Chapter No 2

Literature Review

Menstrual Health

Menstruation is defined as the periodic discharge of blood, mucus, and cellular debris

from the uterine mucosa. The menstrual cycle is a repetitive phenomenon caused by the

interaction of the hypothalamic-pituitary-ovarian system and can be divided into three stages: the

follicular phase, recruitment and growth of a new follicle; the ovulatory period, at which time an

oocyte is released into the peritoneal cavity; the luteal phase, at which time a newly formed

corpus luteum produces progesterone (Ferin, 11996). The cycle is mainly regulated by the

hypothalamus, in which gonadotropin releasing hormone (Gn-RH) is released in pulses to

stimulate pituitary gonadotrophs to secrete follicle-stimulating hormone (FSH) and luteinizing

hormone (LH). These gonadotropins in turn promote follicular development with ovulation and

corpus luteum formation in the ovary, inducing steroid hormone production. The estradiol-

positive feedback loop causes the midcycle Gn-RH and LH surges to in duce ovulation in the

matured preovulatory follicle.

Since positive estrogen feedback system on the hypo thalamus and pituitary is developing

throughout puberty, menstruation following menarche is usually irregular and/or anovulatory.

The frequency of ovulation gradually increases as puberty progresses, but it is common for 25-

50% of adolescents to still be anovulatory 4 years after menarche descents to still be anovulatory

4 years after menarche. Several years after menarche, transient disturbances of progesterone

secretion in the luteal phase are commonly observed in adolescents (Vuorento & Huhtaniemi,

1992). The average age of menarche in Western European countries appears to have declined

over the past 150 years from over 16 to under 14 years (Wyshak & Frisch, 1982). In the United
States, the normal age range of menarche is 9.1-17.7 years with a median of 12.8 years

(Zacharias et al., 1976). There is no evidence that the age of menarche has decreased over the

past 30 years in USA. The declining age of puberty has been attributed to improved standards of

living such as adequate nutrition and health care (Tanner, 1996).

Menstrual cycle length is mainly determined by the rate and quality of follicular growth

and development. Although many textbooks in reproductive medicine describe typical menstrual

cycle as 28 days (Yen 199)., there is limited discussion regarding the definition of normal range

of the regular menstrual cycle. This is probably because there is considerable variation in

menstrual cycles among women. More than one hundred years ago, it was reported that mean

and/or median menstrual cycles are between 28 to 30 days (Kennedy, 1993). In 1939, Arey

analyzed 12 reports from 1989 to 1937 and reported that the mean interval of menstrual cycles

was 28.4 days (Arey, 1939).

In 1942, Haman showed an almost identical distribution of menstrual cycle by analyzing

150 normal housewives (Haman, 1942). In 1968, the mean of menstrual intervals was reported to

be 29.1 days by analyzing 2,316 women (Chiazze et al., 1986). In this study, when the study

population was limited to women having menstrual intervals between 15 and 45 days, the mean

of menstruation was re-calculated as 28.1 days. Treloar et al. demonstrated that the mean of the

menstrual intervals gradually decreased from 30 to 26 days along with the narrowing of the 90

percentile ranges (Treloar et l.,1967). Variability in cycle length among females is in principle

due to the varying number of days required for follicular growth and development. The key

hormone was shown to be inhibin, not estrogen ( Sherman & Koreman, 1975).

In the late 30’s years when FSH increases and inhibin decreases (Hughes et al.,1990), the

mean length and variability of menstrual cycles become the shortest. In 1984, Lenton et al.
analyzed 293 British women with ovulatory menstrual cycles and reported that mean interval of

follicular phase was 12.9 days with 95% confidence limits between 10.3 to 16.3 days (Lenton et

al., 1984). This study also showed that follicular phase length was significantly decreased along

with aging, from 14.2 days in women aged 18-24 years old to 10.4 days in women aged 40-44

years old. In 1992, Munster et al. analyzed 3743 Danish women aged 15-44 with regular

menstrual cycles and found that in women with regular menstrual cycles, the 5-95 percentile

range of usual cycle length of 23-35 days in the 15-19 years age group decreased to 23-30 days

in the 40-44 years age group. Based on these findings, it can be concluded that the interval

between menstrual periods has not been changed during a century and that the median interval is

28 days during active reproductive years (Munster et al., 1992).

Menstrual Health is firmly on the global agenda

Menstrual Health was not on the agenda of the International Conference on the

Population and Development or the Millennium Declaration. Nor it is explicitly stated in the

Sustainable Development Goals targets for goals 3 (health), 5 (gender equality) or 6 (water and

sanitation). However, it has been placed on the global health, education, human rights, and

gender equality/equity agendas by grass-roots workers and activists from the global South,

drawing attention to reports of women’s and girls’ experiences of shame and embarrassment, and

the barriers they face in managing their period because they do not have the means to do so, with

consequences for their life opportunities including their rights to education, work, water and

sanitation, non-discrimination and gender equality – and ultimately to health. WHO salutes the

grass-roots workers and activists, notably those from the global South, who have doggedly

championed menstrual health, and welcomes the inclusion of Menstrual Health in the Human

Rights Council agenda (WHO, 2022).

To support menstrual health, individuals must be able to select care practices that are

preferable and comfortable for them, and be able to afford the resources required for self-care

(Hennegan et al., 2019). These practices should support hygiene and minimize the risk of

infection and harm. Women, girls, and others who menstruate must be able to care for their body

with the level of privacy they desire such that they feel free from unwanted observation or

disturbance (Sclar, 2018), and in safety such that they are protected from risk of physical,

emotional or social harm. Safety must be considered in the location of infrastructure and ser

vices, the quality of menstrual materials, infrastructure, and disposal practices.

The menstrual health of the individual requires that disposal practices protect from

emotional and social harm, while disposal practices are also contributors to environmental

health. Research has identified a broad range of practices undertaken by individuals to care for

their body during menses, and the infrastructure and services required to support these (House,

2012). Self-care needs are not limited to accessing materials to collect menses, but include

transporting and storing materials, and require facilities and services for changing materials,

washing hands and the body, disposing of used materials and cleaning reusable materials which

may include washing, drying and other sterilizing practices such as Ironing or boiling (Hennegan

et al., 2019).

These care needs are relevant throughout the day and night, both at and away from the

home. Materials, facilities, and ser vices need to be accessible to people with disabilities.

Difficulties managing menstruation are a source of distress, irritation and discomfort, have been
identified as barriers to education and employment, have been linked to potential reproductive

tract infections, and can com promise social well-being (Hennegan & Montgomery, 2016).

Menstrual health as a public health and human rights issue

Before the COVID-19 pandemic, of the 1·9 billion individuals who menstruate, an

estimated 500 million were unable to attain menstrual health.1 Achieving menstrual health is

fundamental to the equality, rights, and dignity of all individuals who menstruate. Nonetheless,

menstrual health is still not considered a priority by all. As the COVID-19 pandemic puts

additional pressure on existing resources, we risk leaving behind the individuals who menstruate.

We advocate for the prioritization of menstrual health as an integral part of sexual and

reproductive health programmes, and for holistic approaches that address menstrual health, given

that it is affected by the social determinants of health and is not just a sexual and reproductive

health issue. Menstrual health is defined as complete physical, mental, and social wellbeing in

relation to the menstrual cycle (Hennegan et al., 2021). This definition reflects the multifaceted

nature of menstruation and the many ways the lives of those who menstruate can be affected by

their ability to properly manage their menstrual health.

Achieving good menstrual health is not just a matter of ensuring access to menstrual products but

also relies on individuals having the resources they need to participate fully in all spheres of life

during their menstrual cycle. These resources might illustratively include information, supplies,

sanitation facilities, supportive environments (including sensitized teachers and work

supervisors), and accessible health-care workers trained in menstrual health disorders. Millions

of women and girls worldwide experience period poverty, described as limited access to period

products, menstrual education, or adequate water sanitation and hygiene facilities (Sanchez,

2019). In addition, cultural norms, stigma, and taboos surrounding menstruation create further
barriers to achieving menstrual health. Although people’s experiences of period poverty are

varied and unique, the social determinants of health and structural determinants of gender

inequality act as key drivers of period poverty across the globe.

Through experiencing these barriers to achieving menstrual health, all those who

menstruate are being denied their basic human rights. Many of these human rights have shaped

the development framework of the UN Sustainable Development Goals, including poverty,

education, health, water and sanitation, and gender equality; therefore, addressing menstrual

health is crucial to reaching these goals by 2030.4 We propose four action points for achieving

menstrual health for all. First, there is a strong need to provide an enabling sociocultural

environment for those who menstruate to manage their menstrual needs with dignity and

comfort.

We can transform the social environment by creating structural level changes, such as

promoting messaging to challenge societal norms by including men and boys, along with those

who menstruate, towards reducing menstrual stigma, which is often a product of patriarchal

norms (Sommer, 2021). Second, shift the focus away from principally one of access in relation to

period products. Across many countries seeking to address menstrual health, distributing period

products is the priority; however, interventions should augment these efforts by providing

affordable quality materials, and information on different types of products, so that individuals

can make an informed choice about the product that best suits their needs.

Additionally, menstrual health curricula should be available for all those who menstruate

to promote understanding of the menstrual cycle within reproductive health, consideration of

menstrual disorders, and reduce stigma and shame through normalizing discussion of

menstruation. Third, we need to ensure the provisioning of adequate sanitation facilities, water,
changing and bathing spaces, and work with governments to support the development of waste

management systems that support the disposal of used menstrual materials (Goddard et al.,

2020). Fourth, health workers should be better trained on menstrual health, menstrual disorders,

and gender responsive approaches to understanding the needs of all the individuals who

menstruate, including girls and women, people with disabilities, transgender people, and gender

non-binary individuals.

We need health-care systems that treat menstruation as an important sign of health and

wellbeing and a key indicator of population health (Kirk, 2006). Lastly, individuals who

menstruate are often neglected, including those in emergency contexts, which directly affects

their rights to health, education, nondiscrimination, and gender equality. There is a need to

recognise menstrual health as a key right within the right to health. This has never been clearer

than during the COVID-19 pandemic, as those who menstruated faced barriers to safe, hygienic,

private places to manage their menstruation, along with shortages of menstrual products, an

essential item for health and dignity.

Cultural Beliefs and Restrictions during Menstruation

Menstrual hygiene practices were affected by cultural norms, parental influence, personal

preferences, economic status, and socioeconomic pressures. Menstrual beliefs refer to

misconceptions and attitudes towards menstruation within a given culture or religion. Menstrual

beliefs, knowledge, and practices were all interrelated to the menstrual hygiene management

(Aniebue et al., 2010). By reviewing literature and articles published in journals and reports

available on the Internet we found many cultural and religious beliefs followed by people

regarding menstruation. These norms were the barriers in the path of good menstrual hygiene
practices. Many women experiencing restrictions on cooking, work activities, sexual intercourse,

bathing, worshipping, and eating certain foods (Rakshayani et al., 1994).

These restrictions were due to the overall perception of the people regarding menstruation

as they consider it dirty and polluting (Jogdand et al., 2011). In some parts of the country there

were restrictions on bathing and a taboo against burial of bloodied menstrual cloth. Cloths should

first be washed and then buried or reused. Washing and drying thought to be done secretly or in a

hidden corner so that it cannot be seen by others. Menstrual f low was seen as dirty, polluting,

and shameful, so women hide menstrual cloths for fear of being cursed. In similar findings, it

was believed that menstrual waste was linked to witchcraft and danger, so it must be buried

unless witches (Rajaratnam, 2010).

Theories of Menstruation health

Theories about menstruation have evolved over centuries, reflecting the intersections of

medical knowledge, cultural beliefs, and societal norms. In ancient Greece and Rome, the

Humoral Theory suggested that menstruation was a mechanism for expelling excess bodily

fluids, or "humors," to restore balance and prevent illness (King, 1998). This notion laid the

groundwork for later ideas, such as the Toxic Blood Theory in medieval Europe, which viewed

menstrual blood as inherently impure and harmful, reinforcing stigmas around menstruating

women (Shail & Howie, 2005).

Modern biological theories offer more nuanced explanations. The Evolutionary Theory

posits that menstruation serves to protect the uterus from pathogens by regularly shedding the

endometrial lining, thus preventing infections (Strassmann, 1996). Another hypothesis, the

Energy Conservation Theory, argues that maintaining a thick endometrial lining continuously

would be energetically costly, and shedding it when pregnancy does not occur conserves energy
(Profet, 1993). The Embryo Elimination Theory suggests menstruation evolved as a way to expel

non-viable embryos, thereby enhancing reproductive efficiency by allowing only healthy

embryos to implant (Finn, 1996).

Socio-cultural theories provide additional layers of understanding. The Ritual Purification

Theory highlights how many cultures view menstruation as a time for ritual purification,

imposing specific practices and restrictions on menstruating women to signify a form of

cleansing (Buckley & Gottlieb, 1988). In contrast, the Social Constructivist Theory focuses on

how societal norms and cultural narratives shape perceptions and experiences of menstruation,

often marginalizing women and perpetuating taboos (Chrisler & Johnston-Robledo, 2002).

Relationship of Dietary Habit and Menstruation

Dietary habits play a critical role in influencing menstrual health, as the intake of

essential nutrients directly impacts hormonal balance and menstrual cycle regularity. A diet rich

in fruits, vegetables, whole grains, and lean proteins provides the vitamins and minerals

necessary for the proper functioning of the endocrine system, which regulates the menstrual

cycle. For instance, deficiencies in iron, magnesium, and omega-3 fatty acids have been linked to

increased menstrual pain and irregularities (Pal et al., 2015). Conversely, diets high in refined

sugars and unhealthy fats can exacerbate symptoms of premenstrual syndrome (PMS) and

dysmenorrhea by promoting inflammation and hormonal imbalances (Chocano-Bedoya et al.,

2017). Additionally, research has shown that maintaining a balanced diet helps mitigate the risk

of polycystic ovary syndrome (PCOS), a common endocrine disorder that affects menstrual

health (Banaszewska et al., 2016). Thus, promoting healthy dietary habits is essential for
supporting menstrual health and reducing the prevalence of menstrual-related disorders among

young adult girls.

Dietary habits significantly influence menstrual health, with various nutrients playing crucial

roles in regulating menstrual cycles and alleviating symptoms associated with menstruation. A

diet rich in fruits, vegetables, whole grains, and lean proteins provides essential vitamins and

minerals, such as magnesium, calcium, and vitamins B6 and E, which have been shown to

reduce menstrual pain and improve overall reproductive health (Dibaba et al., 2013).

Conversely, high intake of saturated fats, refined sugars, and salt has been linked to

menstrual irregularities and increased severity of symptoms like bloating and cramps (Chavarro

et al., 2007). Omega-3 fatty acids, found in fish and flaxseeds, have anti-inflammatory properties

that may help reduce menstrual pain and the intensity of menstrual cramps (Zeng et al., 2014).

Additionally, maintaining a balanced intake of protein and iron is crucial, as deficiencies in these

nutrients are associated with anemia and irregular menstrual cycles (McLean et al., 2009).

Studies also suggest that the consumption of phytoestrogens, found in soy products and legumes,

can help modulate estrogen levels, potentially alleviating symptoms of premenstrual syndrome

(PMS) (Setchell et al., 2003). Therefore, a well-balanced diet tailored to individual nutritional

needs can enhance menstrual health and mitigate associated discomforts.

In addition to the fundamental nutrients mentioned, dietary fiber also plays a pivotal role

in menstrual health. High-fiber diets help regulate blood sugar levels and promote hormonal

balance, reducing symptoms of PMS and dysmenorrhea (menstrual pain) (Barr et al., 2004).

Women consuming diets rich in fiber often report fewer instances of menstrual irregularities and

less severe menstrual cramps. Furthermore, the consumption of dairy products has been studied
for its dual effects: while calcium and vitamin D in dairy can alleviate PMS symptoms, excessive

intake of high-fat dairy products might exacerbate symptoms due to the presence of saturated fats

and estrogens (Bertone-Johnson et al., 2005). Caffeine and alcohol intake are also critical factors

affecting menstrual health. High caffeine consumption has been linked to increased menstrual

discomfort and irregular cycles, likely due to its impact on estrogen levels and potential for

causing dehydration, which can intensify cramps (Fenster et al., 1999). Similarly, excessive

alcohol consumption can disrupt hormone regulation and lead to menstrual irregularities and

more severe PMS symptoms (Mumford et al., 2014).

The relationship between body weight and menstrual health is also closely tied to dietary

habits. Both undernutrition and obesity can lead to menstrual disturbances. Underweight women,

often due to restrictive diets, may experience amenorrhea (absence of menstruation) due to

insufficient body fat necessary for estrogen production (Frisch, 1984). Conversely, obesity,

frequently linked to diets high in processed foods and low in nutrients, can cause irregular

menstrual cycles and conditions such as polycystic ovary syndrome (PCOS) due to insulin

resistance and elevated androgen levels (Hoeger et al., 2006). Moreover, hydration is an often-

overlooked aspect of diet that affects menstrual health. Adequate water intake helps alleviate

bloating and reduces the severity of menstrual cramps by aiding in the smooth function of the

muscles involved (Proctor & Murphy, 2001). Finally, the timing and frequency of meals can

influence menstrual health. Skipping meals or prolonged fasting can lead to blood sugar

imbalances, which may exacerbate PMS symptoms and menstrual irregularities (Goshtasebi et

al., 2013). Eating regular, balanced meals helps maintain stable blood sugar levels and supports

overall hormonal balance

Throughout a person’s life, certain events will occur which is of particular importance

and is considered as a turning point in their lives (Afaghi et al., 2012). Adolescence is a period of

rapid growth and the appearance of secondary sex characteristics (West and McNamara, 1999).

Due to rapid physical growth of adolescents, physiological activities are increased and they need

more energy to meet increasing demands in comparison to previous developmental period.

Breakfast is the most important meal in the dietary plan of an adolescent. Adequate intake of

animal and plant sources of protein is vital for adolescence. Vitamins and minerals such as

calcium, iron, and iodine must be included in adolescents’ diet. Best sources of vitamins are

fruits and vegetables while milk and dairy products are the best sources of calcium (Hallstrom et

al., 2012). Unfortunately, in some countries too little attention has been given to adolescent

nutrition. The result of these insufficient attentions is either insufficient or excessive diet. For

example, Fidler (2012) showed the in appropriation of adolescents’ dietary habits in Slovenia

were associated with the growth problems. In China, the average quantity of protein

consumption in children and adolescents in 1991 to 2009 has decreased and caused

A study reported that high school students with irregular daily meal patterns had poorer

health status and lower academic achievements than those who had regular meals. In Korea,

increased rate of eating out, fast-food consumption, and over consumption of sweets and

carbonated beverages have increased the adolescent obese population, which has led to the

incidence of chronic diseases such as diabetes, hypertension, and arteriosclerosis. Adolescents

want to become slim and the obese shape can be excluded in the peer group because of great

interests in appearance and body weight (Ro, 1998). The Indian meal pattern is affected by the

kinds of foods available. For example, rice is grown in certain parts of the country, and it forms
the staple in those regions. Similarly, wheat, jawar (barley), bajra (millet), makka (corn), and ragi

(finger millet) are used as staples where they are the major crops.

The kinds and amount of food eaten are affected by the money that can be spent for food.

The family’s meal pattern is dictated by geographic region, religion, and community and family

practices that have developed over several generations (1995). Adolescents and young adults are

usually open to new ideas; they show curiosity and interest. Many habits acquired during this

time will last a lifetime. Furthermore, with increasing age, youth’s personal choices and

preferences gain priority over eating habits acquired in the family, and they have progressively

more control over what they eat. Good nutritional status in adolescents and adults is decided by

proper nutritional knowledge, eating habits, and food behavior, which plays an important role not

only in the improvement of physical development but also in the maintenance of mental and

emotional stabilization.

Researches’ Results generally demonstrate that, among women in developed societies,

socioeconomic status is strongly inversely related to body weight and risk for overweight and

obesity (Crow, 2006; Duncan et al., 2006; Mirza, 2005; Newman, 2006; Ricciardelli, 2003;

Robinson, 2001; Yates, 2004). Information about developing countries are still less therefore,

This study was undertaken to assess the food habits of adolescents and adults girls in Mysore

urban area and exploring any relationships between SES, age groups and food preference and

behavior.

The deduction of weight and height among adolescents (Lopes et al., 2012). Overby

(2012) showed that Norwegian adolescents that consuming appropriate diet and do not omit

breakfast have lesser behavioral problems. However, studies in some countries such as South

Africa showed decreased consumption of breakfast among adolescents (Lopes et al., 2012).
Several studies have stressed adolescents need to understand the importance of nutrition in this

stage and have emphasized the importance of educational interventions (Sichert-Hellert et al.,

2011; Kersting et al., 2008). In addition, families have important role in creating appropriate

eating habits and physical activities. Support and encouragement from families and parental

modeling would result to healthy nutrition and the performance of physical exercise or the

opposite situations would result to less encouraging results (Menon et al., 2013). Meanwhile,

adolescent girls’ nutrition is vital because improving female adolescence nutrition behaviors is an

investment for improving health among future generations (Locks et al., 2013; Huffman and

Schofield, 2013).

In a study conducted on students aging 11 to 18 years in the Healthy Heart Project

conducted by Esfahan Medical University of Medical Sciences has reported that these girls have

moderate knowledge regarding nutrition (Boshtam et al., 2010). In addition, students’ attitudes

towards the importance of nutrition in adolescents and parental education were not found to be

significant however; there exist a significant relationship between the students’ awareness and

nutritional behavior to their parental educational level, This study and the studies conducted

regarding the important role of parents in encouraging their children towards adopting healthy

nutrition and performance of exercise during adolescence are consistent (Sleddens et al., 2012;

Totland et al., 2013).

However, the study conducted by the Cardiovascular Research Center, Esfahan

University of Medical Sciences has not found any significant relationships between the

nutritional score of the subjects of the study and the level of parental education and this finding

is inconsistent with the findings in our study (Totland et al., 2013). However, in the study

conducted by Lopez and associates in 2012, did not point out directly the relationship between
awareness, nutritional practices and parental educational level but they reported the students

having parents with lower educational levels have lower BMI, weight and height in comparison

to adolescents with parents having higher educational level (Lopez et al., 2012).

Diet Management for Menstruation

Dietary habits play a crucial role in the menstrual health of young girls. Proper nutrition

is essential for the regularity and comfort of menstrual cycles, while poor dietary habits can lead

to various menstrual disorders. Nutrient deficiencies, such as low levels of iron, calcium, vitamin

D, and omega-3 fatty acids, can significantly impact menstrual health. Iron deficiency anemia is

common among menstruating girls due to blood loss, leading to fatigue and exacerbated

menstrual discomfort. Adequate intake of calcium and vitamin D is crucial for bone health and

can help alleviate menstrual pain, with calcium particularly shown to reduce symptoms of

premenstrual syndrome (PMS). Omega-3 fatty acids, found in fish and flaxseeds, can reduce

inflammation and menstrual pain (Alquaiz et al., 2013)

A balanced diet rich in fruits, vegetables, whole grains, and lean proteins supports overall

health and menstrual regularity. Conversely, diets high in fat and sugar are linked to more severe

PMS symptoms and irregular menstrual cycles, as these foods can cause fluctuations in blood

sugar levels, leading to hormonal imbalances. Weight management is also critical; underweight

girls may experience amenorrhea (absence of menstruation) due to insufficient body fat needed

for estrogen production, while excess body weight can lead to irregular menstrual cycles and

conditions like polycystic ovary syndrome (PCOS), characterized by infrequent or prolonged

menstrual periods. Eating disorders such as anorexia and bulimia can severely disrupt menstrual

cycles due to extreme calorie restriction and nutrient deficiencies, often leading to amenorrhea or

oligomenorrhea (infrequent menstruation) (Thys-Jacobs et al., 1998).

reduce PMS symptoms such as mood swings and irritability, while adequate magnesium intake is

associated with reduced menstrual pain and PMS symptoms. In addition to dietary habits,

lifestyle factors play a significant role. Regular physical activity helps maintain a healthy weight

and reduce PMS symptoms, though excessive exercise can lead to menstrual irregularities.

Managing stress is essential, as high stress levels can disrupt the menstrual cycle by affecting

hormonal balance. Stress-reducing practices like yoga and meditation can be beneficial. Proper

hydration is also crucial, as it helps reduce bloating and alleviate menstrual cramps, supporting

overall bodily functions and energy levels during menstruation (Harel et al., 1998). Maintaining

a balanced diet rich in essential nutrients is vital for the menstrual health of young girls. Avoiding

excessive intake of unhealthy foods and managing weight through proper nutrition and physical

activity can help prevent and manage menstrual disorders. Addressing nutrient deficiencies and

promoting healthy eating habits are key strategies in supporting regular and comfortable

menstrual cycles.

A poor diet can have profound effects on the menstrual cycle, impacting both its

regularity and the severity of associated symptoms through various mechanisms. Nutrient

deficiencies, particularly of iron, calcium, vitamin D, and omega-3 fatty acids, are prevalent

among individuals with inadequate dietary habits and can significantly influence menstrual

health. Iron deficiency, a common issue among menstruating adolescents due to monthly blood

loss, often leads to iron deficiency anemia, characterized by fatigue and exacerbated menstrual

discomfort (Alquaiz, Khoja, & Alsharif, 2013). Adequate intake of iron is crucial for the
formation of hemoglobin, necessary for transporting oxygen throughout the body and supporting

healthy menstrual function.

Calcium and vitamin D are essential for bone health and muscle function, with emerging

research suggesting their roles in mitigating menstrual pain and regulating menstrual cycles.

Studies indicate that deficiencies in these nutrients may exacerbate premenstrual symptoms and

contribute to irregular menstrual patterns (Thys-Jacobs et al., 1998). Omega-3 fatty acids, found

abundantly in fish, flaxseeds, and walnuts, possess anti-inflammatory properties that can

alleviate menstrual pain and reduce the intensity of symptoms associated with menstruation

(Harel, 2006).

Moreover, the quality of dietary choices plays a crucial role in hormonal balance. Diets

high in processed foods, sugars, and unhealthy fats can lead to disruptions in blood sugar levels

and insulin response, impacting hormone levels such as estrogen and progesterone. These

hormonal imbalances can manifest as irregular menstrual cycles, skip periods, or heighten

premenstrual symptoms (Gold, Wells, & Rasor, 2008). A study highlighted in the Journal of

Adolescent Health indicated a significant association between poor diet quality and increased

severity of menstrual symptoms in young women, underscoring the importance of nutrition in

menstrual health management (Gold et al., 2008). Furthermore, lifestyle factors such as

excessive alcohol consumption and inadequate hydration can exacerbate menstrual irregularities

by affecting overall hormonal balance and bodily function. Proper hydration, along with a

balanced diet rich in whole grains, fruits, vegetables, and lean proteins, supports overall health

and can contribute to maintaining regular menstrual cycles (ACOG, 2006).

profoundly influencing the experience and management of menstruation. A balanced diet rich in

essential nutrients such as iron, calcium, vitamin D, and omega-3 fatty acids plays a critical role

in supporting menstrual function and alleviating associated symptoms. Iron is vital for

replenishing blood lost during menstruation and preventing iron deficiency anemia, which can

exacerbate fatigue and menstrual discomfort (Alquaiz et al., 2013). Calcium and vitamin D

contribute to bone health and muscle function, potentially reducing menstrual pain and

supporting overall menstrual regularity (Thys-Jacobs et al., 1998). Omega-3 fatty acids possess

anti-inflammatory properties that can mitigate menstrual pain and inflammation, offering natural

relief during menstruation (Harel, 2006).

Furthermore, dietary choices influence hormonal balance, impacting menstrual regularity

and symptom severity. Diets rich in fruits, vegetables, whole grains, and lean proteins provide

essential nutrients that support hormonal regulation and overall health. Conversely, diets high in

processed foods, sugars, and unhealthy fats can disrupt hormonal equilibrium, potentially leading

to irregular menstrual cycles and heightened discomfort (Gold et al., 2008). Hydration also plays

a crucial role in menstrual health, influenced by dietary habits. Proper hydration helps maintain

blood volume, supports bodily functions, and reduces bloating and discomfort during

menstruation. Adequate water intake contributes to overall well-being and enhances comfort

during this physiological process. In addition to dietary considerations, proper menstrual

hygiene practices are essential for maintaining comfort, cleanliness, and health during

menstruation. Regular changing of menstrual products and meticulous hygiene routines help

prevent infections and promote overall well-being (ACOG, 2006).

comprehensive approach to women's health supports optimal menstrual management and

enhances overall quality of life. By prioritizing nutritionally balanced diets and adopting proper

hygiene habits, women can effectively manage menstrual symptoms, promote hormonal balance,

and sustain long-term health and well-being throughout their menstrual cycles (Gold et al.,

2008).

Theories of Dietary Habits

The dietary habits of women are influenced by a complex interplay of biological,

psychological, social, and cultural factors. One prominent theory is the Biological Theory, which

emphasizes the role of hormonal fluctuations in shaping dietary preferences and behaviors. For

instance, research has shown that women may experience increased cravings for high-calorie

foods during the luteal phase of their menstrual cycle due to changes in levels of hormones like

estrogen and progesterone (Dye & Blundell, 1997). These hormonal influences can also affect

metabolism and appetite regulation, contributing to variations in dietary intake throughout the

menstrual cycle.

The Psychosocial Theory highlights the impact of societal expectations and body image

on women's eating habits. Social pressures to conform to certain beauty standards can lead to

restrictive eating behaviors and dieting, often resulting in disordered eating patterns (Striegel-

Moore & Bulik, 2007). Media representations of ideal body types further exacerbate these

pressures, influencing women to adopt diets that promise weight loss or body shaping, regardless

of their nutritional adequacy (Levine & Piran, 2001).

From a cultural perspective, the Cultural Theory explores how cultural norms and

traditions shape dietary habits. Different cultures have varying beliefs and practices regarding
food, which influence women's dietary choices. For example, some cultures emphasize plant-

based diets rich in fruits, vegetables, and grains, while others may focus on meat and dairy

consumption (Nestle, 2002). These cultural dietary patterns are often passed down through

generations and can significantly impact women's nutritional status and health outcomes.

The Socioeconomic Theory examines how economic status and access to resources affect

dietary habits. Women from higher socioeconomic backgrounds tend to have better access to a

variety of healthy foods, while those from lower socioeconomic backgrounds may face barriers

such as food insecurity and limited access to nutritious options (Darmon & Drewnowski, 2008).

This disparity can lead to differences in diet quality and health outcomes across different

socioeconomic groups.

Finally, the Life Course Theory considers how women's dietary habits change throughout

different stages of life, influenced by factors such as pregnancy, lactation, and menopause.

Nutritional needs vary significantly during these life stages, requiring adjustments in dietary

intake to meet the body's changing demands (King, 2000). For example, pregnant women need

increased intake of certain nutrients like folic acid and iron to support fetal development, while

postmenopausal women may need more calcium and vitamin D to maintain bone health.

Menstrual Hygiene

Menstruation is defined as the periodic discharge of blood from the uterus occurring more

or less at regular monthly intervals throughout the active reproductive life of a female

(Critchley,1986). Menstruation, a normal physiological process, may be looked at as more than

just a physiological process. It may be viewed either positively or negatively by the society. A

positive perception of menses would be by considering it a sign of femininity, fertility, youth, or

purification of the body. The negative perceptions include a linkage to being vulnerable and
susceptible to different illnesses, or creating feelings of disgust and shame. In some societies,

these negative perceptions become the basis of certain practices, like placing restrictions on

religious, social and domestic activities of a menstruating woman. A woman usually has two

kinds of perceptions of bleeding: one from her actual experience and the other she learns from

her elders and peers (Kalman, 2003).

A study conducted in India showed that 42.6% of respondents reused cloths for the

absorption of bleeding, which is not a bad practice. However, the cloth needs to be hygienically

washed and properly dried under sun to avoid bacterial contamination (Dasgupta & Sarkar,

2008).In another Indian study, it was reported that 77% of women used old pieces of cloth, and,

based on a hygienic practices scale, women having low scores also had the highest

proportion(34.1%) of white discharge, compared to medium and high scoring women.

Information collected from a study conducted in Bangladesh showed that 80% females reused

the same cloth for absorption of bleeding, but among them only 42% dried the cloth in sunlight

and the rest dried them in hiding (Mathews,1995).

Although females preferred to use sanitary towels, which were more absorbent and

thicker, they were unable to afford those (Mathews, 1995). According to a study conducted in

Pakistan, the affordability of sanitary pads is not the only reason for its under usage; rather,

females are more comfortable with either using a cloth or homemade pads. It was found that

82% of Punjabi and 65% Sindhi preferred to use homemade pads, whereas 15% Sindhi females

do not use any material. Instead, they change the trousers frequently to absorb bleeding (Khan et

al.,1998).

A study conducted by Abioye and Dasgupta reported that some girls perceived menstrual

period as unclean (Abioye-Kuteyi, 2000; Dasgupta & Sarkar, 2008). Similar perceptions are
reflected in our study as well, especially that women avoid prayer and attending religious

ceremonies. The reaction to menstruation depends upon awareness and knowledge of the subject.

The manner in which a girl learns about menstruation and its associated changes may have an

impact on her response to the event of menarche. As in our study girls felt fear and anxiety at the

time of menarche. This has been also supported by studies conducted in India and Nigeria

(Abioye-Kuteyi, 2000; Dasgupta & Sarkar, 2008; Khanna et al., 2005). In our study, those who

had some prior knowledge about menstruation received it mainly from their elder sisters and

mothers. Researchers have demonstrated that mothers in many cultures are an important resource

for menstrual preparation for their daughters (Dashiff,1992; Koff & Rierdan,1995a,1995b;

McGrory,1995; Tucker, 1990).

The poor literacy and the socioeconomic status of females in the community serve as an

inhibition to impart the significance, and a healthy attitude towards menstruation, as well as the

teaching of hygienic practices in regards to it. This is consistent with the study by Dasgupta and

Sarkar (2008). An Indian study conducted on schoolgirls studying in grade nine reported that

97.5% of these study participants did not know the source of bleeding during menstruation. less

than one-fourth of the participants were ignorant of this fact. Furthermore, this study reported

that girls were frightened to see and feel blood at menarche (Khanna et al., 2005). They were

worried, they wept and felt ashamed. Similar findings are reported from our study that

participants were fearful, worried and had anxiety. Many participants did not have any

knowledge regarding menstruation which is similar to the findings reported in Nigerian and

Indian studies (Abioye-Kuteyi, 2000; Khanna et al., 2005).

However, there were significant differences in terms of prior knowledge about

menstruation amongst the three groups. first, the government schools are more accessible to
researchers and non-governmental organizations (NGOs) for conducting health education

sessions as compared to private schools; second, the national curriculum taught in the public

schools gives some content related to reproductive health, and in addition community health

nurses visit these public school as part of the nursing curriculum and conduct sessions to create

awareness of issues related to adolescent reproductive health; third, private schools have their

own curriculum which may or may not significantly include reproductive health as part of their

curriculum; fourth, with the awareness of discrimination of gender in education at the

international level, the government has also set priorities for female education and has taken

some concrete steps to promote it.

Use of material for soaking blood

Generally in Pakistani culture, girls are either unaware of how to manage menstruation in a

hygienic manner or they cannot afford to manage it with modern menstrual materials (e.g.

commercial sanitary pads). Several people were aware of the fact that it is healthier to use pads

than rags, but could not afford them even occasionally (Ali et al., 2007; Fikree, Ali, Durocher, &

Rahbar, 2004). Furthermore, due to poverty, sanitary pads were seldom bought. Homemade pads,

if used hygienically, are also considered fine (Fikree et al., 2004). It was also noted that for some

of the participants the affordability of sanitary pads was not an issue.

Theyreportedthatpadsprovedtobeuncomfortableandcausedirritationorrashestotheuser. Some

females used new cloths and towels during menstruation, which were reused after being, washed

(Ali et al., 2006). According to our study, half of the girls used sanitary pads and the others used

old and new, washed or unwashed cloth material. These findings are consistent with a study

conducted in Bangladesh where upper middle class women residing in urban areas used

disposable sanitary towels. The same study reported that women belonging to the middle class
used reusable materials like cotton cloth torn from an old sari(Mathews,1995).An Indian study

reported that most of the girls used old cloth during menstruation and very few used sanitary

pads. Those who were using old cloth material did not wash them properly before use (Khanna et

al., 2005). A study conducted in Egypt reported that all 513 schoolgirl participants used sanitary

pads during menstruation (El-Shazlyet al.,1990). In contrast, our study found that most of the

girls used homemade pads. According to a Bangali study, women rinsed the stained cloth with

soap and water and then dried it in hiding under the bed or in a damp and dark place

(Mathews,1995). According to another study conducted in India, these cloths are washed with

soap but are later dried and stored in hidden and secret places for reuse (Khanna et al., 2005).

Another study conducted by Walraven et [Link] cloth away from the eyes of others. The cloth was

viewed as a source of vulnerability and potential embarrassment, and great efforts were made to

avoid this situation (Ullrich, 1992). The findings of an Egyptian study are almost consistent with

them. Similarly, most of the girls in both studies used 1–3 pads daily while some used 5–8 pads

(El-Shazly et al., 1990). It is very difficult to verify the thickness of the pads and the material

used as absorbent because the homemade could vary. Even the commercially available pads have

different absorbing capacity.

Theories of Menstrual Hygiene

Theories of menstrual hygiene encompass a range of perspectives that consider the

biological, social, cultural, and economic factors influencing menstrual health practices. The

Biomedical Theory emphasizes the importance of maintaining hygiene to prevent infections and

other health issues. This perspective is grounded in understanding the biological processes of

menstruation and the need for clean, absorbent materials to manage menstrual flow effectively

(Das et al., 2015). Proper menstrual hygiene management (MHM) practices, such as using
sanitary pads, tampons, or menstrual cups, are crucial in preventing conditions like urinary tract

infections and reproductive tract infections (House et al., 2012).

The Social Constructivist Theory examines how societal norms and cultural beliefs shape

menstrual hygiene practices. In many cultures, menstruation is surrounded by taboos and stigma,

influencing how women and girls manage their menstrual health. These social constructs can

lead to practices such as using homemade or unsanitary materials, often due to a lack of access to

commercial products or because of cultural prohibitions against discussing menstruation openly

(Mahon & Fernandes, 2010). This theory highlights the need for education and cultural change to

improve menstrual hygiene practices and reduce the stigma associated with menstruation.

The Economic Theory explores how socioeconomic status affects access to menstrual

hygiene products and facilities. Women and girls in low-income settings often face significant

barriers to accessing affordable and safe menstrual hygiene products, which can impact their

health, education, and overall well-being (Sommer et al., 2015). Economic constraints can lead

to the use of inadequate materials, which are not only uncomfortable but also pose health risks.

Addressing these economic barriers through policies and programs that provide free or

subsidized menstrual products is essential for promoting menstrual health equity.

The Environmental Theory considers the sustainability of menstrual hygiene products

and practices. With growing awareness of environmental issues, there is an increasing focus on

the environmental impact of disposable menstrual products, which contribute significantly to

plastic waste. This theory advocates for the use of eco-friendly alternatives such as menstrual

cups, reusable cloth pads, and biodegradable products, emphasizing the need for sustainable

menstrual hygiene practices that reduce environmental harm (van Eijk et al., 2019).
 The Educational Theory underlines the role of education in improving menstrual hygiene

management. Comprehensive menstrual health education can empower women and girls with the

knowledge and skills to manage their menstruation effectively and hygienically. Education

programs that provide information about the menstrual cycle, hygiene practices, and the use of

menstrual products can reduce stigma and promote healthy behaviors (Chandra-Mouli & Patel,

2017). Schools, communities, and healthcare providers play crucial roles in disseminating this

information and supporting menstrual health education initiatives.

Dietary changes during menstruation

We found that girls consider themselves as unclean during menstruation and were restricted from

social outings, bathing, and nutritional intake (with the belief that certain foods would either

make them ill in the present or in future). Many foods which are avoided during menstruation are

high in iron (e.g. liver, eggs) which could relate to the fact that anemia is a major health concern

amongst adolescent females. Saudi Arabian girls altered their nutritional intake, including foods,

drinks, and other activities (Moawed, 2001). Similarly, Bengali women also altered their food

intake and were restricted from eating meat, eggs, fish and leafy vegetables (Mathews,1995).

According to our study, half of the subjects were restricted by their family members and friends

from eating hot and cold foods like eggs and meat. These practices are worrisome from a health

and hygiene point of view.

Social limitations of maturational hygiene

According to a study conducted in Egypt, girls do not go to school and prefer to stay at home

during menstruation, either because of the pain or fear of bleeding (El-Shazly et al., 1990).

Similar findings were found in this study where about 60% of girls avoid socialization and limit
their movements. Furthermore, they avoided religious practices. This finding has been supported

by literature. In India, during their menstrual period women were not allowed to cook and enter

or touch any kitchen item. In rural areas, girls are restricted from passing through cross roads for

fear that they get caught by evil spirits and become mad ,and were also prohibited from attending

religious activities such as visiting temples and performing poojas (Dasgupta &Sarkar, 2008). A

Saudi Arabian study reported that girls were restricted for fasting, reciting Holy Koran, attending

mosque and could not be divorced during this period (Moawed, 2001).

According to our study, 50% of our subjects did not take bath during menstruation as they

were restricted by their mothers from doing so. Similar findings were consistent with Saudi

Arabian and Egyptian girls. However, an Egyptian study reported that 75.63% of girls bathed

during menstruation. This study also reported that bathing was thought to be unhealthy and that

there were many disadvantages to doing so during menstruation: backache, hair loss,

menorrhagia, cessation of bleeding, and maceration of the skin (El-Shazly et al., 1990). One

important finding of our study is that the adolescents who did not go to school held more

misconceptions and their practices were unhygienic compared to school-going girls. This has

been supported by by another study conducted in 2007 at Hyderabad, Pakistan, stating that

married women with higher education were more likely to indulge in hygienic practices than

those with no formal education (p 0.0001); there was no significant difference in menstrual

management practices among the income levels, as measured in our study (Ali et al., 2007).

According to a review article, women with higher education manage menstruation more

hygienically (Ullrich,1992). This indicates that literacy among adolescent girls would ensure a

healthier reproductive life. Schooling provides an environment that gives an insight into this

natural phenomenon of menstruation along with the ability to rationalize the related conceptions
and misconceptions and adopt the healthy and hygienic practices accordingly. There is no

defined curriculum in schools that talks directly about the process and management of

menstruation but in fact emphasizes healthier living.

Diet Hygiene and Menstruation

Research on diet, hygiene, and menstruation in Pakistan highlights several critical areas

of concern and progress. A study by Bhutta et al. (2013) emphasized that nutritional deficiencies

are prevalent among Pakistani women, particularly iron deficiency anemia, which is exacerbated

during menstruation. This nutritional inadequacy is often due to socio-economic factors that limit

access to a balanced diet rich in iron and other essential nutrients. Hygiene practices during

menstruation are also a significant public health issue.

Ali and Rizvi (2010) conducted a comprehensive survey revealing that only 50% of

women in rural areas use sanitary pads, while the rest rely on traditional methods such as cloth,

which are less hygienic and can lead to infections. This study highlighted the need for increased

awareness and accessibility to menstrual hygiene products to improve the overall health of

women in Pakistan.

Furthermore, a qualitative study by Alam et al. (2017) explored the cultural taboos and

misconceptions surrounding menstruation in Pakistan. The research found that menstruation is

often viewed as a taboo subject, leading to inadequate menstrual education among young girls.

This lack of knowledge contributes to poor menstrual hygiene practices and health issues. The

study called for educational programs to address these misconceptions and promote better

menstrual health management. The work by Shahid and Upadhyay (2019) on the impact of

socio-economic factors on menstrual health in Pakistan revealed that women from lower socio-
economic backgrounds face more significant challenges in managing their menstrual health. The

study noted that economic constraints limit access to hygienic menstrual products, adequate

nutrition, and healthcare services, further complicating the menstrual health landscape in the

country.

Conceptual Framework

The conceptual framework for the research on the "Relationship of Dietary Habits,

Hygiene, and Menstrual Health" is grounded in the Social Ecological Model (SEM). The SEM

posits that individual behavior is influenced by multiple levels of factors: intrapersonal,

interpersonal, organizational, community, and public policy (Bronfenbrenner, 1979). This model

is particularly relevant for understanding how dietary habits and hygiene practices impact

menstrual health, as these behaviors are shaped by a complex interplay of personal, social, and

environmental influences.

At the intrapersonal level, dietary habits, including nutrient intake and eating patterns,

affect hormonal balance and menstrual cycle regularity (Schoenaker et al., 2014). A diet rich in

essential nutrients like iron, calcium, and vitamins can mitigate menstrual discomfort and

improve overall reproductive health (Joshi et al., 2015). Hygiene practices, such as the use of

sanitary products and maintaining personal cleanliness, are critical in preventing infections and

ensuring genital health during menstruation (Dasgupta & Sarkar, 2008).

Interpersonally, family, peers, and healthcare providers play significant roles in shaping

dietary and hygiene behaviors. For instance, cultural norms and peer influences can impact

dietary choices and hygiene practices (Kumar & Srivastava, 2011). Organizational factors,
including schools and workplaces, can provide education and resources that promote healthy

dietary and hygiene behaviors (Sommer et al., 2016).

At the community level, access to clean water, sanitation facilities, and nutritional food

sources are essential for maintaining good menstrual health. Community-based interventions can

enhance awareness and improve practices related to menstrual hygiene and diet (Mahon &

Fernandes, 2010). Public policy is also crucial, as policies that ensure access to affordable

sanitary products, nutritional support programs, and clean water can significantly improve

menstrual health outcomes (House et al., 2012). By employing the SEM, this framework

highlights the need for multi-level interventions that address individual behaviors and broader

socio-environmental factors. This holistic approach is essential for developing effective

strategies that enhance menstrual health through integrated dietary and hygiene practices.

Dietary Habits

Menstrual Health

Hygiene Practices

Conceptual Model