Teenage Use of Smartphone Applications for Menstrual Cycle Tracking

The current generation of adolescent girls entering puberty are digital natives, never knowing a world without the seemingly constant presence of smartphones. The ability to stay continuously connected through Internet-capable mobile devices is facilitated by a growing array of digital tools for tracking, quantifying, and sharing most facets of personal life. Although several smartphone health applications (apps) allow for tracking of health behaviors and data, a subset of these apps focus exclusively on menstruation, gynecologic health, and sexual activity. Smartphone-based period trackers have a clear appeal to young users, who are more comfortable engaging with the world through technology than were earlier generations, who often tracked similar information on paper calendars. Although the prototypical user envisioned by the developers of these apps is often a heterosexual, monogamous adult woman, young people at the onset of puberty may be particularly drawn to period-tracking apps, both for their appeal as a seemingly private way to explore a budding interest in health and as a natural way to track and understand emerging patterns in their developing bodies. Consequently, the information stored and generated in these apps holds great potential to empower adolescent users with predictive information about their cycle and assist them in communicating menstrual patterns and deviations with health professionals.¹  However, these apps also present particular challenges for pediatric patients.

First, teenage users may not understand the ways in which their data can be used or shared by app developers. Relevant data-sharing practices, disclaimers about the limitations of fertility predictions, and waivers of liability are communicated via privacy policies and terms of service agreements. However, research suggests that these documents are unlikely to be read by most users and are likely incomprehensible to those who do.²  For example, in earlier research of 15 popular period-tracking apps, we found that the average grade level required to read both privacy policies and terms-of-service agreements was ∼14, which is 2 years beyond completion of a high school diploma.³  Admittedly, the critique that terms of service are indiscernible to anyone without a law degree is one that can, and has, been leveled against most Web- and smartphone-based consumer technologies. Nevertheless, this issue is particularly problematic in the context of period-tracker apps given the sensitivity of the information collected and the aforementioned shortcomings in both the data security protections used and the accuracy of the generated predictive information.⁴  As a result, users of all ages may lack the information they need to make informed choices about app use, a problem that is exacerbated for pediatric users, who, on average, have lower literacy levels than the general population.

Second, pediatric users may interact with period-tracking apps in ways that are unintended or unanticipated by developers and parents. For example, some apps also allow users to share their account information with other parties, such as sexual partners. Apps often promote this functionality as permitting heterosexual couples to use period-tracking apps for shared reproductive decision-making, enabling secondary users to access such diverse and highly intimate information as when the primary user last had intercourse, if the user smoked or drank, physical symptoms related to menstruation, or whether the user is likely to be fertile on the basis of the date in the cycle or the results of recent ovulation tests. By contrast, in pediatric populations, account-sharing features may instead be used to share this information among groups of friends. Although anecdotal reports of this practice from an author (C.G.) focus on positive social interactions and mutual support, the intimate nature of this intentional data sharing may foreseeably expose users to less positive consequences, such as enabling peers to deduce a possible unintended pregnancy as a result of subsequent missed periods and resulting gossip, bullying, or peer pressure. At least 1 parenting Web site also advises that parents can use this functionality to track their children’s periods without the children’s knowledge.⁵  Although such guidance is framed in a positive light, advising parents as to when they might choose to take a supportive, rather than critical, posture toward their children, teenagers might reasonably perceive such undisclosed surveillance as intrusive, which may undermine trust.

Finally, comprehensive sexual education is not consistently or uniformly available to adolescents in the United States. As a result, pediatric users may turn to Web- and app-based gynecologic and sexual health resources to take the place of formal education.⁶  However, challenges arise with respect to accuracy of content and predictive ability and intended use of period-tracking apps outlined in the terms of service.⁴  For example, a user may misinterpret predictions for “fertile” and “nonfertile” days as an appropriate substitute for other forms of reliable contraception even when terms of service contain disclaimers alerting users that an app is not intended for contraceptive use or other medical purposes. This misunderstanding is perhaps reasonable in light of the US Food and Drug Administration’s recent decision to permit a visually and conceptually similar product, Natural Cycles, to be marketed as contraception. Young users, especially those who are reluctant to speak to parents or providers about their sexual behavior, may be especially vulnerable to this mistake. Moreover, overreliance on the accuracy of fertility predictions may prove to be additionally troublesome in light of shrinking access to other forms of birth control through new restrictions on Title X funding.

Pediatric use of period trackers may differ from adult use in meaningful ways that merit further attention and research. However, as with adult populations, period-tracking apps hold great promise as a means of empowering young users to understand their bodies and effectively communicate health patterns with their providers and other trusted adults. Screening patients for use of these apps presents a valuable opportunity to educate patients about both gynecologic and sexual health and the risks of data sharing involving intimate and sensitive information. Counseling could include that period-tracking apps may be useful for understanding emerging patterns in developing bodies but are not effective forms of contraception and do not prevent sexually transmitted infections. Furthermore, given that young people are unlikely to receive information from the terms of service and privacy policies in the apps themselves, pediatricians have a critical role to play in anticipating unique aspects of pediatric use of period-tracking apps, understanding app limitations, and providing recommendations.⁷  Information about the risks of these apps should be part of a broader discussion about social media use and potential impacts on adolescent safety and health. Although understanding the nuance and legal implications of app-specific terms is impractical for any provider, it is important for pediatricians to be aware of the growing popularity of these apps and the risks and benefits they present for their patients.

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