Menstrual health is a general biological marker for many cisgender women, transgender men and non-binary people. Despite more than half of the population being people who menstruate, stigma, lack of conversation and pressing social needs around menstrual health persists throughout medicine.1 Discussions around menstruation and menstrual management can be difficult for individuals, whether it is with friends or family, or in the healthcare setting.1 Patients who have never discussed menstruation with a clinician may not know what is healthy, assume that an abnormal experience is normal and may endure periods that negatively affect their life, career or well-being.2–5 Menstruation plays a vital role in overall well-being and contributes significantly to an individual’s quality of life. Given their scope of care, family medicine clinicians are poised to identify red-flag menstrual symptoms in their routine visits with patients, reducing time to diagnosis of menstrual disorders. We urge family medicine clinicians to have renewed conversations surrounding menstrual health with their patients. The purpose of this report is to supply a brief overview of the importance of menstrual communication in primary care and serve as a resource to enhance menstrual communication between patient and clinician, with the ultimate goal of decreasing menstrual stigma and promoting improved menstrual health and experiences for patients.
Menstrual health is a nuanced topic that can vary greatly from person to person and region to region. There are differences in menstrual health and wellness measures and norms between high-income countries (HIC) and low-income and middle-income countries (LMICs). This paper focuses on menstrual health in HIC specifically. This is not to say that the points described do not apply to LMIC, but to acknowledge that the topic of menstrual health in these areas is greater than the scope of this singular work.
Family medicine clinicians and menstrual health
Family medicine clinicians care for people of all ages and life stages. They are on the front lines of preventative medicine and can be a great resource for patients trying to improve their quality of life through medical and lifestyle means. By caring for people across their lifespans, family medicine clinicians are well poised to address menstrual health with patients who menstruate. They may see their patients who menstruate when they first begin menstruating in adolescence, when they become sexually active, when they are trying to become pregnant, when they are trying not to become pregnant, when their periods begin to slow at perimenopause, and at all other times in between. Family medicine clinicians are trained to provide comprehensive women’s health services and should include menstrual history as a vital sign to be addressed at routine visits.4 The scope of menstruation and menstrual wellness is expansive, with connections to family planning, sexual wellness, diet and exercise habits, and mental health.6 Patients can feel more in control of their bodies by understanding their menstrual cycle and its full-body impacts overall.1
Common menstrual concerns to discuss with patients
A discussion on exact timing of symptoms in relation to the menstrual period can help guide prompt diagnosis and treatment. Menstrual concerns may include weight changes, abdominal pain, back pain, headache, swelling and tenderness of the breasts, nausea, change in appetite, constipation, and mental health concerns including, an increase in anxiety, irritability, anger, fatigue, mood swings and heavy or painful bleeding.1 Additional concerns may be leakage, physical activity limitations, fear of toxic shock syndrome, cost of products, painful or irregularity of bleeding, adolescents worried that they have not started menstruating because their friends have or ability to get pregnant.5–7 For menstruators who identify as non-binary or transgender, menstruation can be a trigger for gender dysphoria.2 Another concern is period poverty. Period poverty, the lack of access to menstrual products, clean facilities and health education, impacts nearly one in four menstruating people at least once in their life.6–8 Menstruators may perceive heavy bleeding as normal, fear embarrassment and dismissal by clinicians who do not validate their concerns.9 Family medicine clinicians should proactively engage in these discussions by eliciting a detailed menstrual history. Family medicine clinicians can help normalise these conversations, provide reassurance regarding the common physiological symptoms of menstruation, while also addressing abnormal symptoms, and work with patients to optimise their menstrual health for their individual circumstances at various stages across the lifespan.7–9
Menstrual products
There are excellent resources available online that detail birth control options, however, there are no sites that provide the same level of detailed information about options for menstrual products. Some menstruators may only be familiar and comfortable with what they first started using when they began menstruating as an adolescent or what they were introduced to by their parent/caregiver. The choice of a menstrual product that fits best with a patient’s lifestyle can impact their quality of life.4 Products such as tampons and menstrual cups/discs might allow a patient to be more active. Cups and discs can allow for much longer wear without changing compared with tampons and pads. Period underwear allows the patient to essentially free bleed without fear of leakage. A period tracker app, though not a traditional menstrual product, can be useful for both patient and clinician to notice changes in a patient’s menstrual cycle throughout their life as well as predict when any symptoms may start regardless of whether it aligns with bleeding. Below is a table of available period products as well as some discussion points for talking to patients about each one (table 1).
Table 1
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Menstrual product overview
Conversation starters
Asking a patient when their last menstrual period was is fairly common practice to gauge regularity and risk of pregnancy. It should not be assumed that because a patient does not bring up their menstrual cycle it is not negatively affecting their life.9 For example, premenstrual dysphoric symptoms affect 75%–90% of women3–6 and are often seen as normal and something that people who menstruate just cope with. However, many of the symptoms can be treated with hormonal contraceptive options, anti-inflammatory medications or even just general counselling from a clinician. Despite this, menstrual history-taking varies among primary care clinicians and is often incomplete.3 Detailed history-taking can help assess how a patient’s menstrual cycle is affecting their life. Here are several such questions that you can ask any menstruating patient to assess whether they have any symptoms that you can help treat (table 2).
Table 2
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Menstrual health conversation starters during clinical encounters
With these simple conversation starters, it is possible to identify patients with menstrual concerns that may not have otherwise been reported. Each of these prompts could segue into an opportunity for counselling and/or medical treatment that can easily be provided and improve the patient’s quality of life. These questions can be incorporated as part of wellness visits and as needed for related problem visits. Use the International Federation of Gynecology and Obstetrics table to guide normal and abnormal menstrual symptoms to guide clinical decision-making10 (figure 1).
International Federation of Gynecology and Obstetrics (FIGO) 2018 abnormal uterine bleeding (AUB) 1 system.10
Consider having patients complete a questionnaire regarding their menstrual health as it may assist provide privacy and avoid embarrassment around this sensitive topic. Family medicine clinicians should continue to emphasise the normalcy of these issues with patients, reassure them that these conversations are appropriate and necessary and that their clinician is a readily available resource for questions surrounding all these issues.
Conclusion
Menstrual health is a vital part of primary care for menstruating patients. It is important for clinicians to have these conversations with patients. These conversations may be uncomfortable for both clinicians and patients due to societal stigma on menstruation.5 We encourage clinicians to work to fight this stigma and build strong, and long-lasting relationships with their patients so conversations can be as comfortable as possible for both parties.5 It is important to recognise, and acknowledge, that family physicians do not have a lot of time to discuss everything they would ideally like to discuss with patients during a single session. Thus, the purpose of this work is to bring heightened awareness to menstrual health in primary care. Our synthesis is simply a starting place for downstream conversation and investigation into menstrual health and wellness in clinic practice. Clinicians must be educated on normal menstruation and trained in identifying their own implicit biases, in what they perceive as ‘normal’, so they do not brush off any patient’s menstruation-related concern as normal.2 We also recognise that having access to a primary care clinician, let alone one with whom you can develop a strong relationship, is a privilege that many people do not have. Those heavily impacted by the social determinants of health are less likely to be able to have these conversations. Moreover, there are also many different cultural understandings of menstruation and menstrual care, as well as limited trust in the healthcare systems based on current and past influences of racism, sexism and the intersections that impact the physician–patient relationship.2–7 While this paper focuses on conversations in HIC between clinicians and patients, future work should examine different approaches or practices that may be needed in LMIC where topics such as menstruation-related violence and less access to information may be more prevalent. Family medicine clinicians can work closely with the communities they care for, building trust, reducing stigma and providing culturally sensitive care. We call on family medicine clinicians to bring menstrual health into the focus of primary care visits for the holistic wellness of all menstruators.
