Clinicians need to make discussion of menstruation a routine and meaningful part of clinical care to ensure menstrual health in their patients, according to findings from a qualitative study presented at the annual meeting of the American Academy of Pediatrics in San Diego and published August 30 in Frontiers in Adolescent Medicine. 

Sarah E. Combs, PhD, MPH, MSW, of Columbia University Mailman School of Public Health in New York City, and colleagues recommended normalizing conversations about menstruation, providing anticipatory guidance to patients ahead of menarche, and improving clinical workflows using a history-taking guide. They recommended the mnemonic MENSES, introduced in a previous paper, for history-taking: 

M = Menarche, when menstruation first starts
E = Every X days, how often their period starts
N = Number of days of bleeding
S = Supplies and products used
E = Effect on life
S = Start of last menstrual period 

“Menstrual health is a critical component of adolescent health,” and “pediatric [healthcare] providers play a unique role in identifying menstrual disorders early, normalizing conversations around menstruation, and improving long-term reproductive health outcomes,” the authors wrote.

Trish Hutchison, MD, a pediatrician, AAP spokesperson, and campus physician at the College of Charleston in South Carolina, was not involved with this study but viewed the findings and supported use of the mnemonic. 

“Just as we ask about sleep, school, nutrition, and mental health, we should routinely ask about menstruation when appropriate for a patient's age and stage of development,” Hutchison told Medscape Medical News. 

Because pediatric clinicians usually see patients before menarche, they can help prepare patients “for what to expect, reduce anxiety, and normalize menstruation,” said Hutchison, co-author of YOU-ology: A Puberty Guide for Every Body, co-founder of Girlology, and executive director of the Period Education Project, which educates young people about menstrual health and helps “prepare future healthcare providers to communicate about menstrual health confidently and compassionately.”

She advises pediatricians to use clear, nonjudgmental language, ask open-ended questions, start the conversation before menarche, and explain that periods can vary but that symptoms that affect daily life need attention. 

“We should also make space for questions about the impact of menstruation on school attendance, sports, sleep, mood, and overall quality of life,” she said.

Menstrual Health Clinical Conversations Vary

The AAP endorsed the 2015 committee opinion of the American College of Obstetricians and Gynecologists that the menstrual cycle should be a vital sign in female patients, but clinical practice regarding menstrual health varies across healthcare providers and often overlooks “broader quality-of-life concerns,” the authors wrote.

“We know the system works against [providers] spending more time on these issues,” said co-author Marni Sommer, DrPH, MSN, RN, a professor of sociomedical sciences at Columbia’s Mailman School. Sommer’s previous research has found that US adolescent girls often lack information about what is — and is not — normal for menstrual bleeding and pain and what symptoms of menstrual disorders are. 

Further, a study in 2020 found that over half (58%) of 462 pediatricians surveyed were “not at all” or only “slightly” familiar with AAP guidelines on anticipatory guidance around menarche. A quarter reported not discussing menarche with pre-menarchal patients, and a third didn’t discuss menstruation with post-menarchal patients.

Sommer’s team therefore conducted qualitative, semistructured, in-depth Zoom interviews from August 2024 to January 2025 with 46 pediatric healthcare providers in 22 states from four US geographic regions. About half the clinicians (54%) came from urban settings, 20% were rural, and 26% were suburban. Most were female (87%) and MDs (78%), with 13% nurse practitioners, 7% doctors of osteopathic medicine, and 2% physician assistants. Practice settings included academic institutions (20%), private practice (30%), a hospital or clinic (26%), and federally qualified health centers (FQHC; 24%).

Sommer said the study was intended to give a picture of what some clinicians are doing and what their recommendations are. “Our hope is to find out how to make it easier for clinicians to integrate this into their time with patients and perhaps encourage those who have not thought to spend more time on it.” 

Questions focused on how pediatric healthcare providers engage with menstrual health during routine clinical encounters and what barriers and facilitators affect integration of menstrual health into routine care. 

More Medical Training Needed

Analysis of the interviews revealed three key themes. First, formal training and experiential learning shape clinician engagement on menstrual health. One physician recalled observing a doctor asking a patient how many pads or tampons she used.

“Asking about products is a starting point, but it's not the same as taking a meaningful menstrual history or understanding how a patient's cycle affects their health and daily life,” Hutchison said. 

Hutchison acknowledged the challenge of incorporating these discussions into routine practice without sufficient education and training for pediatric clinicians on menstrual health.

“There is no consistent, standardized menstrual health curriculum across medical schools, residency programs, and continuing medical education in the United States,” Hutchison said. She said clinicians need to know what questions to ask, how to recognize symptoms requiring further evaluation, and how to discuss treatment options without normalizing unnecessary suffering.

A second theme focused on structural and relational factors affecting how much menstrual health is integrated into clinical encounters. One female MD from an urban FQHC in the Northeast, for example, said that menstruation questions “get pushed to the side,” largely because there isn’t enough time during appointments. “I can’t skip your school form and I can’t skip your vaccines,” she said. 

“Clinicians are managing preventive care, mental health, school concerns, chronic conditions, and so many other issues,” Hutchison said. “When menstrual health isn't built into the routine workflow, it's easy for it to become another topic that gets pushed aside when time runs short.”

A “Window Into Overall Health” 

The third theme was that considering biological, quality-of-life, and condition-specific aspects of menstrual health can “create a more complete understanding of menstruation and support effective clinical care,” the authors wrote. 

Hutchison said that periods are an important window into a patient’s overall health, with past research finding that menstrual cycle irregularity during adolescence is associated with cardiovascular and cardiometabolic health risks in adulthood. 

“These conversations can help us identify concerns earlier, provide appropriate treatment, and recognize conditions that might otherwise go undiagnosed,” Hutchison said. “In some cases, early recognition may also create opportunities for intervention that could improve long-term health outcomes.”

Sommer was pleased to learn that healthcare providers broadly reported believing menstrual health is important. She also noted how menstrual pain was discussed.

“We’ve been normalizing the discomfort and pain and heavy bleeding of periods for a very, very long time,” Sommer said. 

Hutchison similarly noted the importance of paying attention to how menstruation affects daily life.

“Painful or heavy periods, irregular bleeding, and symptoms that interfere with school, sports, sleep, or daily activities shouldn't simply be dismissed as something patients have to tolerate,” she said. Learning about those issues means overcoming the role of stigma in these conversations. 

“Menstruation has historically been treated as an uncomfortable or private topic, and that can influence both patients and providers,” Hutchison said. “Patients may not bring up their symptoms unless they're asked, and pediatricians may assume that if a patient doesn't mention a problem, there isn't one.

“When we talk about periods openly and without stigma, we send a powerful message: menstrual health is health,” said Hutchison. “Young people should feel comfortable asking questions and confident that their concerns will be taken seriously. We have an opportunity to establish that trust early, before a patient has spent years believing that period pain or other symptoms are just something they have to live with. Ultimately, making menstrual health a routine part of care is one way we can work toward decreasing gaps in girls' and women's health.”

The research was funded by the Sid & Helaine Lerner MHM Faculty Support Fund. The authors and Hutchison reported no relevant financial relationships. 

Tara Haelle has been an independent science/health journalist for over 15 years. She is based in Dallas, Texas.