Menstrual health - knowledge, experiences and practices among medical students: a cross sectional study

INTRODUCTION

Menstrual health plays a vital role among females, especially of women in the reproductive age group relevant to all sustainable developmental goals (SGDs), which aim towards universal access to adequate, equitable sanitation, hygiene and the impact of stigma, shame and stress around menstruation for all.¹ Healthy menstrual hygiene management (MHM) includes the usage of safe materials to adsorb or collect menstrual blood that can be changed as frequently as required and in privacy, cleaning private parts with soap and water, and enabling access to facilities for the safe disposal of the materials used for menstrual management.^2,3

Menstruation is considered as a taboo to speak about, thus its social barrier in inculcating hygienic practices in many developing countries, including India. Thus, menstrual hygiene is a noteworthy public health issue that is associated with toxic shock syndrome, reproductive tract infections (RTI), other vaginal diseases, human rights, social justice, and the education of girls, which are imperative for achieving gender equality.^4,5

The environmental impact of menstrual products and awareness regarding menstrual waste disposal which is non-biodegradable in nature is less likely to be addressed in low and middle income countries.^6-8 The problem is attenuated not only from lack of options for disposal but also from myths, misconceptions and stigma associated with menstrual waste, leaving poor outcomes for future generations. Understanding the menstrual hygiene practices and knowledge of the undergraduates will provide an insight into the current MHM practices. With this background, the study was done with the following objectives: to assess the knowledge, experiences and hygienic practices related to menstrual health among female medical undergraduate students in SUIMS, Shivamogga; and also to assess the knowledge regarding the environmental impact of menstrual products used by the undergraduate students.

METHODS

A cross-sectional study was conducted from 01 July to 05 August 2023 among undergraduate female students at Subbaiah Institute of Medical Sciences (SUIMS), Shivamogga, Karnataka.

All the 317 female students from 1^st to 3^rd year MBBS were included in the study by convenient sampling technique. The estimated sample size for the study was 320, based on 3% prevalence of menstrual cup usage, an allowable error of 2% and 10% non-response rate.⁶

Inclusion criteria

Female undergraduate students present on the day of data collection were included.

Exclusion criteria

Those who were not willing to participate were excluded.

The students were approached after the class hours by obtaining permissions from college authorities’, the data was collected from a pre-designed, pretested, structured, self-administered anonymous questionnaire via Google Forms. The purpose of the study was explained to the students present on the day of collection and those who gave consent were included in the study.

The questionnaire addressed various areas like socio-demographic profiles, age of menarche, issues related to the first menstrual cycle, menstrual symptoms, health-seeking behaviour, menstrual hygiene practices, menstrual products, and knowledge of the environmental and economic impact of these products. Informed consent was obtained from participants, and confidentiality was assured. The study was approved by the institutional ethical committee, with reference number IEC-SUIMS/01/2024-25.

Statistical analysis

The collected data were compiled in Microsoft excel and analyzed using statistical package for the social sciences (SPSS) version 20.0. Categorical variables were presented as frequencies and percentages, while quantitative variables were expressed as mean and standard deviation. The chi-square test was employed to determine statistical significance, with a p value of <0.05 considered significant.

RESULTS

Socio-demographic profile

This study presents important insights into menstrual hygiene practices and attitudes among medical students. 290 (91.48%) students among 317 female students from 1^st, 2^nd and 3^rd year responded to the survey. Among the surveyed students 242 (83.4%) are residing in the hostel, 199 (68.6%) come from urban areas, 217 (75%) of fathers and 179 (61%) of mothers are graduates (Table 1).

The average age of the students was 20.46±1.35 years and age of menarche was 13.25±1.302 years. 124 (42.8%) students reported avoiding college during menstruation and 275 (94.8%) are willing to seek help from healthcare providers for menstrual issues.

Out of 270 girls, 93% received menstrual education before their first menstrual cycle. Of these, 61.4% received information from their mothers, 48.3% from secondary school, and 24.1% from friends. When they experienced their first menstrual cycle, 83.4% of the girls shared their experiences with their mothers, and 93.4% used disposable sanitary pads. Moreover, 74.5% of the girls followed some form of sociocultural restrictions during their first menstrual cycle, with 61% of them experiencing school absenteeism as a result (Table 2).

In their last menstrual cycle, most women (90.3%) used disposable sanitary pads, while a smaller proportion (7.9%) used reusable menstrual products such as menstrual cups, period underwear, and reusable sanitary pads. When disposing of used sanitary products, a significant number (58.6%) wrapped them in plastic paper provided with the pad, whereas a smaller proportion (34%) used paper or cloth to wrap them before disposal. The majority (92.4%) of women disposed of their sanitary products along with household trash. During their heavy flow days, many women (72.7%) changed their menstrual products 3-4 times a day. In terms of handwashing practices, 57.6% of women washed their hands before changing their menstrual products, and an even higher percentage (97.6%) washed their hands after changing them (Table 3).

The adequate knowledge among the medical students regarding the time taken for decomposition of the sanitary pad (>500 years) was 22.8%, waste generated by women per year (60 kg) was 27.6%, and average money spent on menstrual products per month was rupees 100-300 in 36.2% of students. However, only around 13.1% of the students knew that the silicon menstrual cup can be used for 5-6 years (Table 4).

Impact of socioeconomic factors

Mother’s education, place of residence, and income levels did not significantly (p>0.05) influence knowledge (including environmental and economic implications), practices, menstrual problems or health-seeking behavior among the students.

This study highlights areas for potential improvement in menstrual hygiene education, particularly around the use of soap for washing, proper disposal methods and encouraging students to seek help for menstrual issues.

DISCUSSION

Women spend approximately 7-8 years of their lives menstruating, making menstrual issues a significant concern, especially for adolescents and young adult females. The mean age of menarche in our study was 13.25±1.3 years, closely aligning with findings from various other studies conducted across different populations in India.^9-11

In our study, nearly 93% of participants were aware of menstruation before experiencing menarche, consistent with the study by Bushra et al. However, our participants demonstrated a higher level of pre-menarcheal knowledge, compared to medical students surveyed from other regions in the country, where awareness ranged from 56.92% to 84.24%.^9,11-13 Majority of our participants 90.3%used disposable sanitary pads, with only 8% opting for reusable menstrual products like menstrual cups, period underwear, and reusable sanitary pads, consistent with findings from other studies across India.^9-13 This suggests an improved awareness among girls about menstruation, as an impact of MHM program.

Premenstrual symptoms such as mood swings (61.7%), low back pain (58.6%), and acne (53.1%) reported by our participants were similar to those observed in studies by Bushra et al and Mohapatra et al.^10,11 During menstruation, 82% experienced low back pain, 33% reported dysmenorrhea, and 42% missed work or college, findings that align with various other studies.

The rising prevalence of dysmenorrhea in the recent past among adolescent girls and young women, has been linked to changes in lifestyle, including diet, sleep patterns, and increased stress levels.^14-17 Given that 94% of students expressed a willingness to seek help from healthcare providers, providing counseling, identifying those with severe dysmenorrhea and providing appropriate treatment would be a step towards improving MHM. However, the focus has shifted towards providing menstrual leaves for women in higher educational institutes and work places. Additionally, the menstrual leave policy may become a barrier towards women empowerment and limit their socially and economically productive roles in society.

The frequency of changing menstrual products was satisfactory, with 196 (67.5%) participants changing them every 6-8 hours on heavy flow days, a practice comparable to the findings of Sharma et al and Patel et al and better than that reported by Bushra et al.^9,10,12

However, a study by Pokle revealed that 56.69% of participants changed pads two times or less per day, a concern echoed in our study, where 21.2% of participants reported similar practices. Prolonged use of sanitary pads can be harmful, potentially emitting carcinogens, being bacteriologic ally unsafe, and altering the pH of the female reproductive tract.¹⁸

Menstrual hygiene practices during cycles, including hand washing and genital washing, were found to be lacking among our participants. Only 57.6% washed their hands before changing menstrual pads, among them 82.7% either used soap only sometimes or never at all for hand washing and 15.8% washed their genitals less than two times per day. However, hand washing practices after changing pads were better, with 97.6% following the practice, and 84.1% washing their genitals more than twice a day.^9,10,12,13 Given the variations in hand washing and genital washing practices observed in various studies, MHM sensitization programs need to address these areas and ensure an enabling environment with soap, water, and adequate privacy.

Menstrual products should be disposed of in a manner that minimizes environmental pollution. In our study 58.6% of participants wrapped sanitary pads in the plastic provided with the pad, and 92.4% disposed of them with household rubbish. Similar disposal practices have been observed in studies across middle- and low-income countries, underscoring the need for regulated sanitary pad disposal methods, such as wrapping in paper, separate disposal, and the establishment of incinerators, particularly in hostels and establishments with large groups of reproductive-age women.^8,13,19,20

Knowledge about the degradation of sanitary pads, the amount of waste generated per menstrual cycle from disposable pads, and the reusability of menstrual cups was found to be grossly inadequate among 80% of participants. With only 8% of women using reusable menstrual products, and nearly half spending between Rs 3,600/- to Rs 6,000/- annually on menstrual products, there is a pressing need to raise awareness about the health, economic, and environmental benefits of switching to sustainable menstrual products as part of MHM education for all women of reproductive age rather than just emphasizing on usage of sanitary pads.

Limitations

The reasons for inadequate hand hygienic practices and improper disposal of sanitary pads would have been included in the study.

CONCLUSION

The study highlights several key aspects of menstrual health and hygiene management among young female students as it the most neglected health related issue. While awareness of menstruation before menarche is relatively high, and most students use disposable sanitary pads, there remain significant gaps in knowledge and practices related to menstrual hygiene. Issues such as inadequate hand washing, improper disposal of menstrual products, and insufficient use of reusable menstrual products point to the need for enhanced education and resources. Additionally, the rising prevalence of dysmenorrhea and other menstrual-related problems emphasizes the importance of extending the scope of MHM to improve access to health care contributing to their overall well-being and academic success, rather move towards menstrual leave policy.

Recommendations

Integration of comprehensive menstrual health education into the school curriculum and community based education focusing on hygiene practices, the benefits of reusable products, and the environmental impact of disposable sanitary pads is need of the hour. Institutions should ensure that girls and young women should have access to clean, private facilities with adequate supplies of soap and water. Schools and colleges should offer regular counseling sessions on menstrual health, focusing on the management of dysmenorrhea and other menstrual-related issues.

Relevance to preventive medicine

Menstrual health awareness programs in schools and communities should go beyond merely addressing menstrual symptoms and the use of sanitary pads.

They should also focus on remedies for menstrual issues, promote the use of reusable menstrual products, and educate about the environmental impact of disposal methods. Additionally, these programs should also address the hygienic practices, cultural rituals, seeking medical care, and tackling the stigma and taboos surrounding menstruation. Ensuring access to privacy, soap, and water is also crucial.

The introduction of menstrual leave policies to address painful menstruation requires thorough examination and consultation with all relevant stakeholders, including healthcare professionals, lawmakers, students, educators, employers, governments, and women's empowerment NGOs. Such policies must be carefully considered, as they may impact women's participation in society.

Implications for clinical practice

Premenstrual symptoms (PMS) and dysmenorrhea should be addressed at all levels of healthcare by providing appropriate management and support. This approach will help prevent the loss of women's participation in various societal activities and improve their overall quality of life.

ACKNOWLEDGEMENTS

Authors would like to thank Dean and Management of Subbaiah Institute of Medical Sciences (SUIMS), Shivamogga.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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