPME, Standing Committee of European Doctors

Authors: Peggy Maguire, Teresa Keating, Kristin Semancik and Vanessa Moore

© 2018 European Institute of Women’s Health, CLG

33 Pearse Street, Dublin 2, Ireland

Telephone: +353-1-671-5691

Email: info@eurohealth.ie

Website: https://www.eurohealth.ie


References

 

[i]                             Latthe P., Champaneria. R. Dysmenorrhoea. BMJ Clinical Evidence. 2011: 0813. 

[ii]                            Fraser, I., Mansour, D., Breymann, C. et al. Prevalence of heavy menstrual bleeding and experiences of affected women in a European patient survey.  J Gynaecol Obstet. 2015 Mar, 128(3), 196-200.

[iii]                           Eurostat. Population on 1 January 2017 by age group and sex. http://appsso.eurostat.ec.europa.eu/nui/submitViewTableAction.do Accessed 27/10/2017.

[iv]                           Hapangama, D., Bulmer, J. Pathophysiology of heavy menstrual bleeding. Women’s Health (Lond). 2016 Jan, 12(1), 3-13.

[v]                            Bernardi M., Lazzeri, L, Perelli, F. et al. Dysmenorrhea and related disorders F1000 Research 2017, 6:1645.

[vi]                           De Sanctis, V., Soliman, A., Bernasconi, S. et al. Primary Dysmenorrhea in Adolescents: Prevalence, Impact and Recent Knowledge. Paediatric Endocrinology Reviews. 2015, 13(2), 465-73.

[vii]                          Iacovides, S., Avidon, I., Baker, F. What we know about primary dysmenorrhea today: a critical review. Human Reproduction Update.2015, 21(6), 762–78.

[viii]                         Liu, Z., Doan, Q., Blumenthal, P. et al. A systematic review evaluating health-related quality of life, work impairment, and health-care costs and utilization in abnormal uterine bleeding. Value Health. 2007,10(3), 183–94.

[ix]                           Bitzer, J., Serrani, M., Lahav, A. Women’s attitudes towards heavy menstrual bleeding, and their impact on quality of life. Open Access Journal of Contraception 2013:4 21–28.

[x]                            Weisberg, E., McGeehan, K., Fraser, S. Effect of perceptions of menstrual blood loss and menstrual pain on women’s quality of life. The European Journal of Contraception & Reproductive Health Care. 2016, 21(6).

[xi]                           Santer M, Wyke S, Warner P. What aspects of periods are most bothersome for women reporting heavy menstrual bleeding? Community survey and qualitative study BMC women’s health. 2007,7(8).

[xii]                          Barnard, K., Frayne, S., Skinner, K. et al. Health status among women with menstrual symptoms. Journal of Women’s Health. July 2004, 12(9), 911-19. 

[xiii]                         Bitzer, J., Serrani, M., Lahav, A. Women’s attitudes towards heavy menstrual bleeding, and their impact on quality of life. Open Access Journal of Contraception. 2013, 4,21–8.

[xiv]                          Iacovides, S., Avidon, I., Baker, F. Reduced quality of life when experiencing menstrual pain in women with primary dysmenorrhea. Acta Obster Grnecol Scand. 2014 Feb, 93(2), 213-17.

[xv]                           Liu, Z., Doan, Q., Blumenthal, P. et al. A systematic review evaluating health-related quality of life, work impairment, and health-care costs and utilization in abnormal uterine bleeding. Value Health. 2007,10(3), 183–94.

[xvi]                          Brantelid, I., Nilvér, H., Alehagen, S. Menstruation during a lifespan: A qualitative study of women’s experiences. Health Care for Women International. 2014, 35(6), 600-16.

[xvii]                         Jackson, T., Falmagne, R. Women wearing white: Discourses of menstruation and the experience of menarche. Feminism & Psychology. 2013, 23(3), 379-98.

[xviii]                        O’Flynn, N. Menstrual symptoms: the importance of social factors in women’s experiences. Br J Gen Pract.2006 Dec;56(533):950-57.

[xix]                          Burbeck, R., Willig, C. The personal experience of dysmenorrhoea: An interpretative phenomenological analysis. Journal of Health Psychology.2014, 19(10), 1334- 44.

[xx]                           Bernardi M., Lazzeri, L, Perelli, F. et al. Dysmenorrhea and related disorders F1000 Research 2017, 6:1645.

[xxi]                          Wong, L. Attitudes towards dysmenorrhoea, impact and treatment seeking among adolescent girls: a rural school-based survey. Aust J Rural Health.2010, 19, 218–23.

[xxii]                         Matteson, K., Clark, A. Questioning our Questions: Do frequently asked questions adequately cover the aspects of women’s lives most affected by abnormal uterine bleeding? Opinions of women with abnormal uterine bleeding

                       participating in focus group discussions. Women Health. 2010 March; 50(2): 195–211.

[xxiii]                        Bahamondes, L., Moazzam, A. Recent advances in managing and understanding menstrual disorders. F1000 Prime Reports 2015, 7:33.

[xxiv]                        National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. Clinical guideline Published: 24 January 2007 nice.org.uk/guidance/cg44.

[xxv]                         European Board and College of Obstetrics and Gynaecology (EBCOG). Standards of care for women’s health in Europe: Gynaecology Services. 2014.

[xxvi]                        European Commission. Europe 2020 – A European strategy for smart, sustainable and inclusive growth.2010

[xxvii]                       Eurostat. Employment and activity by sex and age 2017 http://appsso.eurostat.ec.europa.eu/nui/submitViewTableAction.do  Accessed 27/10/17.

[xxviii]                      European Agency for Safety and Health at Work (OSHA). Priorities for occupational safety and health research in Europe 2013-2020. 2013.

[xxix]                        World Health Organisation (WHO). Strategy on women’s health and wellbeing in the European Region. 2016.

[xxx]                         European Commission. Action Plan on Human Rights and Democracy 2015-2019. 2015.

[xxxi]                        World Health Organisation (WHO). Action plan for sexual and reproductive health: towards achieving the 2030 Agenda for Sustainable Development in Europe – leaving no one behind. 2016.

[xxxii]                       Directorate-Generale for Health and Consumers (DG SANTE) (2009). Data and Information on Women’s Health in the European Union.

[xxxiii]                      European Community (1996) State of women’s health in the European Community. https://ec.europa.eu/health/state/publications/1996_state_women_en.