Can periods be culturally different?

This year, I have had the absolute pleasure of being the medical advisor for Women Empowered International (WE Int) on their six-part online webinar series on periods. This organisation was set up by young international professionals in Japan for other young international professionals to address issues important to them such as gender equality and sustainability. The thing that I like about them is that any member can suggest a topic and they will work to educate and empower their members around it – hence six webinars on the topic of periods. You can click here to see the infographics from the series. On the panel were Dr Yosuke Matsumiya, an obs and yynae doctor (OBGYN), Dr Magali Matsumiya, science teacher and author of several highly influential research papers, and me, a family physician, so we had a lot of ground covered between the three of us.

As much as I was there to impart my medical knowledge, I felt that I learnt so much from this experience. It was a real opportunity to get asked burning questions from the general public and to learn about things that really bothered young women about their periods. One of the things that I was really struck by is how little women talk to each other about periods, even in this day and age. As a result of this, a lot of questions were around what is normal. “How many days should I be bleeding?” “What products am I supposed to be using?” “How long should my cycle be?” It was an initial challenge to get people thinking differently and learn what is normal for yourself.

In preparation for these talks, I spent a lot of time talking to my own friends about periods and, for the first time, we shared our own stories of what products we were using, how we used to scrub blood off pants as teenagers (cold water better than hot, everyone!), and even missing sports or sometimes even school or work once a month.

One friend shared with me that, when she was younger, her dad had overheard her changing her sanitary towel in the toilets at home and, when she came out, he accused her of eating sweets in secret. Rather than admitting to him that she was on her period, she stayed quiet and let him believe that she was eating candy improperly in the bathroom. One girl in the group shared how anxiety-provoking it would be having a new partner stay over for the first time during her period due to their heaviness not knowing how they would react.

One of my closest friends told me that she had gone to her GP about her heavy periods and was essentially told it was part of life and to get on with it. This is exceptionally heart-breaking for me to hear because I would see my very strong and very resilient friend become a heaped mess for four days a month when we all know that there are medical options for painful periods. Periods are a part of life but not having a quality of life doesn’t have to be. I was interested to hear that many of the women who attended worked for companies who offered ‘period days,’ which is fantastic news for diversity and inclusion, but how this could be appropriately implemented was up for debate. Would it be unfair for those who didn’t suffer from bad periods? Does this count as sick leave? How could time off work be fairly distributed? The great thing about starting the conversation is that we can share our vast array of experiences to have better empathy for those who don’t have it as good. When menstruation can be a part of life for over 30 years for people who menstruate, why do we allow it to be shrouded by so much shame?

Period products

One of the sessions was on period products. When I was at school, I remember only learning about tampons and sanitary towels as effective ways of managing periods including, aged 12, watching with horror how much a tampon can expand in a measuring cylinder of water. “Is that what is going to happen in my vagina???” Traumatic to say the least!

It was fascinating to see that sustainability was an important factor for young women and the days of single-use products may be coming to an end. Here is a list of products that we talked about:

  • Sanitary towels – absorbant pads that are worn externally, often made to stick to underwear. These can be disposable or reusable.
  • Tampons – absorpant product that sits internally in the vagina. They can come with an applicator or without. If these remain in the body too long, there is a risk of toxic shock syndrome but we had to reassure the menstruators that normally this would take days and their risk wasn’t that high if they left a tampon in for a few minutes longer than recommended. A word of warning for the clinicians who ever have to remove a retained tampon, have a specimen bottle handy so that you can put it in there once you have fished it out and screw the lid on tightly. The smell is pungent and it is the gift that keeps on giving if you do not dispose of it appropriately in a sealed container.
  • Moon cups – these are little plastic cups that are used internally – a bit like a resusable tampon. They can be emptied, rinsed and reused. It takes some getting use to but are discrete and sustainable and are really useful in low-resource settings.
  • Period pants – These are absorbant reusable pants that can be worn instead of underwear. These are sustainable but can be quite costly although the running costs are minimal.
  • Sponges – these are not licensed period products (according to an intenet search) but are the best period product if you want to have sex on your period. Although unofficial feedback informs me that it can feel a little like having sex on a brillo pad (!). They are quite hard to get out so it’s not for the faint-hearted – you might have to rummage a bit to extract it.

I was also fascinated to see that anecdotally my Japanese attendees were less likely to use internal products such as tampons compared to the Western members. In fact, one Japanese woman, who had swum competitively when she was younger was told by her swimming teacher that the water pressure would keep the blood inside meaning that they were not encouraged to use tampons. She said that the women in the team could spot which fellow female members were on their periods as they would be the ones rushing out of the pool to the changing rooms instead of doing the cool-down exercises after their session. I’m not sure where this cultural divide comes from but I would certainly be interested to know if there were any other cultural differences when it comes to period products (you can comment below)!

Contraception

I have completed my DFSRH (UK Diploma in Fertility and Sexual Reproductive Health) and, being a female GP, spend a lot of time counselling women about birth control. I’m also known amongst my friends to dish out contraception advice at the pub because, for me, contraception is not just about preventing pregnancies but it is also about feminist rights. Being able to plan your family and being able to enjoy sex without the fear of pregnancy should be a choice allowed for both genders. Allowing women to do this challenges the social, political and religious narratives that have held women back for centuries and how we counsel women on the use of contraception needs to be without judgement and certainly without us imposing our own values on our patients.

In the UK, contraception is free since it is cheaper to fund contraception than it is to fund abortions so I was surprised to hear that, in Japan, contraception is not covered by insurance. Generally speaking, in Japan, hormonal pills such as the combined oral contraceptive (COCP) is prescribed only for medical indications such as menorrhagia or polycystic ovarian syndrome (PCOS). I’m sure that most Brits will be shocked to hear that the progesterone-only pill (POP), depot injection, and implant are not available at all for use in Japan and the intrauterine coils are licensed but are do not have a high uptake.

In a country where viagra is covered by insurance but contraception is not, what are we saying about how the country observes the needs of 50% of its population?

Lifestyle and medicine

When we think of period product adverts, what do we think of? A group of young smiling women wearing white trousers who are leaping and jumping and looking generally great? That’s what I think of. “Don’t let your period hold you back.” Doesn’t it make you feel a bit inadequate when you just wanted to sit on your sofa with a blanket and watch mind-numbing programmes on Netflix? I genuinely think we should be less hard on ourselves and accept that it’s ok to curl up with a hot water bottle and contemplate life instead.

When I was doing my research for this webinar, I came across lots of mainstream articles on what supplements to take for period health. In my opinion, the wellness industry likes to find a quick fix or a miracle cure and some of the work done in terms of research were often comparatively small studies which makes it very different to draw firm conclusions. My advice here very much was to follow the six pillars to good health as encouraged by lifestyle medicine which are:

  • Good sleep
  • Cessation of alcohol, smoking and recreational drugs
  • Good nutrition and diet
  • Physical activity and exercise
  • Good social relationships
  • Stress reduction and maintenance of wellbeing

There may be more research in the future that suggests that some supplements are good but, at the moment, there’s just not enough evidence.

Period poverty

We had three incredible speakers to talk about period poverty – Tanya Khera, CEO of the Samanta Foundation, Ayanda Mhlongo, a researcher at the University of Cambridge, and Urara Takeseki, CEO of Omotete.

We know that, for most people, periods happen monthly for about 30 to 40 years of their lives. In order to have good menstrual hygiene management (MHM), menstruators require the following:

  • Access to quality absorbants (disposable or reusable) which are available and affordable
  • Access to privacy which is safe
  • Access to soap and water
  • Access to disposable facilities
  • Access to menstrual education which is dignified, without fear and embarrassment

If a menstruator does not have access to the above, this leads to period poverty – i.e. having a period holds someone back from participating in everyday activities. The most obvious one is school attendance – if a girl does not have access to MHM and have to miss school, their educational attainment will be compromised leading to gender inequality. In the UK, we have just made period products exempt from VAT (consumption tax) to show that these are essential goods and not a luxury. Although it is a step in the right direction, not all period products are included – most notably period pants. Although much better now, beer in Germany was subject to less tax than period products as it was seen as more of a necessity than period products – now it is taxed the same. What are we saying when we are taxing women for something that is essential to their natural bodily functions?

In Japan, local authorities are doing what they can to manage period poverty but in a well-meaning but meaningless way by handing pads out at the town hall. I try to imagine what it would feel like to go and ask for sanitary products from my local town hall clerk and just the idea makes me blush. Whilst there is still the culture of concealment that we need to combat, there are some more practical aspects like taking time off work to get to the town hall that is only open during working hours. Also,how am I supposed to get to the town hall without a sanitary product if I am already menstruating? When periods are seen as a female problem and many spaces are male-dominated or designed by men, we need more compassionate leadership to normalise menstruation. This will be from either more menstruators in leadership roles or more non-menstruators as allies. What is becoming more and more apparent is how the dominant (in this case, men and boys) need to be educated on how the marginalised (in this case, the other half) lives.

This talk really opened my eyes to how often we gloss over MHM as a human right. Some of the research discussed covered how refugee women found it difficult to ask for sanitary products because of language barriers and access barriers. We know where we can buy sanitary products in our own countries but how do we know when we are abroad? We also talked about homeless women who lack privacy and safe facilities to change their sanitary products. Some women are forced to stay with partners because they are not, amongst other things, able to access sanitary products if they leave. We take so much for granted when we lead comfortable lives that we must not forget our privileges. Periods are a part of life for many people and we should not be stigmatising it nor should we be concealing it. As doctors, we really should start the conversation without judgement around periods for our patients because what we think is normal for us is not always normal for someone else.

Some final words

I’m delighted to announce that I will be having a permanent position as medical advisor for WE int. They will be running several series on women’s health in the future and you can follow them on Linkedin or Facebook

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