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Menstruation: science and society

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Women’s health concerns are generally underrepresented in basic and translational research, but reproductive health in particular has been hampered by a lack of understanding of basic uterine and menstrual physiology. Hilary Critchley discusses the research gaps and opportunities in menstruation science.

Image courtesy of interviewee. April 4, 2024

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This video video discusses the importance of addressing menstruation as a taboo topic that has often led to the normalization of associated problems in society. It emphasizes the need for education about menstruation starting in schools for both girls and boys, recognizing it as a significant physiological process. The speaker highlights menstruation's impact on absenteeism in schools and workplaces, and the necessity of public resources to understand menstrual health.

Additionally, it details the physiological aspects of menstruation, including the roles of hormones such as estrogen and progesterone, and the complexities of the body's response to these hormones. It addresses the rising prevalence of issues like heavy menstrual bleeding (HMB) and uterine fibroids, which are often overlooked yet common in reproductive-age women.

This video video advocates for a multidimensional approach to menstrual health, framing it as a health and human rights issue rather than merely a hygiene issue. It calls for improving access to menstrual products, education, and healthcare, and stresses that menstrual health should be recognized globally as a priority. The speaker urges a cultural shift towards positive messaging around menstruation to combat stigma and enhance understanding, particularly in low- and middle-income countries, but also in higher-income nations. Ultimately, the text calls for more research into menstrual science to better address these vital issues.

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X-TIMESTAMP-MAP:LOCAL=00:00:00.000,MPEGTS=900000

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For far too long.

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Menstruation has remained a taboo topic.

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That means that the problems

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of menstruation are also not talked about.

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They are far too often normalized, not just

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by the individual, but by families in the workplace

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and by society.

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So I think it's well overdue that we bring attention

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to this really, really important topic.

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And we shouldn't forget that menstruation is an amazing

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and important physiological process.

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Menstruation, problems of menstruation are one

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of the reasons why time is lost from school.

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If you are a child or an adolescent

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or from the workplace, if you are an adult.

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And I think it's been recognized that we need

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to do a lot more around education.

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And this education should start early in schools.

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It should be for girls, it should be for boys.

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And I think there is a real, appetite,

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for the public to also have,

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well-informed sites they can go to,

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to learn about this natural process

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and understand what, drives it

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and what might happen when things

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with periods don't work out quite as you expect.

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And also to recognize what is normal

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and what may be out with the boundaries of normal.

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So huge amount more needed to be done on education

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and inflammation provision.

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It is the endometrium, the lining of the womb.

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That is what is bleeding.

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It is not the muscle of the uterus that is bleeding.

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It is the lining of the womb, the endometrium.

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And that is a site in the body that responds to two female

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hormones produced by the ovary, estrogen, and progesterone.

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So estrogen is the hormone

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dominant in the first half of the cycle.

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And progesterone, along with estrogen,

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but particularly progesterone,

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is the dominant hormone in the second half of the cycle.

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And that, hormone progesterone is the one

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that is important for the establishment

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and maintenance of pregnancy.

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Now, when you are not pregnant, the structure in the ovary

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that makes progesterone, that we call the corpus lutetium,

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declines it di it, you know, it, dies effectively.

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But in doing so, it means the levels

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of hormone, of progesterone circulating in the body fall.

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And it is that critical fall, the hormone progesterone,

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which is what triggers bleeding from the endometrium.

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Menstruation. And that will happen

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whenever you take hormone away from the lining of the womb.

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So when you're on the combined pill for three weeks

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and you stop it, you have a withdrawal bleed.

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'cause, 'cause you've taken hormone away.

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If you are on progestin based pills, perhaps

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to manage your periods

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and you forget one hormone is taken away

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and you can expect an unscheduled spotting a few days later.

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So it's really important that we understand that the lining

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of the womb has this really carefully coordinated exposure

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to estrogen, then estrogen

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and progesterone, progesterone withdrawal.

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And when that withdrawal happens, you trigger,

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in effect a wound.

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So the lining

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of the womb is an amazing physiological example

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of a wound that repeatedly injures and repairs each month,

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but incredibly without scarring.

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And I always use the analogy that if as a child

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or your own children, you fell on a gravel path

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and grazed your knee

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and you got a red raw surface on your kneecap, that's

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what the inside of the lining

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of the womb looks like when you menstruate.

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So it's got all the same features of an injured wound.

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You have white cells come in, you have inflammatory markers,

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sorry, mediators and products like prostaglandins.

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And that's why for four decades we've used

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nonsteroidal anti-inflammatories, which are prostaglandin

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syntase inhibitors to treat menstrual periods just

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for a few days at the time

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of menstruation can reduce menstrual blood loss.

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So it is a structure that has this,

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well coordinated both in space

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and time production of, if you like, a jigsaw

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of actions which have to come together.

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And if they come together correctly, your period will stop

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and it will last an expected, length of time.

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So it's when those pieces of the jigsaw become disordered

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or in their wrong places that we see prolongation

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of bleeding, excessive bleeding.

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Because if you're gonna stop your periods,

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you have to have three things.

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You have to constrict the blood vessels that are bleeding.

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You have to have a stoppage of bleeding,

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and you have to repair that injured surface of the wound.

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So I think this is where we have to say a huge thank you,

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first of all, faculty

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for recognizing the importance of the topic.

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But this topic would not have been written,

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written about in the article,

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highlighted if it hadn't been for the foresight

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of colleagues in 2018, in the autumn of 2018,

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in the gynecologic health

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and disease branch of the Eunice Kennedy Shriver,

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national Institute of Child Health and Human Development.

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So I needed to say a huge thank you to the colleagues there

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for convening this two two day meeting on Menstruation

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Science and Society.

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And what it aimed to do was identify gaps

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and opportunities in menstruation science

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and raise awareness of the need

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for more research in this field.

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So the, group of colleagues

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and a huge thank you to every single one of them

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who co-authored with me the article, menstruation Science

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and Society, later published in the American Journal

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of Obstetrics and Gynecology,

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because they ranged from those

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who studied the evolutionary role of menstruation to basic

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scientists working on the endometrium,

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those working in translational medicine

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and the broader societal cha challenges, those from,

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non-governmental organizations.

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So it was an incredible multi-discipline group coming

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together to talk about the same challenges, as I say,

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to identify the gaps

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and think about how we could move the field forward.

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We've also, arrived at a time, in,

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you know, history when if we looked at the experiences

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of our grandmothers

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or their predecessors,

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then menstruation was not such a common event 40 times a

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year because now, there are

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abilities to choose family size

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and couples are having fewer children, breastfeeding,

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will still be encouraged very much so,

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but may not be for quite so long.

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And so as a consequence,

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we have more periods than we did in the past.

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So instead of 40, maybe 400 a year.

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So if you're having more periods, that gives you more time

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to have more period problems.

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And we don't understand why certain associated,

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conditions,

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but also an even more common condition.

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Uterine fibroids may be present in 70%

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of reproductive age, women

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by the age of 50.

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That's a large percentage, again, under recognized.

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But both of adenomyosis

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and fibroids are commonly associated with the problems

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of heavy menstrual bleeding.

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We call it HMB

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or abnormal uterine bleeding that we refer to as a UB.

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And we will be seeing these perhaps more often or maybe

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because of the developments in, medical imaging,

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we are detecting them more often. And so

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Another gap is

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what we don't understand is if you have fibroids

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or adenomyosis

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or both, is the presence of a fibroid in the womb

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or adenomyosis in the womb exacerbating the problem

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of heavy bleeding or was the problem there all along?

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So that, that's perhaps a bit more subtle gap,

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but it's a very important gap.

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I think a third gap I'd like

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to raise is the under recognition

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and indeed the whole field is I could I,

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the three u's under recognized, under researched,

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under recognized is that if you lose a lot of blood,

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you will also lose a lot of iron and iron deficiency.

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And the then later iron deficiency anemia are

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hugely impactful.

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They're really, represented in low

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and middle income countries as well

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as high income countries.

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But what we aren't recognizing sufficiently is the links to,

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poorer pregnancy outcomes

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and perhaps even impacts on the infant and the neonate.

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So, you know, these are big gaps.

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I mean, that's maybe a extension of the brief

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of the discussion today,

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but since heavy menstrual bleeding

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is such an important cause

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of iron deficiency on iron deficiency anemia,

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I do feel we have to call that out as a gap.

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If we have these structural features in the womb

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that may be, causing an exaggerated inflammation

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or an inadequate hemostasis

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or an inadequate vasoconstriction,

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then these are areas we need to research and to help this,

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and again, I I really want to raise this

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for the community listening is how incredibly important,

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especially as we develop these huge data resources

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with all the omic studies, is that

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to understand their power, we have to have good phenotyping

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of the individuals, the patients that we study.

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And so the figo, which is the International Federation

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for Gynecology and Obstetrics

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through its first menstrual disorders committee,

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and then its menstrual disorders

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and related health impacts committee of which I will,

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declare my conflict that I have had the privilege

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of being in for many years

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and being the chair of, between 21

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and 23, that with my colleagues, Matt Monroe,

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definitely the leadership there, our late colleague,

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so, much a contributor to the field, Ian Fraser

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and myself, we've led this classification system

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to really try and help define,

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the structures in the uterus

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or the, non-structural conditions associated

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that you can't see under this figo system too.

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It's called the Palm Coin Classification.

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So palm with a coin on your hand.

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And now in teaching, for the public, for educators,

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for doctors in training, for healthcare providers,

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by having this important classification, we can begin to,

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clearly describe our patients.

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And that is the road

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or the, the, the, the gateway to being able

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to do really good science

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or really good epidemiological studies.

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'cause we will have described our populations.

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And so the gap is actually the education piece

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of encouraging researchers, those in industry

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who do clinical trials to adopt

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and use these classification systems,

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which were not just developed by a small group of people,

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but involved a process with global stakeholders across most

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of the continents of the world.

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The advocacy has been hampered by the fact that in

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so many societies there is the taboo

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as people don't talk about periods.

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So there is the education piece needed there also globally,

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26 million girls

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and women of menstruating age a displaced globally.

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And so if we don't tackle this taboo

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and break the taboos around menstruation,

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educate young people, their parents

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and communities, we will not move forward.

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And I think a strap line is,

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heavy period should be treated as a global health priority.

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This was actually used by a colleague

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of mine working very much in the field of bleeding

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and, problems with postpartum hemorrhage,

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exacerbated if women are anemic face in Roberts at the

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London School of Hygiene and Tropical Medicine.

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But the, recognition

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by WHO to call out

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that menstrual health should be recognized, framed,

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and addressed as a health

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and human rights issue, not as a hygiene issue, is one

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of the most important things that will help those in low

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and middle income countries.

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And if I can just, flag at least a couple of,

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the recommendations we need to recognize

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and frame menstruation as a health issue,

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not a hygiene issue.

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And that means addressing physical, psychological

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and social dimensions

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and to recognize the need for information, education,

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access to products, menstrual products

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and access to water, sanitation and privacy.

14:55.905 --> 15:00.005
And I think that the, term menstrual health,

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is used widely.

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And again, stakeholder groups have put together a

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very good definition.

15:06.505 --> 15:09.365
And I quote that definition, it's a state

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of complete physical, mental and social wellbeing

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and not merely the absence of disease

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or infirmity in relation to the menstrual cycle.

15:18.585 --> 15:22.805
And this other term which is very, commonly used period,

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poverty, again, defined, in the literature,

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when there is limited access to affordable, safe,

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and appropriate period projects, hygienic

15:34.005 --> 15:38.205
and private spaces to change or dispose of used products.

15:38.505 --> 15:40.525
So these, this is now becoming

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a truly societal issue.

15:44.385 --> 15:47.565
And others have said how much we need

15:47.565 --> 15:49.925
to reframe the messaging on menstruation

15:50.585 --> 15:54.605
by recognizing menstruation as a normal biological process

15:55.785 --> 16:00.005
and to recognize the unnecessary burden of menstrual stigma

16:00.945 --> 16:02.845
and work towards a much more

16:03.365 --> 16:05.325
positive messaging on menstruation.

16:05.505 --> 16:08.445
And I think if we can achieve that positive menstruation,

16:09.145 --> 16:13.925
we can enhance education, we will help,

16:14.215 --> 16:17.525
those who live in middle, low and middle income countries.

16:17.785 --> 16:21.005
But this is also needed in those higher income countries

16:21.005 --> 16:25.405
too, because too often still menstruation is normalized

16:25.405 --> 16:28.565
either by the individual or by society.

16:29.105 --> 16:31.005
And this is why we need more research

16:31.945 --> 16:33.325
on menstruation science.

00:00 - For far too long. Menstruation has remained a taboo topic. That means that the problems of menstruation are also not talked about. They are far too often normalized, not just by the individual, but by families in the workplace

00:16 - and by society. So I think it's well overdue that we bring attention to this really, really important topic. And we shouldn't forget that menstruation is an amazing and important physiological process. Menstruation, problems of menstruation are one of the reasons why time is lost from school. If you are a child or an adolescent or from the workplace, if you are an adult. And I think it's been recognized that we need

00:48 - to do a lot more around education. And this education should start early in schools. It should be for girls, it should be for boys. And I think there is a real, appetite, for the public to also have, well-informed sites they can go to, to learn about this natural process and understand what, drives it and what might happen when things with periods don't work out quite as you expect.

01:23 - And also to recognize what is normal and what may be out with the boundaries of normal. So huge amount more needed to be done on education and inflammation provision. It is the endometrium, the lining of the womb. That is what is bleeding. It is not the muscle of the uterus that is bleeding. It is the lining of the womb, the endometrium. And that is a site in the body that responds to two female hormones produced by the ovary, estrogen, and progesterone.

01:54 - So estrogen is the hormone dominant in the first half of the cycle. And progesterone, along with estrogen, but particularly progesterone, is the dominant hormone in the second half of the cycle. And that, hormone progesterone is the one that is important for the establishment and maintenance of pregnancy. Now, when you are not pregnant, the structure in the ovary that makes progesterone, that we call the corpus lutetium,

02:24 - declines it di it, you know, it, dies effectively. But in doing so, it means the levels of hormone, of progesterone circulating in the body fall. And it is that critical fall, the hormone progesterone, which is what triggers bleeding from the endometrium. Menstruation. And that will happen whenever you take hormone away from the lining of the womb. So when you're on the combined pill for three weeks and you stop it, you have a withdrawal bleed. 'cause, 'cause you've taken hormone away.

03:00 - If you are on progestin based pills, perhaps to manage your periods and you forget one hormone is taken away and you can expect an unscheduled spotting a few days later. So it's really important that we understand that the lining of the womb has this really carefully coordinated exposure to estrogen, then estrogen and progesterone, progesterone withdrawal. And when that withdrawal happens, you trigger, in effect a wound.

03:31 - So the lining of the womb is an amazing physiological example of a wound that repeatedly injures and repairs each month, but incredibly without scarring. And I always use the analogy that if as a child or your own children, you fell on a gravel path and grazed your knee and you got a red raw surface on your kneecap, that's what the inside of the lining of the womb looks like when you menstruate.

04:02 - So it's got all the same features of an injured wound. You have white cells come in, you have inflammatory markers, sorry, mediators and products like prostaglandins. And that's why for four decades we've used nonsteroidal anti-inflammatories, which are prostaglandin syntase inhibitors to treat menstrual periods just for a few days at the time of menstruation can reduce menstrual blood loss. So it is a structure that has this, well coordinated both in space

04:40 - and time production of, if you like, a jigsaw of actions which have to come together. And if they come together correctly, your period will stop and it will last an expected, length of time. So it's when those pieces of the jigsaw become disordered or in their wrong places that we see prolongation of bleeding, excessive bleeding. Because if you're gonna stop your periods, you have to have three things. You have to constrict the blood vessels that are bleeding.

05:15 - You have to have a stoppage of bleeding, and you have to repair that injured surface of the wound. So I think this is where we have to say a huge thank you, first of all, faculty for recognizing the importance of the topic. But this topic would not have been written, written about in the article, highlighted if it hadn't been for the foresight of colleagues in 2018, in the autumn of 2018, in the gynecologic health

05:48 - and disease branch of the Eunice Kennedy Shriver, national Institute of Child Health and Human Development. So I needed to say a huge thank you to the colleagues there for convening this two two day meeting on Menstruation Science and Society. And what it aimed to do was identify gaps and opportunities in menstruation science and raise awareness of the need for more research in this field. So the, group of colleagues

06:20 - and a huge thank you to every single one of them who co-authored with me the article, menstruation Science and Society, later published in the American Journal of Obstetrics and Gynecology, because they ranged from those who studied the evolutionary role of menstruation to basic scientists working on the endometrium, those working in translational medicine and the broader societal cha challenges, those from, non-governmental organizations.

06:55 - So it was an incredible multi-discipline group coming together to talk about the same challenges, as I say, to identify the gaps and think about how we could move the field forward. We've also, arrived at a time, in, you know, history when if we looked at the experiences of our grandmothers or their predecessors, then menstruation was not such a common event 40 times a year because now, there are

07:32 - abilities to choose family size and couples are having fewer children, breastfeeding, will still be encouraged very much so, but may not be for quite so long. And so as a consequence, we have more periods than we did in the past. So instead of 40, maybe 400 a year. So if you're having more periods, that gives you more time to have more period problems. And we don't understand why certain associated,

08:06 - conditions, but also an even more common condition. Uterine fibroids may be present in 70% of reproductive age, women by the age of 50. That's a large percentage, again, under recognized. But both of adenomyosis and fibroids are commonly associated with the problems of heavy menstrual bleeding. We call it HMB

08:38 - or abnormal uterine bleeding that we refer to as a UB. And we will be seeing these perhaps more often or maybe because of the developments in, medical imaging, we are detecting them more often. And so Another gap is what we don't understand is if you have fibroids or adenomyosis or both, is the presence of a fibroid in the womb or adenomyosis in the womb exacerbating the problem of heavy bleeding or was the problem there all along?

09:16 - So that, that's perhaps a bit more subtle gap, but it's a very important gap. I think a third gap I'd like to raise is the under recognition and indeed the whole field is I could I, the three u's under recognized, under researched, under recognized is that if you lose a lot of blood, you will also lose a lot of iron and iron deficiency. And the then later iron deficiency anemia are hugely impactful.

09:52 - They're really, represented in low and middle income countries as well as high income countries. But what we aren't recognizing sufficiently is the links to, poorer pregnancy outcomes and perhaps even impacts on the infant and the neonate. So, you know, these are big gaps. I mean, that's maybe a extension of the brief of the discussion today, but since heavy menstrual bleeding

10:20 - is such an important cause of iron deficiency on iron deficiency anemia, I do feel we have to call that out as a gap. If we have these structural features in the womb that may be, causing an exaggerated inflammation or an inadequate hemostasis or an inadequate vasoconstriction, then these are areas we need to research and to help this, and again, I I really want to raise this for the community listening is how incredibly important,

10:54 - especially as we develop these huge data resources with all the omic studies, is that to understand their power, we have to have good phenotyping of the individuals, the patients that we study. And so the figo, which is the International Federation for Gynecology and Obstetrics through its first menstrual disorders committee, and then its menstrual disorders and related health impacts committee of which I will, declare my conflict that I have had the privilege

11:30 - of being in for many years and being the chair of, between 21 and 23, that with my colleagues, Matt Monroe, definitely the leadership there, our late colleague, so, much a contributor to the field, Ian Fraser and myself, we've led this classification system to really try and help define, the structures in the uterus or the, non-structural conditions associated that you can't see under this figo system too.

12:07 - It's called the Palm Coin Classification. So palm with a coin on your hand. And now in teaching, for the public, for educators, for doctors in training, for healthcare providers, by having this important classification, we can begin to, clearly describe our patients. And that is the road or the, the, the, the gateway to being able to do really good science or really good epidemiological studies.

12:39 - 'cause we will have described our populations. And so the gap is actually the education piece of encouraging researchers, those in industry who do clinical trials to adopt and use these classification systems, which were not just developed by a small group of people, but involved a process with global stakeholders across most of the continents of the world. The advocacy has been hampered by the fact that in so many societies there is the taboo

13:13 - as people don't talk about periods. So there is the education piece needed there also globally, 26 million girls and women of menstruating age a displaced globally. And so if we don't tackle this taboo and break the taboos around menstruation, educate young people, their parents and communities, we will not move forward. And I think a strap line is, heavy period should be treated as a global health priority.

13:45 - This was actually used by a colleague of mine working very much in the field of bleeding and, problems with postpartum hemorrhage, exacerbated if women are anemic face in Roberts at the London School of Hygiene and Tropical Medicine. But the, recognition by WHO to call out that menstrual health should be recognized, framed, and addressed as a health and human rights issue, not as a hygiene issue, is one

14:17 - of the most important things that will help those in low and middle income countries. And if I can just, flag at least a couple of, the recommendations we need to recognize and frame menstruation as a health issue, not a hygiene issue. And that means addressing physical, psychological and social dimensions and to recognize the need for information, education, access to products, menstrual products

14:50 - and access to water, sanitation and privacy. And I think that the, term menstrual health, is used widely. And again, stakeholder groups have put together a very good definition. And I quote that definition, it's a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity in relation to the menstrual cycle. And this other term which is very, commonly used period,

15:22 - poverty, again, defined, in the literature, when there is limited access to affordable, safe, and appropriate period projects, hygienic and private spaces to change or dispose of used products. So these, this is now becoming a truly societal issue. And others have said how much we need to reframe the messaging on menstruation by recognizing menstruation as a normal biological process and to recognize the unnecessary burden of menstrual stigma

16:00 - and work towards a much more positive messaging on menstruation. And I think if we can achieve that positive menstruation, we can enhance education, we will help, those who live in middle, low and middle income countries. But this is also needed in those higher income countries too, because too often still menstruation is normalized either by the individual or by society. And this is why we need more research on menstruation science.

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