The hidden tales menstruation may tell: time to break the silent spell

There is no doubt menstruation is a major event in human life as it exerts a powerful effect not only in those who are subjected to the monthly bleeding but also for those around them including, family, partners, and coworkers. Unfortunately, as menstruation is surrounded by taboos and myths, the topic has been neglected for many years as research has hardly focused on menstrual health. In fact, there seems to be a silent agreement that the physically and psychologically related menstrual symptoms should be accepted as “normal” including pain.

Despite being physiological phenomenon characterized by monthly bleeding episodes, menstruation may be accompanied by various physical and psychological symptoms such as pelvic pain, headaches, anxiety, and depression among others, which adversely affect almost half of the world population at some point in their lives. In March, we celebrated both International Women’s day and Endometriosis Awareness Month, which is an excellent opportunity to raise the issue of menstrual health. Such concept encompasses not only the reproductive axis but may also interfere with disease development and mortality. Recent data, however, shows that the silent spell should be broken as menstrual cycle regularity may be related to diseases such as cancer and overall mortality (Wang et al. 2020, 2022).

Wang et al. (2022) reported on 78,943 pre-menopausal women with no cancer history who had regular menstrual cycles. The presence of irregular cycles at age 29–46 years increased the risk of total invasive cancer by 11 percent when compared to women with regular menses. Such association, however, was restricted to obesity-related neoplasia including breast and endometrial cancers. Menstrual cycle irregularity in adolescence and adulthood may also be linked to increased risk of premature mortality (age <70 years) (Wang et al. 2020). Cognition may also be affected by the phases of the menstrual cycle and the ovarian hormones, although current studies have not met a consensus so far (Bernal and Paolieri 2022).

Endometriosis affects one out of every 10 women worldwide and is an important cause of chronic pelvic pain and infertility. Despite international awareness campaigns, women continue to take years searching for diagnosis and treatment for dysmenorrhea and other pain-related menstrual symptoms. Unfortunately, menstrual pain is considered “normal” by many, including doctors and other healthcare professionals, which further delays adequate management for these women. It goes without saying that these women and their families are extremely affected by the years of pain and unsuccessful treatments. The development of noninvasive techniques for endometriosis diagnosis in addition to new treatment approaches should help alleviate such suffering and reduce healthcare costs. The new guideline on endometriosis released by the European Society and Human Reproduction (ESHRE) brings up-to-date information on the management of women with endometriosis including new topics on adolescents, pregnancy, and fertility preservation, as well as menopause (ESHRE, 2022). Hopefully, it will help mitigate the long distressing lonely saga women with endometriosis face.

If menstruation may be associated with disease, absence of the cyclic ovarian steroid production that happens in menopause may also affect women’s health and quality of life in several ways including cardiovascular protection, cognition, and longevity (Akter et al. 2021). It appears logical that estrogen replacement should counteract these adverse effects of hypoestrogenemia. Unfortunately, it is not that simple, and studies published so far cannot find a balance between the beneficial and the undesirable effects of estrogen replacement on women’s lives. Therefore, current indications for hormone replacement in the menopause should take into consideration the presence of distressing symptoms as well as individual factors such as age, years since menopause, and present health status. Counseling women on the risks and benefits as well as the treatment of concomitant diseases such as obesity should also be on the agenda (Genazzani et al. 2021).

There are various menstrual-related diseases ranging from abnormal uterine bleeding, anovulation, and endometriosis to name a few. They affect millions worldwide and deserve much needed attention for their care. Therefore, the Terminology Action Group of the Global Menstrual Collective (https://www.globalmenstrualcollective.org) defined the term Menstrual health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, in relation to the menstrual cycle.” The definition encompasses all aspects of health according to the World Health Organization (WHO) definition (Hennegan et al. 2021). The broad concept of menstrual health entails that individuals who menstruate should have access to adequate treatments to menstrual-related symptoms and diseases as well as to hygiene products and proper care during menses. Education and information on menstruation in an environment free from violence, stigma, and discrimination complete the agenda.

Although it may seem obvious, menstrual health should receive proper attention as it concerns almost half of the world population but affects everyone around them, the theme remains neglected. The time to review the research agenda has come. The Women’s Health Access Matters (WHAM), a nonprofit organization that aims at promoting awareness and financing on women’s health research, concluded a study showing that investments on just three areas on female health would result in improvements in the quality of life and work productivity and decreased healthcare costs. Menstrual health unfortunately was not included. As COVID-19 slowly transitions into endemic, the time to reappraise our priorities on women’s health has arrived at last.

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