There is a knowledge gap around menstruation in NZ – and this puts people at risk

New Zealand girls and young women, as well as nonbinary persons who bleed every month, have a limited understanding of menstruation. This lack of knowledge about their own bodies is affecting their overall health and wellbeing.

Our ongoing research, currently under peer review, looks at the menstrual health literacy of premenopausal females between 20 and 34 years old (in this article the term “female” is used to refer to individuals with the reproductive organs and hormones that enable menstruation. However, the authors do acknowledge that sex is not binary). We examined how people understood the purpose of hormonal changes and health outcomes (acute and long-term) associated with the menstrual cycle.

The results are concerning in a country where more than half the population is female, and where health education starts in the first year of school.

But this lack of knowledge is not just a health issue. Anxiety over menstruation, what is normal and what isn’t, spills over to every element of a person’s life, affecting participation in activities such as sport, work, and school.

If New Zealand wants to encourage equal participation in life, then we need to start by properly educating females about how their bodies work.

A lack of general understanding

We used a 25-question survey to test menstrual cycle literacy. The questions were divided into four categories: the menstrual cycle, menstruation, symptoms and health outcomes. The final online survey was shared online and completed by 203 females aged 16-40 years.

We found the overall knowledge score for functional menstrual health literacy was low (less than 50%). This means more than half of menstruating individuals may not have an understanding of how hormones within their body can affect them and what symptoms are associated with menstrual cycle changes or disruption.

In particular, we have found a gap in knowledge around the second key hormone governing a person’s menstrual health. While respondents were familiar with estrogen and its effects on the body, few were aware of how the second key reproductive hormone progesterone affects their bodies.

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Progesterone is a key hormone for fertility and has roles in maintaining bone health, body fluid regulation and body temperature. It is also the first hormone to change when there is a subtle menstrual cycle disruption.

Failing to understand the importance of this hormone means most females are unaware of how to identify these subtle disruptions. They would most likely miss a lot of the initial warning signals from their body.

Approximately 38% of survey respondents were not aware of what is considered a normal length of the menstrual cycle. This may be associated with increased stress and anxiety commonly experienced with the “unexpected” arrival of their period.

Interestingly, we noted that females tended to score higher on questions where they could use or refer to personal experience (for example, menstrual cycle symptoms and menstruation).

But even here only 50% of females could correctly quantify normal or heavy menstrual blood loss values. Only 10% knew of the changes to cervical mucous that occur with ovulation and are recommended for fertility tracking.

Missing the danger signs

The lowest health literacy was reported for the awareness of adverse health outcomes associated with menstrual cycle disruption.

The majority (65%) were unable to correctly identify adverse health and wellbeing outcomes.

High stress, dieting, substantial weight loss and over-training are factors that independently and cumulatively have been found to increase the risk of menstrual cycle disruptions.

These changes in the menstrual cycle will often result in increased gastrointestinal upset, decreased immune response – and in severe cases increase the risk of bone stress injuries.

But the majority (95%) of survey participants only selected “increased risk of bone stress injuries”, the most severe outcome. They were unable to identify any of the other common negative health outcomes that may present first.

It is not uncommon for females to see multiple health or medical professionals when they are concerned with their reproductive health.

The lack of knowledge about what is happening in their body means there can be diagnostic delays or lack of diagnosis. In New Zealand, the average time for a endometriosis and polycystic ovary syndrome (PCOS) diagnosis is between two and eight years.

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Similarly, the majority of females were unable to identify all the factors that could affect the menstrual cycle. Most selected exercise as a key factor responsible for any menstrual cycle disruption.

As a result, most females reported that stopping exercise was what was needed to help menstrual cycle health.

This perception may be a contributing factor to the participation in sports gap between young females and males – rising from a 17% gap in sport activity per week at age 16 to a 28% gap at 17.

Talking about what is (and isn’t) normal

Our survey results show a pervasive knowledge gap in menstrual cycle health. Most females we surveyed were not aware of what is “normal” for their menstrual cycle, nor did they have a good understanding of the health outcomes associated with menstrual cycle disruptions.

There is a high risk that many females may have a poor quality of life, health and wellbeing due to not being able to access, understand or communicate menstrual health information when it is needed.

This ongoing research is the first step to understanding this pervasive knowledge gap in menstrual cycle health within New Zealand. More research is required to quantify menstrual health literacy in adolescent girls and peri- and post-menopausal women.

Understanding the gaps will give researchers, advocates and educators insight into where we can help improve this basic knowledge – and achieve better outcomes for all those who bleed.