Case
When N.S. last came to clinic, she was planning her future after high school. Like many 18-year-olds in our care, she was thoughtful and hopeful. She was sexually active and wanted to avoid pregnancy for many years. She relied on condoms for contraception and used emergency contraception once. She knew she would struggle to take daily pills or change a patch weekly or a ring monthly so wanted a longer-acting method. A previous trial of depo medroxyprogesterone acetate (DMPA)* had been frustrating because of persistent unscheduled bleeding. She was interested in the subdermal contraceptive implant. However, when informed that her bleeding pattern could change and she may have unscheduled bleeding, she became concerned.
Since N.S. shared menstrual materials with her mother, her mother could track her menstruation. Given the cost of menstrual supplies, her mother vigilantly monitored their stockpile. Her mother disapproved of her boyfriend, so N.S. hid her sexual activity. She declined the implant, because unscheduled bleeding could result in more-frequent menstrual material use and unwanted questions from her mother. She continued using condoms and emergency contraception.
Menstrual Equity
N.S.’s experience illustrates an overlooked barrier to contraceptive choices for low-income individuals: menstrual poverty. Menstrual poverty is the inability to acquire menstrual materials, including tampons, pads, cups, underwear, and other cloth products such as diapers.2 Menstrual poverty has been linked to missed school and work, and lower quality of life, which can perpetuate poverty.3–5 Menstrual equity aims to eliminate menstrual poverty through addressing issues of access, affordability, and safety of menstrual materials.6
Since the inaugural “Menstrual Hygiene Management in 10” meeting in 2014, considerable strides have been made toward menstrual equity. International agencies, national governments, and private foundations have funded studies and projects to fulfill the 10-year plan for addressing menstrual equity in schools.7 However, the focus of these efforts has largely been low- and middle-income countries. Within the United States, menstrual materials are often treated as “luxury” items and are taxable in 24 states.8 Furthermore, public assistance programs such as Supplemental Nutrition Assistance Program, Special Supplemental Nutrition Program for Women, Infants, and Children, and Medicaid cannot be used to purchase menstrual materials.9
Over the last several years, growing evidence has demonstrated the significant prevalence of menstrual poverty in the United States. In a survey of 183 low-income women, 64% reported having been unable to afford menstrual supplies in the previous year, and 20% experienced this monthly. Women reported borrowing, stealing, and relying on community donations and using toilet paper, rags, and diapers to manage menses.10
Unsurprisingly, adolescent and young adults (AYAs), those aged 11 25 years,11 face similar barriers. In a 2021 study, 10% of 440 US college students reported monthly menstrual poverty, and almost half used tampons and pads longer than recommended. Students experiencing menstrual poverty were more likely to identify as Hispanic or Black.12 Among 119 urban high school students, of which 98% identified as Black, almost 30% reported monthly menstrual poverty, and 17% missed at least 1 day of school per month because of inadequate materials.13 These high rates of menstrual poverty are a consequence of underlying structural inequities, including systematic racism. Given the long-term consequence of menstrual poverty, failure to address it may further perpetuate structural inequities.
Adolescent and Young Adult Contraceptive Use and Menstrual Poverty
There has been growing emphasis on the use of long-acting reversible contraceptives (LARCs) to reduce the risk of unintended pregnancies over the last decade.14 LARCs, such as the etonogestrel subdermal implant (ie, Nexplanon) and the copper and levonorgestrel intrauterine devices, have lower failure rates with typical use (<1%) than oral contraceptive pills (OCPs) (8%) or condoms (15%).15 However, among AYAs, the external condom, coitus interruptus, and OCPs remain the most commonly used methods.16
Several barriers complicate the use of LARCs in AYAs, including cost, awareness, parental attitudes, misconceptions about safety, and confidentiality.17–19 Although both the American Academy of Pediatrics and American College of Obstetrics and Gynecology endorse the use of LARCs as first-line contraceptives in AYAs,20,21 provider comfort with placement and misconceptions about safety limit AYA uptake.18 Without insurance, obtaining a LARC can cost >$1000,22 but Title X family planning programs makes no- or low-cost contraceptives available to AYAs while protecting confidentiality.23
Patient priorities also influence contraceptive choice. Although efficacy is an important feature motivating some AYAs’ choices, side effects are almost as important and are a major driver for discontinuation.24 Hormonal LARCs and DMPA often reduce menstrual blood volume and are used to manage heavy menstrual bleeding.25 However, unscheduled and unpredictable bleeding are also common. This alteration of the menstrual cycle is concerning to some AYAs, who worry that it will negatively impact their health and future fertility.26–28 When patients start these methods, providers may counsel them to always wear a thin pad. Therefore, unscheduled bleeding can be problematic because it can be inconvenient and unpredictable, and, because of the need for additional menstrual supplies and undergarments, it can also be expensive. As a result, the potential for irregular and bothersome bleeding can be a deterrent against these methods.
Despite growing recognition of menstrual poverty in the United States and the fact that hormonal contraceptive methods change bleeding patterns, little attention has been paid to the interplay between menstrual poverty and contraception use. Bleeding reduction may alleviate menstrual poverty. For example, during the Australian government-sanctioned coronavirus disease 2019 lock-down, women used continuous OCPs to skip menstrual cycles because they were unable to access sufficient menstrual materials.29 However, changing bleeding patterns may exacerbate menstrual poverty. In a study on menstrual poverty and stigma in the United States, 2 students reported that unscheduled and increased bleeding from their contraceptives created significant financial strain, especially given that they hid their contraceptive use from their parents.30 These cases, along with that of N.S., demonstrate the additional complexity of protecting AYAs’ confidentiality when providing contraception.
Promoting Menstrual Equity
Eliminating menstrual poverty requires a multitiered approach. Below are several avenues for promoting menstrual equity that are especially salient for AYAs.
Ask patients about menstrual poverty. If your patients experience food insecurity, they likely experience menstrual poverty.10,13 Asking about menstrual poverty will normalize discussing it and may uncover other socioeconomic factors impacting your patients’ health.
Study how menstrual poverty influences contraceptive choice and how contraception impacts menstrual poverty.
Develop contraceptives with menstrual poverty in mind. Contraceptive methods that are least likely to affect bleeding profile (eg, condoms and pills) have the highest user error. Longer-acting methods reduce user error and improve privacy but are prone to unscheduled or increased bleeding. Developing inexpensive and effective contraception that minimizes unscheduled bleeding will improve patient satisfaction, promote continued use, decrease risk of unintended pregnancy, and allow AYAs more contraceptive choice.
During contraceptive counseling, discuss how menstrual material needs may change and familiarize yourself with local organizations that provide no- or low-cost materials so that menstrual poverty does not inhibit contraceptive choice.
Advocate for universal insurance coverage of continuous-use contraceptives. Continuous-use OCPs, patches, and rings allow individuals to skip menstrual cycles, reducing material need. However, some insurance companies only permit monthly prescription refills and require preauthorization for early refills.
Improve access. We recommend clinics and hospitals provide free menstrual materials to patients and employees.
Advocate for making menstrual materials more affordable nationally and free for students and incarcerated youths. This includes advocating to eliminate taxation on menstrual products and to allow public assistance programs, such as the Supplemental Nutrition Assistance Program and the Special Supplemental Nutrition Program for Women, Infants, and Children, to cover menstrual materials. Legislative toolkits and information about enacting policy changes can be found on Web sites such as the American Civil Liberties Union6 and PeriodEquity.org.31
Menstrual poverty can have serious, lifelong implications, such as lost educational opportunities and unintended pregnancy. Addressing menstrual needs is a vital component of comprehensive AYA health care and contraception, an integral aspect of menstrual equity.
Screening Questions for Menstrual Poverty
“What materials** do you use to manage your period?”
“How often do you not have enough materials to manage your period?”
“What do you do when you need materials but do not have them?”
“Have you ever missed school or other activities because you did not have enough materials?”
Drs Bedrick, Sufrin, and Polk conceptualized the article, drafted the initial manuscript, and reviewed and revised the manuscript; and all authors approved the final manuscript submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLAIMER: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.
DMPA is associated with a reversible decrease in bone mineral density (BMD), resulting in its “black box” warning. The American College of Obstetrics and Gynecology recommends shared decision-making and weighing the risks and consequences of unintended pregnancy (including BMD reduction) with that of reversible BMD loss.1
We recommend mirroring the terms patients use to describe menstrual materials but avoiding the terms “sanitary” or “hygiene” given their implication that menstruation is unhealthy or dirty.
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