Medicosnext
Adolescent years are a time of confusion; your body goes through transformations that you barely understand. These changes, however, are not always easy, and even more so for girls and women here in Nepal. Menstruation has been a taboo as well as a stigma for women throughout the history of many South Asian countries. With taboo and stigma practices, including not being able to touch other people, unable to enter temples and sacred areas, unable to enter the kitchen and eat with family members, and the practice of sending women and girls to “menstruation huts”. The latter is known as chaupadi, which was formally banned in 2005 and then criminalized in 2017 by the Nepal government. This, however, has not stopped its practice, with the BBC reporting on the death of a 21-year-old woman on December 2, 2019.
Although menstruation is a physiological process, perception around it has made small improvements over the years. Due to lack of education, many of the traditional practices are continuing to be practiced in various parts of the country. Even when education has begun to be disseminated throughout schools, the facilities are not in place to support women and girls in school and the workplace.
The disconnect across different sectors has brought much national and international attention to Nepal, to try and devise a way to better disseminate knowledge, as well as implement practices, to serve the women and girls of the country. These concerns have especially attracted the attention of gynecologists, as they work with them directly to promote better practices, protect their health, and champion their human rights.
Dr. Laxmi Acharya Gautam, Consultant Obs /Gynecologist, Star Hospital, has seen the difficulties and challenges that women are facing throughout Nepal. We sat down to discuss her thoughts and concerns regarding gynecology and menstruation here in Nepal.
You mentioned menstrual health is an important topic, but it escapes much of the mainstream dialogue, can you elaborate on why you think it’s so crucial?
Menstruation is a physiological process that women go through, which is the shedding of the uterine lining (endometrium). It starts during puberty, which begins at various ages for different women, and stops permanently at menopause, which again, happens at various ages for different women. However, this is not being scientifically taught as a part of educational program to girls in Nepal, and due to lack of education, persisting taboos and stigma, limited access to hygienic menstrual products, and poor sanitation infrastructure, women’s opportunities are being undermined. These include education, health, and social status.
Menstruation is different for every woman, can you elaborate on some of the abnormalities that may occur?
Menorrhagia is clinically defined as menstruation lasting more than seven days, or blood flow exceeding more than 80 ml per cycle. Menorrhagia must be distinguished clinically from other common gynecological diseases, which include metrorrhagia (flow at irregular intervals), menometrorrhagia (frequent excessive flow), polymenorrhagia (bleeding at interval less than 21 days), and, dysfunctional uterine bleeding (abnormal uterine bleeding without any obvious structural and systemic abnormality). It is very important to have knowledge of normal menstrual function. It is imperative in understanding the etiologies of menorrhagia. Four phases constituting the menstrual cycle are—follicular, luteal, implantation, and menstrual. The etiologies of menorrhagia are divided into four categories:
1. Organic causes: infection, bleeding disorder, organ dysfunction.
2. Anatomic causes: uterine fibroids, polyp, endometrial hyperplasia, and pregnancy.
3. Endocrinologic cause: thyroid and adrenal gland dysfunction, pituitary tumor, anovulatory cycles, polycystic ovarian syndrome (PCOS), obesity, and vasculature imbalance.
4. Iatrogenic causes: intra uterine device, steroid hormones, chemotherapy agents, and some medications (e.g. anti-coagulant).
Some women experience abnormal uterine bleeding (AUB) in which they miss their menses; what causes this to happen?
Broadly understood, AUB includes the following—absence of bleeding; irregular bleeding; abnormally heavy bleeding; and bleeding in between periods. AUB, according to the International Federation of Gynecology and Obstetrics (FIGO) System, is determined by the frequency, regularity, duration, and volume.The most common causes of AUB is due to ovulatory dysfunction. This is commonly due to the immaturityof the hypothalamic-pituitary-ovarian HPO axis and PCOS, coagulopathy, pregnancy, and pelvic infections.
With the absence of a menses (more accurately defined as amenorrhea), the causes can be either primary or secondary. Primary amenorrhea is defined as either the lack of menstruation by the age of 15 years or within three years of menarche; or the lack of secondary sexual characteristics by the age of 13 years. Primary amenorrhea may be due to hypothalamic-pituitary-ovarian (HPO) axis, as well as the uterus and other endocrine disorders that could affect menstruation, such as anatomic defects, primary hypogonadism, adult onset adrenal hyperplasia, Cushing syndrome, and thyroid disease, besides others.
With regard to taboos and stigma, have you noticed any shift in the perception of people towards menstruation?
There have been some changes, however, they have been inadequate, and despite the efforts of the government, as well as national and international partners, very few women even access health services regarding gynecology. Due to stigma and the fear of embarrassment, many girls are afraid to seek menstrual hygiene health services. There has been more rapid change within the major cities due to the access to education, media from around the world, as well as the return of individuals from abroad. Although this is positive, this is still the minority of the population.
You mentioned that lack of proper education can directly put women’s health in danger. What are these health risks?
People need to understand that menstruation is a biological process that is related to the reproductive system of women, and it has nothing to do with common beliefs of gods being angry, or that it is a curse. Second, if hygiene is not maintained, there is a severe risk of infection and other medical complications for the women, such as UTI, reproductive tract infection, and cervical cancer, due to chronic infection and infertility.
Women are 14 times more likely to get a UTI than men. This is due to the urethra being shorter in women, so perineal and fecal flora have a shorter distance to travel. The lower third of the urethra is continuously contaminated with pathogens from the vagina and the rectum. Blood allows for these pathogens to travel between them, so improper hygiene during menstruation and inadequate fluid intake are prone to cause infection in the urethra. If recurrent infection occurs, there may be risk of pelvic inflammatory disease, which may lead to changes in normal cells, and eventually lead to cervical cancer or infertility.
What education are girls and women getting on menstruation? Does it differ in rural settings from bigger cities?
Currently, the education system provides little to no education regarding menstrual health, and girls are forced to learn from their friends or family members. However, the government has identified adolescents as an important and underrepresented population that is critical to achieving the national health and development goals. There has been an increase in inter-sectoral collaboration efforts in order to develop and implement strategies to improve adolescent health. The 2015 draft on National Strategy on Adolescent Sexual and Reproductive Health calls for increased involvement of the private sector in meeting adolescent need. The strategy especially calls for the integration of a menstrual health and hygiene (MHH) component, including sexual and reproductive information and education on menstruation. This includes adolescent health and development strategy (2015 training package), water supply, sanitation and hygiene sector development plan (2016-2030). I would like to see education being rolled out to more women and girls in Nepal, especially in remote areas, as studies have shown they have been using improper techniques for sanitation, such as using old and dirty cloths to manage their menstruation.
Building on the education aspect, what are some basic menstrual hygiene rules every woman should follow?
• They should change sanitary napkin every four to six hours.
• Wash and clean themselves properly.
• Not use artificial hygiene products frequently.
• Discard sanitary napkin properly.
• Have proper diet and adequate hydration.
• Avoid heavy workload.
There are various menstruation hygiene products available, what do you believe to be the best option for women here in Nepal? What about for women with menorrhagia?
Eco-sanitary pads have yet to take off in the market due to lack of awareness regarding the product. These pads are better than disposable sanitary pads in term of quality and price, besides being beneficial to the environmental. Also, there are reusable pads that are easy to make and are becoming more widespread here in Nepal; however, these take a steady supply of water to use, as they require washing after use. Finally, there are menstruation cups, but these are not widely known of or used.
Do you have any final remarks?
I would like us all to work together in all aspects regarding women’s health. I think we should focus more on school health programs that include menstrual health and hygiene (MHH) in the curriculum. This would help girls going through puberty become more aware of and understand better their anatomy and physiology, which would help them comprehend the biological processes of menstruation. By increasing the basic understanding of menstrual health, we can help improve their attendance and performance at school, break down taboos and misconceptions, raise self-esteem, and ultimately help them participate fully in all aspects of society.
Taboos and stigma in Nepal are controlling the access to both education and facilities for women. This is damaging not only to their everyday lives, but also to their health, in general. With a study showing that, on average, a woman will get menstruation for six-eight years of their life, it is crucial that the basic knowledge about menstrual health, the risks and concerns of improper hygiene, and overall anatomy of a women’s body are transferred to both men and women of all ages. We need to promote menstrual health as self-care. It is a valuable health indicator as girls and women learn about their body, track their cycle, and gain understanding in terms of bleeding, period pain, and many other symptoms. This practice will enable girls and women to become skilled professionals for their own health and bodies.
