Open Access Original

Article DOI: 10.7759/cureus.9894

Perceptions, Practices, and Challenges Regarding

Menstrual Hygiene Among Women in Karachi,
Pakistan: A Comparison Between General
Population and Healthcare Workers
Shajeea Arshad Ali 1 , Mariam Baloch 1 , Lubna Riaz 2 , Ayman Iqbal 1 , Ramsha Riaz 1 , Bushra Perveen 1 ,
Maham Siddiqui 3 , Asadullah Arshad Ali 1

1. Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, PAK 2. Forensic Medicine and
Toxicology, Dow Medical College, Dow University of Health Sciences, Karachi, PAK 3. Internal Medicine, Dow
International Medical College, Dow University of Health Sciences, Karachi, PAK

Corresponding author: Shajeea Arshad Ali, [email protected]

Abstract
Background
Menstruation is a natural physiological phenomenon, yet considered a stigmatized subject, particularly in
low- and middle-income countries like Pakistan. It is seldom discussed openly, leading to flow of incorrect
and incomplete knowledge. The resultant unhealthy practices not only affect the health of the menstruator
but can also contribute to considerable psychosocial stress. Menstrual hygiene management (MHM) is an
important facet, which is associated with a variety of practices and beliefs in different parts of the world,
some of which may not be correct. Identifying these poor methods is necessary in order to rectify them.
Hence, our study aimed at determining the level of knowledge, beliefs, and practices pertaining to
menstruation in the general female populace of Karachi. Healthcare workers have a potential role in the
dissemination of authentic knowledge and practices. Therefore, we assessed and compared the accuracy and
reliability of the aforementioned parameters in them and the need for an educational intervention.

Methods
A descriptive, cross-sectional study was conducted on females visiting the Gynecologic and Obstetrics
Outpatient Department (OPD), and healthcare workers employed at Dr. Ruth K. M. Pfau Civil Hospital
Karachi and Dow University Hospital Ojha. Using non-probability convenience sampling, a self-structured
questionnaire was used to collect data from 353 respondents over a duration of three months from October
2019 to January 2020. Data was tabulated in Statistical Package for the Social Sciences (SPSS) version 24.0
(IBM Corp., Armonk, NY, US). In accordance with the objectives of the study, descriptive analysis was
performed, and data was presented in the form of frequencies and percentages.

Received 08/13/2020 Results

Review began 08/14/2020
Review ended 08/14/2020 Of the 353 participants, 176 were from the general population and 177 were healthcare workers. At
Published 08/20/2020 menarche, only 28.4% of the general population and 29.4% of healthcare workers had an idea of menses and
proper placement of absorbent. Significantly lower number of females from the general population were
© Copyright 2020
Arshad Ali et al. This is an open access found to be aware of tampons and menstrual cups (15.9% and 11.4% respectively) as compared to healthcare
article distributed under the terms of the workers. For both groups, the source of knowledge was mostly their mother. The study showed that 77.8% of
Creative Commons Attribution License the general population and 66.1% of healthcare workers avoided bathing on certain days during menses,
CC-BY 4.0., which permits unrestricted
with the most common reason being that "it causes irregular flow". As compared to healthcare workers, a
use, distribution, and reproduction in any
medium, provided the original author and
significantly higher number of women from the general population had restrictions of activity (53.4%) and
source are credited. avoided washing of groin area during menstruation (31.2%). Majority of women from the general population
mentioned that they were scared when they menstruated for the first time. The most common absorbent
used by respondents was pads, followed by cloth. The data showed 64.2% of females from the general
population and 28.8% of healthcare workers abstained from eating certain foods. Seeking treatment for
gynecological issues was not widespread among respondents.

Conclusion
Our study demonstrated insufficient menstrual knowledge, and consequent incorrect practices in the female
population of Karachi. Destigmatizing menstruation and educating women and young girls is indispensable
to overcoming this gap. At the same time, reinforcing the availability of MHM products is long overdue and
is a crucial milestone towards facilitation of MHM for the women of Pakistan.

Categories: Family/General Practice, Obstetrics/Gynecology, Epidemiology/Public Health

Keywords: menstruation, menarche, menstrual cycle, menstrual management, healthcare workers, reproductive
health, reproductive tract infections, pakistan, menstrual hygiene, low- and middle-income country

How to cite this article

Arshad Ali S, Baloch M, Riaz L, et al. (August 20, 2020) Perceptions, Practices, and Challenges Regarding Menstrual Hygiene Among Women in
Karachi, Pakistan: A Comparison Between General Population and Healthcare Workers. Cureus 12(8): e9894. DOI 10.7759/cureus.9894
 Introduction
Menstruation is an essential phenomenon transitioning a female’s body from childhood to pubertal age. It is
a life-altering event where, although ceremonial attention to “coming of age” is paid, very little factual
information is given regarding its management and practices [1]. According to the United Nations Children's
Fund (UNICEF), menstrual hygiene management (MHM) is hygiene related to the menstrual process. MHM is
defined as women and adolescent girls having access to menstrual hygiene products, soap and water, and
adequate sanitation facilities throughout the duration of a menstrual cycle. It also includes the aspect of
women understanding the basic facts related to the menstrual cycle and how to manage it with confidence
and dignity [2].

MHM begins at menarche; albeit the concepts, beliefs, and practices employed vary in different parts of the
world owing to a variety of factors including access to water, sanitation, and hygiene (WASH) facilities at the
household level, socioeconomic status, education of the menstruator, source of knowledge, divergent
ethnicities, and religious and cultural differences [3].

There is a stigma and taboo associated with menstruation, especially in low- and middle-income countries
(LMICs). It is considered ‘dirty’ or ‘impure’, something that should be ‘shrouded in secrecy’ and suffered in
silence [4]. Most of the women are hesitant to discuss matters pertaining to sexual health and do not discuss
it openly, which serves as a major barrier to proper education regarding menstrual hygiene [3]. With
inadequate information being disseminated, they harbor myths and preconceived notions that are reflected
in their unhealthy menstrual practices. This not only has medical implications like increased risk of urinary
tract infections (UTIs) and reproductive tract infections (bacterial vaginosis, candidiasis, vaginal scabies),
but can also contribute to considerable psychosocial stress [5-7].

There has been a significant amount of research on myths and traditional strategies governing the
menstruation in other resource-limited countries like Ghana, Tanzania, Ethiopia, Nepal, and India [3,4].
However, the same cannot be said for Pakistan, which also has straitened resources and similar MHM state.
The topic has not been sufficiently studied with only a few cross-sectional studies conducted in some cities
of Pakistan such as Quetta, Peshawar, and Lahore [8-10]. There is a lack of availability of the recent data in
the literature regarding this topic in Karachi, which is the major metropolis of the country. The recent
Census of Pakistan of the year 2017 states a figure of 101,331,000 (48.77%) females from the total population
of 207,774,520 [11]. Considering that the females constitute an almost equal fraction of the population, the
lack of research of their most basic life event is dismal, to say the least. Therefore, to bridge this gap, the
primary objective of our investigation was to determine the knowledge, perceptions, practices, and
challenges regarding menstruation faced by the women in Karachi, Pakistan.

Furthermore, the World Health Organization (WHO) defines the health workforce as “all people engaged in
actions whose primary intent is to enhance health” [12]. These include clinical staff, such as physicians,
nurses, pharmacists, and dentists. Vigorous and extensive study designs have not been developed to assess
the competence of health workers in fulfilling the needs of a specific population [12]. This, however, is
imperative for the governance of an efficient healthcare system. With regard to menstrual management, the
role played by healthcare workers has been studied less commonly and has always been cited as
unsupportive or as a rare source of information [3,4]. Considering this, the secondary objective of our study
was to compare the aforementioned parameters in healthcare workers and to determine the need or the lack
thereof of their counselling in this context.

Materials And Methods

A descriptive cross-sectional study was conducted between October 2019 and January 2020 to compare the
beliefs and practices regarding menstruation between healthcare workers and the general female population
in Karachi, Pakistan. It was a questionnaire-based study with a sample size of 353 participants. The data was
collected from two tertiary care hospitals, i.e. Dr. Ruth K. M. Pfau Civil Hospital Karachi and Dow University
Hospital Ojha.

The sample size was calculated using OpenEpi.com sample size calculator, version 3.01 [13]. Using an
anticipated frequency (p) of 67.1%, margin error of 5%, and a confidence interval (CI) of 95%, minimal size
of the sample was computed to 340 [13,14]. The sample was divided into two groups, health workers and
women visiting the gynecologic and obstetrics out-patient department (OPD) of the two hospitals. 400
women were approached to participate in the study, 200 from the general population and 200 healthcare
workers. Among those women, 353 consented to participate in the study, and the response rate was
calculated to be 88.25%.

Females having undergone menarche and those of reproductive age were included in the study, while those
women falling in the category of precocious puberty and undergone menopause, having any chromosomal
aberrations, undergone hysterectomy, facing severe language barrier, or any declared mental and
psychological disorder were excluded. Resident trainees, physicians, nurses, and house officers (interns)
were subsumed under healthcare workers.

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 2 of 29

 Data was collected through a self-reported, self-administered questionnaire with a total number of 38
questions. There was one open-ended and 37 close-ended questions. In order to ensure the reliability and
validity of the questionnaire and to prevent ambiguities, a pilot study was conducted where 15 health
workers and populace meeting the inclusion criteria were asked to fill the questionnaire and their feedback
was incorporated to upgrade the final version. Expert opinion of a senior gynecologist was also gained to
refine and finalize the questionnaire. The participation of candidates was voluntary, and permission was
taken through a written informed consent form at the beginning of the questionnaire. Personal information
was kept confidential and anonymous. Questions were translated in the national Pakistani language and
lingua franca, Urdu, to help participants who were unable to read or understand English language, and
assistance was given by investigators if the respondents faced difficulties.

The questionnaire was subdivided into four parts: sociodemographic characteristics, knowledge of the
participants regarding menstruation, reactions and practices pertaining to menstruation, and problems and
challenges faced by women during menstruation. The socio-demographic characteristics of the participants
included age, marital status, educational status, mother’s educational status, family income, and religion.
The second section regarding knowledge of the participants included questions such as source of knowledge
related to menstruation, awareness regarding tampons and menstrual cups, knowledge about menstruation
at the time of menarche, and awareness regarding the cause of infrequent menses.

Third section of the questionnaire included questions associated with general menstrual hygiene practices
like taking bath, reasons for avoiding bath, materials used while taking bath, exercise, washing groin area,
and restriction of activities. It also interviewed women regarding sanitary choices to avoid staining (for
example cloth, pad, tampon, and cups), the reasons behind them, ways of disposing of them, and the
number of times the absorbent was changed. Moreover, this section covered questions pertaining to
reactions of women when they menstruated for the first time (scared, guilty or confused), and if they were
openly able to discuss any gynecological issues they were facing.

The last section of the questionnaire listed the problems and challenges faced by participants during
menstruation such as going out of their homes, avoiding certain food items, refraining from taking
medicines, unavailability of sanitary pads in their institute/workplace, and experiencing any other issues
like bloating, anxiety, nausea, etc., or having complaints of a bad odor during periods. The participants were
also asked if they had ever faced a few of the common gynecological complaints and if they sought any
treatment for it.

Data was tabulated in Statistical Package for the Social Sciences (SPSS version 24.0, IBM Corp., Armonk, NY,
US) and presented in the form of mean, frequencies, and percentages. In accordance with the objectives of
the study, descriptive analysis was performed. Chi-square test was applied for categorical variables, while
independent sample t test was applied to analyze continuous variables. P-values less than 0.05 were
considered to be statistically significant.

Results
The current study was conducted employing 353 females, amongst which 176 were from the general
population and 177 were healthcare workers. As shown in Table 1 below, the mean age of the general
population was 29.89 ± 9.17 with the age range being 14-50 years, while the mean age of the healthcare
workers was 30.54 ± 6.52 with the age range being 23-54 years. Most of the females amongst the general
population were uneducated (26.1%), while the majority of the healthcare workers were graduates (62.1%).
Similarly, 51.1% of the general population's females’ mothers were uneducated while 58.8% of healthcare
workers’ mothers were graduates. The majority of respondents from both categories were Muslims and lived
in a brick-built house. 62.5% of the general population was observed to have family income of below 40,000
Pakistani Rupee (PKR) and 55.9% of healthcare workers had a family income between 40,000-100,000 PKR.
A large fraction of females from the general population were married (65.9%) while the majority
of healthcare workers were single (66.7%).

Sociodemographic variables General population, N (%) Healthcare workers, N (%) P-value

Mean age (years) ± SD 29.89 ± 9.17 30.54 ± 6.52 0.447

Age range (years) 14-50 23-54

Education 0.000

Postgraduate 4 (2.3) 67 (37.9)

Graduate 42 (23.9) 110 (62.1)

Intermediate 29 (16.5) 0 (0)

Secondary 34 (19.3) 0 (0)

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 3 of 29

 Primary 21 (11.9) 0 (0)

Uneducated 46 (26.1) 0 (0)

Education of mother 0.000

Postgraduate 6 (3.4) 17 (9.6)

Graduate 20 (11.4) 104 (58.8)

Intermediate 16 (9.1) 30 (16.9)

Secondary 20 (11.4) 18 (10.2)

Primary 24 (13.6) 6 (3.4)

Uneducated 90 (51.1) 2 (1.1)

Total family income per month 0.000

Above PKR 100,000 18 (10.2) 56 (31.6)

Between PKR 40,000-100,000 48 (27.3) 99 (55.9)

Below PKR 40,000 110 (62.5) 22 (12.4)

House Structure 0.000

Pakka (brick-built) 104 (59.1) 172 (97.2)

Semi Pakka (tin roofing or sheets) 35 (19.9) 5 (2.8)

Kaccha (no bricks) 37 (21.0) 0 (0)

Marital Status 0.000

Married 116 (65.9) 57 (32.2)

Widowed 2 (1.1) 2 (1.1)

Divorced 1 (0.6) 0 (0)

Single 57 (32.4) 118 (66.7)

Religion 0.645

Islam 172 (97.7) 170 (96.0)

Christianity 2 (1.1) 4 (2.3)

Hinduism 2 (1.1) 3 (1.7)

TABLE 1: Socio-demographic characteristics of the participants

SD: standard deviation; PKR: Pakistani Rupee

a Calculated using Chi-square test; P-value of <0.05 considered statistically significant

b Number of females from general population: 176; number of healthcare workers: 177

Knowledge of the participants regarding menstruation and their awareness at the time of menarche was
assessed as shown in Table 2 below. It was found that amongst both categories, the most common source of
information regarding menstruation were the mothers of participants (58.5% for the general population and
53.1% for healthcare workers). Only about one-third of the participants from both groups (28.4% from the
general population and 29.4% from healthcare workers) were completely aware of menstruation and knew
the proper course of action at the time of menarche. Data shows 88.6% of females from the general
population and 57.6% of the healthcare workers were unaware of menstrual cups. While 53.1% of healthcare
workers were observed to be aware of tampons, 84.1% of females from the general population were found to
be lacking in their knowledge of such products. Infrequent menstruation was assumed to be a sign of
pregnancy in 58% of the general population, while only 23.2% of healthcare workers believed such
assumptions to be true.

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 4 of 29

 General Population, N (%) Healthcare workers, N (%) P-value

Source of general overview and do’s and don'ts of menstruation 0.000

Mother 103 (58.5) 94 (53.1)

Grandmother 9 (5.1) 6 (3.4)

Teachers 6 (3.4) 12 (6.8)

Relatives or siblings 28 (15.9) 10 (5.6)

Friends 14 (8.0) 30 (17.0)

Self-knowledge (TV, Books, Internet) 7 (4.0) 22 (12.4)

No one 9 (5.1) 3 (1.7)

Knowledge at menarche 0.000

I was already aware of periods, knew how to prevent staining my clothes and knew how to properly place the cloth/ pad 50 (28.4) 52 (29.4)

I was already aware of periods, knew how to prevent staining my clothes but had no idea of how to properly place the cloth/pad 40 (22.7) 48 (27.1)

I was aware of periods but didn’t know how to prevent staining my clothes 24 (13.6) 39 (22.0)

I thought I had some disease/infection 34 (19.3) 8 (4.5)

I thought I had suffered an injury 14 (8.0) 7 (4.0)

I thought I was pregnant 1 (0.6) 1 (0.6)

I was not aware at all and sought elders 13 (7.4) 22 (12.4)

Are you aware of what a tampon is? 0.000

Yes 28 (15.9) 94 (53.1)

No 148 (84.1) 83 (46.9)

Are you aware of what a menstrual cup is? 0.000

Yes 20 (11.4) 75 (42.4)

No 156 (88.6) 102 (57.6)

Do you believe that infrequent menses is a sign of pregnancy? 0.000

Yes 102 (58.0) 41 (23.2)

No 74 (42.0) 136 (76.8)

TABLE 2: Knowledge of the participants regarding menstruation

a Calculated using Chi-square test; P-value of <0.05 considered statistically significant

b Number of females from general population: 176; number of healthcare workers: 177

The responses of females from both subgroups who were aware of tampons and were questioned regarding
the reasons for not using them are illustrated in Figure 1. The most common reason amongst healthcare
workers was found to be that it is “uncomfortable/ strange to use”, while the majority of the general
population responded that it was “unavailable in local shops”. Lack of affordability due to the high cost of
the product was found to be significantly associated with the general population as compared to healthcare
workers (P-value = 0.049).

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 5 of 29

 FIGURE 1: Reasons for not using tampons amongst general population
and healthcare workers

The respondents were further questioned regarding their reactions and practices pertaining to menstruation
as shown in Table 3. Majority of the respondents amongst the general population (65.9%) and healthcare
workers (75.1%) were able to talk freely about any gynecological issues they were facing. An astounding
finding in our study was that most women from both categories (77.8% of general populace and 66.1% of
healthcare workers) avoided bathing during menstruation. The females were further questioned about the
number of days they avoided bathing, where 48.7% of healthcare workers responded that they avoid it for
the first day and 44.5% of general population avoided it for the first three days of menstruation. Data
showed that 68.8% of general population and 88.7% of healthcare workers responded that they wash the
groin after urination or defecation. Water and soap were the most common means of taking a bath when
menses ended.

General population, N (%) Healthcare workers, N (%) P-value

Are you able to talk freely with your mother or any relatives about any gynecological issues? 0.057

Yes 116 (65.9) 133 (75.1)

No 60 (34.1) 44 (24.9)

Do you avoid bathing during menses? 0.014

Yes 137 (77.8) 117 (66.1)

No 39 (22.2) 60 (33.9)

If yes, how many days do you avoid bathing during menses? 0.013

During the first day 44 (32.1) 57 (48.7)

During the first three days 61 (44.5) 45 (38.5)

During all days 32 (23.4) 15 (12.8)

Do you avoid washing the groin after urination/defecation? 0.000

Yes 55 (31.2) 20 (11.3)

No 121 (68.8) 157 (88.7)

Do you stop doing exercise during menses? 0.175

Yes 24 (13.6) 27 (15.3)

No 40 (22.7) 54 (30.5)

I don’t do exercise regularly 112 (63.6) 96 (54.2)

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 6 of 29

 Do you have any restrictions of activity during menses? 0.002

Yes 94 (53.4) 66 (37.3)

No 82 (46.6) 111 (62.7)

If yes, which ones? 0.015

Climbing stairs 31 (33.0) 12 (18.2)

Lifting weight 41 (43.6) 44 (66.7)

Walking 22 (23.4) 10 (15.1)

What were your feelings when you menstruated for the first time?

Scared 0.043

Yes 74 (42.0) 56 (31.6)

No 102 (58.0) 121 (68.4)

Guilty 0.493

Yes 16 (9.1) 20 (11.3)

No 160 (90.9) 157 (88.7)

Upset 0.045

Yes 32 (18.2) 48 (27.1)

No 144 (81.8) 129 (72.9)

Anxious 0.109

Yes 53 (30.1) 40 (22.6)

No 123 (69.9) 137 (77.4)

Normal 0.003

Yes 20 (11.4) 41 (23.2)

No 156 (88.6) 136 (76.8)

Confused 0.408

Yes 66 (37.5) 74 (41.8)

No 110 (62.5) 103 (58.2)

Miserable 0.005

Yes 12 (6.8) 29 (16.4)

No 164 (93.2) 148 (83.6)

Shame 0.000

Yes 43 (24.4) 12 (6.8)

No 133 (75.6) 165 (93.2)

Excited/Delighted 0.191

Yes 8 (4.5) 14 (7.9)

No 168 (95.5) 163 (92.1)

Which of these do you use during menstruation to avoid staining your clothes? 0.000

Cloth 53 (30.1) 15 (8.5)

Pads 93 (52.8) 151 (85.3)

Cloth and pads 17 (9.7) 9 (5.1)

Tampon 3 (1.7) 2 (1.1)

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 7 of 29

 Tissue paper 1 (0.6) 0 (0)

Cotton 8 (4.5) 0 (0)

Menstrual cup 1 (0.6) 0 (0)

For those using cloth, is the cloth: 0.984

Torn from a new fabric 29 (41.4) 10 (41.7)

Torn from an old worn out shirt 41 (58.6) 14 (58.3)

How many times do you change the menstrual product? 0.074

4 or more times per day 28 (16.0) 17 (9.6)

2-3 times per day 115 (65.3) 127 (71.8)

Once per day 24 (13.6) 30 (16.9)

Use 1 for almost 2 days 9 (5.1) 3 (1.7)

How do you dispose of the menstrual products after using them? 0.000

Bury it 12 (6.8) 1 (0.6)

Burn it 10 (5.7) 1 (0.6)

Flush it in the toilet 2 (1.1) 1 (0.6)

Throw it in waste 133 (75.6) 170 (96.0)

Throw it in sea 4 (2.3) 2 (1.1)

Store it for further use 15 (8.5) 2 (1.1)

What do you use while taking a bath after your period ended? 0.010

Water only 16 (9.1) 8 (4.5)

Water and soap 136 (77.3) 158 (89.3)

Water and antiseptic 24 (13.6) 11 (6.2)

TABLE 3: Reactions and practices of the participants pertaining to menstruation

aCalculated using Chi-square test; P-value of <0.05 considered statistically significant

bNumber of females from general population: 176; number of healthcare workers: 177

Data revealed that 53.4% of general populace was found to have certain restrictions of activity during
menstruation, amongst which the most common was lifting weight. The feelings of the women at the time of
menarche were also questioned. About 42% of women from the general population responded that they were
scared while 41.8% of healthcare workers were confused at the time of menarche. The most common product
used by women from both categories (52.8% of general population and 85.3% of healthcare workers) at the
time of menstruation was sanitary pads, followed by cloth (30.1% of general population and 8.5% of
healthcare workers). Amongst those using cloth, 58.6% of the general population and 58.3% of healthcare
workers were found to be using the fabric torn from an old, worn-out shirt. Majority of women from both
categories (65.3% of the general populace and 71.8% of healthcare workers) changed their menstrual
products two to three times per day. A large fraction of females from both categories disposed of the
menstrual products by throwing them in the waste.

The women were interviewed regarding the reasons they take bath or avoid it during menses. As shown in
Figure 2 below, the most common reason for avoidance of bathing was found to be that "it can cause
irregular flow", amongst both the general population and healthcare workers. None of these reasons were
found to be statistically significant between general population and healthcare workers (P-value > 0.05).

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 8 of 29

 FIGURE 2: Reasons for avoidance of bathing amongst general
population and healthcare workers

As shown in Figure 3 below, the most common reason for taking bath was found to be “hygienic reasons”
amongst both the general population and healthcare workers. The practice of taking bath to soothe cramps
was found to be significantly higher in healthcare workers than in the general population (P-value = 0.047).

FIGURE 3: Reasons for taking bath amongst general population and

healthcare workers

The respondents of the study were questioned regarding the problems and challenges faced by them during
menstruation as shown in Table 4. Around 64.2% of the women from the general population abstained from
eating certain food items whereas only 28.8% of healthcare workers were found to be following this practice.
The women were questioned about whether they experience any premenstrual symptoms, amongst which
most women from the general population experienced fatigue (47.7%), while majority of women from
healthcare workers experienced mood swings/irritability (48.6%). Around 32.4% of women from the general
population and 26% of healthcare workers avoided taking any medicine during menstruation due to the
innate fear that their cycle would be disturbed. Majority of women from both factions (54% of the general
populace and 65% of healthcare workers) went out of their homes without any inhibitions. However, a
comparatively higher number of women from the general population (5.7%) avoided going out of their
homes because they feared evil spirits/black magic.

General population, N (%) Healthcare workers, N (%) P-value

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 9 of 29

 Do you abstain from eating certain food items during menses? 0.000

Yes 113 (64.2) 51 (28.8)

No 63 (35.8) 126 (71.2)

Which one of these complains do you have during menses?

Tension or anxiety 0.711

Yes 69 (39.2) 66 (37.3)

No 107 (60.8) 111 (62.7)

Poor concentration 0.200

Yes 32 (18.2) 42 (23.7)

No 144 (81.8) 135 (76.3)

Abdominal bloating 0.000

Yes 31 (17.6) 68 (38.4)

No 145 (82.4) 109 (61.6)

Change in sexual desires 0.160

Yes 37 (21) 27 (15.3)

No 139 (79.0) 150 (84.7)

Breast tenderness 0.001

Yes 17 (9.7) 39 (22.0)

No 159 (90.3) 138 (78.0)

Crying spells 0.041

Yes 20 (11.4) 34 (19.2)

No 156 (88.6) 143 (80.8)

Hair fall or dandruff 0.195

Yes 20 (11.4) 13 (7.3)

No 156 (88.6) 164 (92.7)

Acne 0.498

Yes 40 (22.7) 35 (19.8)

No 136 (77.3) 142 (80.2)

Mood swings or irritability 0.260

Yes 75 (42.6) 86 (48.6)

No 101 (57.4) 91 (51.4)

Joint or muscle pain 0.000

Yes 65 (36.9) 35 (19.8)

No 111 (63.1) 142 (80.2)

Constipation or diarrhea 0.032

Yes 21 (11.9) 36 (20.3)

No 155 (88.1) 141 (79.7)

Appetite changes or food cravings 0.726

Yes 39 (22.2) 42 (23.7)

No 137 (77.8) 135 (76.3)

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 10 of 29

 Headache 0.008

Yes 52 (29.5) 31 (17.5)

No 124 (70.5) 146 (82.5)

Nausea or vomiting 0.246

Yes 25 (14.2) 18 (10.2)

No 151 (85.8) 159 (89.8)

Trouble falling asleep 0.089

Yes 37 (21.0) 25 (14.1)

No 139 (79.0) 152 (85.9)

Fatigue 0.001

Yes 84 (47.7) 53 (29.9)

No 92 (52.3) 124 (70.1)

Abdominal pain 0.300

Yes 68 (38.6) 78 (44.1)

No 108 (61.4) 99 (55.9)

Social withdrawal 0.025

Yes 46 (26.1) 29 (16.4)

No 130 (73.9) 148 (83.6)

Do you avoid taking any medicine during menses? (fear that the menses will stop) 0.186

Yes 57 (32.4) 46 (26.0)

No 119 (67.6) 131 (74.0)

Regarding going out of your home during periods: 0.071

I avoid going out because I experience a lot of pain 35 (19.9) 33 (18.6)

I avoid going out because I feel my energy gets low during periods 15 (8.5) 12 (6.8)

I avoid going out because I’m scared of the evil spirits/black magic 10 (5.7) 2 (1.1)

I avoid going out because I’m scared of staining my clothes accidentally 21 (11.9) 15 (8.5)

I go out of my home without any inhibitions 95 (54.0) 115 (65.0)

Do you feel that you have a bad odor during periods? 0.000

Yes 109 (61.9) 57 (32.2)

No 67 (38.1) 120 (67.8)

What is the reason for using cloth/tissue paper/cotton? 0.920

Pads are uncomfortable to use 18 (29.0) 6 (40.0)

Pads are unavailable in nearby shops 11 (17.7) 3 (20.0)

Pads are unaffordable 22 (35.5) 4 (26.6)

I feel shy to buy pads because the shopkeepers are male 6 (9.7) 1 (6.7)

I feel shy asking my family men to buy pads for me 5 (8.1) 1 (6.7)

Have you ever had?

Any reproductive tract infection 0.000

Yes 41 (23.3) 12 (6.8)

No 135 (76.7) 165 (93.2)

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 11 of 29

 Foul-smelling/abnormal discharge 0.379

Yes 23 (13.1) 29 (16.4)

No 153 (86.9) 148 (83.6)

Painful sores on pubic area 0.745

Yes 18 (10.2) 20 (11.3)

No 158 (89.8) 157 (88.7)

Rashes on pubic area 0.001

Yes 65 (36.9) 38 (21.5)

No 111 (63.1) 139 (78.5)

Pain or cramps during periods 0.044

Yes 48 (27.3) 66 (37.3)

No 128 (72.7) 111 (62.7)

Early period 0.006

Yes 22 (12.5) 42 (23.7)

No 154 (87.5) 135 (76.3)

Delayed period 0.001

Yes 28 (15.9) 54 (30.5)

No 148 (84.1) 123 (69.5)

Missed/infrequent period 0.568

Yes 35 (19.9) 31 (17.5)

No 141 (80.1) 146 (82.5)

Light flow 0.106

Yes 34 (19.3) 47 (26.6)

No 142 (80.7) 130 (73.4)

Heavy flow 0.624

Yes 36 (20.5) 40 (22.6)

No 140 (79.5) 137 (77.4)

No issues 0.231

Yes 15 (8.5) 22 (12.4)

No 161 (91.5) 155 (87.6)

Treatment sought for gynecological issues? 0.408

Yes 51 (29.0) 57 (32.2)

No 110 (62.5) 98 (55.4)

No issues 15 (8.5) 22 (12.4)

Are there sanitary pads available in your institute/college/workplace? 0.000

Yes 89 (50.6) 109 (61.6)

No 56 (31.8) 68 (38.4)

I stay at home 31 (17.6) 0 (0)

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 12 of 29

 TABLE 4: Problems and challenges faced by participants during menstruation
a Calculated using Chi-square test; P-value of <0.05 considered statistically significant

b Number of females from general population: 176; number of healthcare workers: 177

A significantly higher number of women from the general population (61.9%) felt that they have a bad odor
during menses while most women from healthcare workers (67.8%) refused any such thing. The women using
cloth, tissue paper or cotton were questioned about the reasons for not using pads amongst which the most
common reason in the general population was the lack of affordability of the product (35.5%) while the
majority of the healthcare workers (40%) found the product to be uncomfortable.

The women were further interviewed regarding experiencing any problem related to their reproductive
health. Significantly higher number of women from the general population had experienced reproductive
tract infections (23.3%) and rashes on pubic area (36.9%) as compared to healthcare workers. Similarly, a
significantly higher number of healthcare workers had experienced delayed or early periods (30.5% and
23.7% respectively) and pain or cramps during periods (37.3%) as compared to the general population.
Despite facing these issues, only a small fraction of women from both groups sought proper treatment (29%
from the general populace and 32.2% of healthcare workers). Women were also interviewed regarding the
availability of sanitary pads in their institute/college/workplace to which a significantly higher number
of healthcare workers (61.6%) replied in affirmative as compared to the general population (50.6%).

The women of both groups were questioned regarding the food items they abstained from during
menstruation. As shown in Figure 4 below, pickle, cold drink, cold water, and ice cream were found to be the
most common food items avoided by healthcare workers during menstruation.

FIGURE 4: Food items avoided by healthcare workers during

menstruation

Majority of women from the general population responded that pickle was the most common food item
avoided during menstruation as illustrated in Figure 5 below. Cold drink, cold water, and ice cream were
found to be the second most common food items to be refrained from, while guava was found to be the least
common food item to be avoided.

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 13 of 29

 FIGURE 5: Food items avoided by general population during
menstruation

Around 19.9% of women from the general population and 18.6% of healthcare workers avoided going out of
their homes during periods because they experienced a lot of pain. Moreover, 38.6% women from the general
population and 44.1% of healthcare workers experienced abdominal pain during menses. Hence, the women
were questioned regarding the strategies they employed to relieve abdominal pain during menses. As shown
in Figure 6 below, self-medication was found to be the most common relieving factor amongst the general
population followed by homemade foods such as turmeric milk, tea, hot porridge, soup, and hot fluids.

FIGURE 6: Relieving factors for abdominal pain employed by general

population

A large faction of women from healthcare workers opted self-medication as a remedy for pain during
menstruation as illustrated in Figure 7. A significantly higher number of healthcare workers counteracted
the pain by sleeping as compared to the general population (P-value = 0.027).

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 14 of 29

 FIGURE 7: Relieving factors for abdominal pain employed by healthcare
workers

Discussion
Menstrual hygiene implies understanding the basic facts underlying the menstrual cycle and to manage it
with dignity and comfort. Access to sanitary products, adequate sanitation, and dissemination of
information amidst the stigma, is a challenge for a developing country like Pakistan. In this study, we have
assessed the knowledge, attitude, practices, and challenges regarding menstruation faced by the women in
Karachi. We have also compared these parameters in healthcare workers to assess how their contribution
can bridge the gap.

In concordance to the studies conducted in Quetta, India, and the USA, mothers were the most frequently
cited source of information by both the healthcare workers and general population in our study [1,8,15]. In
our study, the educational status of mothers, of healthcare workers, was considerably better than that of the
general population (P-value = 0.00). Upashe et al. identified a positive correlation between the educational
status of the mother and good menstrual hygiene practice [16]. Mothers with poor knowledge of the
physiology of menses will endorse and propagate unhygienic practices. Unless we bridge the knowledge gap
prevalent among mothers and destigmatize menstruation, we cannot expect proper menstrual hygiene
management by young girls at the time of menarche. Although menarche should be celebrated as a sign of
womanhood and fertility, it is marred by the taboo associated with it in our socio-cultural set-up. Negative
connotations are tied to menstruation, labelling it as dirty or impure blood [8]. For a topic that is draped in
secrecy, acquiring information and seeking support becomes difficult. Thus, the majority of the participants
in our study recalled that they were most likely scared and confused at the time of menarche. In alignment
with our study, being unprepared owing to similar reasons, young girls from impoverished areas across the
USA had negative experiences at menarche [15]. In our study, a significantly higher number of participants
from the general population presumed infrequent menstruation to be a sign of pregnancy (P-value = 0.00).
Infrequent menstruation, apart from being associated with pregnancy, is also a sign that needs to be
investigated and clinically dealt with as it may be due to conditions like polycystic ovarian syndrome (PCOS)
and low body mass index [17]. Hence, healthcare workers should enlighten young girls among the general
population about menstrual irregularities and their impact on their gynecological health.

As healthcare workers had a better family income than the general population, the majority of them could
afford to use pads. To avoid friction in their household, some participants in our study used cloth torn from
a worn-out fabric. Women who use cloth are twice as likely to acquire bacterial vaginosis as compared to
women who use nothing [18]. In a study conducted in Delhi, India it was observed that women reusing the
same cloth are more likely to get infected with bacterial vaginosis [19]. The cost of sanitary pads was the
main deterrent as reported by other studies conducted in India, Tanzania, and Uganda [6,20,21]. In a study
conducted in Ethiopia, girls who earned pocket money from their parents could afford sanitary napkins and
were three times more likely to have good menstrual practice [16]. A study revealed that some women in
Kenya had to resort to transactional sex to afford menstrual products [22]. Surprisingly, the conditions in the
developed world are far from satisfactory. A survey conducted in Canada revealed that one-third of
menstruators had difficulties managing their budgets to be able to afford menstrual products [23]. In
another study, women surveyed in Karachi, Pakistan gave a similar reason as some of our study participants
for not using sanitary pads, i.e., they were uncomfortable and caused rashes [24]. Some of our study
participants (9.7% of the general population and 6.7% of healthcare workers) hesitated to buy menstrual
products from male shopkeepers, hence, again indicating the dire need to address the taboo. Even male

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 15 of 29

 counterparts can play a role in guaranteeing a safe menstrual experience to women. It is highly
recommended that, at a household level, men should prioritize menstrual needs and personal hygiene of the
women by financing the menstrual products. Sanitary pads and tampons are deemed as a ‘luxury’ and not a
basic necessity and thus women have no other choice than to use and reuse the same cloth. Due to this,
women hailing from low socio-economic backgrounds, have to compromise on hygiene and are particularly
vulnerable to the repercussions of poor practices [25].

As healthcare workers had better awareness of tampons as compared to the general population, they can
play a role in disseminating information about potential alternatives to menstrual pads. Tampons are widely
used in the Western world as they allow unrestricted continuance of sports and work during menstruation.
In our study, the cost of tampons proved to be a greater deterrent for the general population than healthcare
workers (P-value = 0.049). It was surprising to find that 57.6% of healthcare workers were unaware of
menstrual cups. A review article suggested that menstrual cups can be a very safe option even for low-
income countries as they salvage the cost of purchasing pads or soap and can be used as a suitable
alternative in the setting of inadequate sanitation facilities [26]. Menstrual cups are a long-term investment
since they can be reused multiple times if sanitized properly, and eventually, save the cost of purchasing
pads. Being able to collect more blood than tampons, they are preferred by women with menorrhagia [25].
The only deterrent is the lack of community and peer support. Healthcare workers should be well acquainted
with these products so that they can encourage their local use.

It was surprising to find that healthcare workers and the general population avoided bathing on the first and
the first three days of menstruation respectively, owing to the similar belief that it caused irregular
menstrual flow, followed by the instructions from elders. These findings are in alignment with studies
conducted in Quetta and Karachi where similar reasons were reported for not bathing [8,24]. An Egyptian
study revealed some other harbored superstitions associated with bathing such as backache, hair fall, skin
maceration, heavy menstrual bleeding, and discontinuation of menstrual flow [24]. Although there is no
medical or scientific basis of these myths, even healthcare workers harbor these beliefs, similar to that of the
general population (P-value > 0.05). Healthcare workers should reevaluate these practices as they are more
likely to endorse and recommend similar practices to the general masses. In fact, not taking a bath
translates as a compromise in hygiene that can culminate in reproductive tract infections [27]. Contrary to a
study conducted in Quetta, where an overwhelming majority of the study participants did not take a bath
but still used soap and water to clean their genitals, 31.2% of the general populace and 11.3% of healthcare
workers in our study avoided washing their groin area after urination or defecation [8].

The majority of our study participants changed their pads/cloth two to three times per day and disposed of it
by throwing it in the waste. Hygiene guidelines recommend changing absorbents every two to six hours
dependent on blood flow [7]. A significantly higher number of women from the general population felt that
they have a bad odor during menses (P-value= 0.00) and had experienced reproductive tract infection (P-
value= 0.00) and rashes on the pubic area (P-value= 0.001) as compared to healthcare workers. This can be
attributed to poor knowledge that translates into poor practices. Infrequently changing the cloth or pad that
is making use of just two or three pads during a whole period lasting three or more days can result in bad
odor. A review article highlighted the finding that bad odor contributed to fear, embarrassment, and distress
among school-going girls [4]. Limited availability of soap and water deters some women from low socio-
economic backgrounds, to ensure frequent washing of groin during menses [4]. Despite facing these issues,
only a small fraction of women from both groups sought proper treatment (29% of the general populace and
32.2% of healthcare workers), which can eventually lead to exacerbation of the pubic sores and infection. It
has been suggested that women with dysmenorrhea or other menstrual disorders were often hesitant to
discuss matters pertaining to sexual health owing to their warped cultural values and many found the
healthcare providers to be unsupportive [4].

More than half of our respondents from the general population abstained from eating certain food items
especially pickles and cold beverages, followed by eggs. Only 28.8% of healthcare workers abstained from
eating similar food items. Our findings are in alignment with another study conducted in Karachi but in
stark contrast to a study conducted in Quetta [8,24]. Food that is too hot or too cold is believed to disturb the
menstrual flow and ovarian function and cause acne. A clinical trial indicated that adherence to a ‘snack
dietary pattern’ that is a diet rich in foods with a high glycemic index such as desserts, tea, coffee and fruit
juices can increase the risk of moderate to severe dysmenorrhea [28]. Hence, healthcare workers should allay
any other unnecessary restrictions that are not based on any scientific grounds and recommend a diet rich
in iron during menstruation.

The majority of women from the general population experienced fatigue, whereas most women from
healthcare workers reported mood swings. In concordance with our results, back pain and pain in the
abdomen were the most commonly reported symptoms in surveys conducted in Quetta, Karachi, and
Mumbai [8,24,29]. Some of our participants (19.9% of the general population and 18.6% of the healthcare
workers) complained of pain during menstruation which deterred them from going out. Menses leave policy
has been implemented in the UK, India, and Australia where menstruators are exempted from working while
they are experiencing severe pain or discomfort [30]. This can empower the women as it is the
acknowledgement of their physiological process. Such policies can be also introduced in Pakistan to
facilitate the healthcare workers and general working force.

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 16 of 29

 It is worth mentioning that a comparatively higher number of women from the general population (5.7%)
avoided going out of their homes because they feared evil spirits/black magic. A review article highlighted
that freedom to participate in daily activities during menstruation empowered women and proved to be an
insignia of proper menstrual practice [4]. Fortunately, as per our study, the condition in Pakistan is still
better than other Asian countries. For instance, in Nepal, a very strict ritual seclusion of “Chaupaudi” is still
practiced where women are ostracized during the entire period of menstruation [4]. Moreover, in India,
women are excluded from religious gatherings, and in rural areas, women are restricted from even entering
the kitchen [27]. The superstition of the association of menstruation with evil spirits is particularly prevalent
in Asia. A menstruating woman deemed impure is more vulnerable to get possessed by demons and hence
some women bury the cloths used during menstruation [27]. Even in our study, a few participants from the
general population buried or burnt the cloth. Hence, it is the responsibility of healthcare workers to dispel
such traditional and cultural myths so that they are not bequeathed to subsequent generations.

In our study, 38.4% of healthcare workers and 31.8% of the general population complained of sanitary pads
being unavailable in their institute/college/workplace. A systematic review was conducted to assess the
effectiveness of "hardware intervention", that is, the provision of absorbing materials to address the material
deprivations and access to WASH facilities [7]. A moderate non-significant effect was observed when
reusable homemade and disposable sanitary pads were provided. To assess the true effectiveness of
hardware intervention, larger trials should be conducted. Nevertheless, it is still believed that the
institutional availability of pads can benefit young girls hailing from a low socio-economic background, as a
study in Ghana revealed that school attendance rose by 9% after five months with the provision of
disposable sanitary pads [7].

It is important to note that since our targeted population was from only one city, Karachi, it should not be
considered an accurate predictor of knowledge, attitude, and practice regarding the menstrual hygiene of
the female population of the entire country. Secondly, our study had a narrow coverage of socioeconomic
classes, with most participants belonging to the lower and middle class. More versatile studies should be
conducted in the future involving a bigger sample size, in order to assess the practices of women of a wider
geographical area. The questionnaire was self-designed and many commonly believed myths might have
been overlooked. The sample population was not randomized and there may have been a recall bias in
answering some questions in the survey.

Conclusions
Our study found insufficient knowledge about menstruation among the females of Karachi, in both the
general population and healthcare workers. Being the principal source of information, mothers with poor
knowledge have the potential to propagate and endorse unhygienic practices. Unless we bridge the
knowledge gap and destigmatize menstruation, we cannot expect proper menstrual hygiene management by
young girls at the time of menarche. To address this void of knowledge and to eliminate incorrect knowledge
and subsequent practices, the most efficient approach would be to deal with the problem at the grassroots:
by introducing basic reproductive health classes at the middle school level, so that the young girls can have a
safe menstrual experience at menarche. Even health care workers harbored some misconceptions, owing to
separate compartmentalization of science from religion and culture. It is imperative to rationally reassess
and obliterate these myths instead of making them a cultural legacy, passed down to the subsequent
generations.

Furthermore, a two-pronged approach is necessary to have a significant impact and for the translation of
correct knowledge into correct practices. Therefore, the availability of absorbents and WASH facilities at
workplaces and educational institutes is essential to facilitate women and ensure adequate provision of this
basic need.

Appendices
Consent form
The study objective has been explained to me by the researcher and I have understood the information
regarding the research project.

I also understand that my participation in this study is entirely voluntary and I voluntarily give my consent
to participate in this study.

Name: ____________ (optional)

Signature: _______________

Please note: All responses provided will remain completely anonymous and confidential. The information
provided will be solely used for research purposes only. By filling this form, you voluntary give consent to be
a part of the research “Perceptions, Practices, and Challenges Regarding Menstrual Hygiene Among Women
in Karachi, Pakistan: A Comparison Between General Population and Healthcare Workers”

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 17 of 29

 Socio-demographic profile
1. Age: _____ years

2. Education level:

o Uneducated

o Primary (Grade 1 to 5)

o Secondary (Grade 6 to 10/Matric/ O-levels)

o Intermediate (FSC/FA/A-levels)/Diploma

o Graduate

o Postgraduate

3. Education of mother:

o Uneducated

o Primary (Grade 1 to 5)

o Secondary (Grade 6 to 10/Matric/ O-levels)

o Intermediate (FSC/FA/A-levels)/Diploma

o Graduate

o Postgraduate

4. Total family income per month:

o Above PKR 100,000 (1 lac)

o Between PKR 40,000-100,000

o Below PKR 40,000

5. House Structure:

o Pakka (brick built)

o Semi Pakka (tin roofing or sheets)

o Kaccha (no bricks)

6. Marital Status:

o Single

o Married

o Divorced

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 18 of 29

 o Widowed

7. Religion:

o Islam

o Christianity

o Hinduism

Knowledge of the participants regarding menstruation

1. What was your source of general overview and do’s and don'ts of menstruation?

o Mother

o Grandmother

o Teachers

o Siblings or relatives

o Friends

o Self-knowledge (TV, Books, Internet)

o No-one

2. What was your level of knowledge at the time of menarche?

o I was already aware of periods, knew how to prevent staining my clothes and knew how to properly place
the cloth/ pad

o I was already aware of periods, knew how to prevent staining my clothes but had no idea of how to
properly place the cloth/ pad

o I was aware of periods but didn’t know how to prevent staining my clothes

o I thought I had some disease/ infection

o I thought I had suffered an injury

o I thought I was pregnant

o I was not aware at all and sought elders

3. Are you aware of what a tampon is?

o Yes

o No

4. Are you aware of what a menstrual cup is?

o Yes

o No

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 19 of 29

 5. Do you believe that infrequent menses is a sign of pregnancy?

o Yes

o No

Reactions and practices of the participants pertaining to menstruation

1. For those who are aware of tampons, what is the reason for not using them?

o Unaffordable

o Uncomfortable/ strange to use

o Unavailability in local shops

o Affects virginity

2. Are you able to talk freely with your mother or any relatives about any gynecological issues?

o Yes

o No

3. Do you avoid taking bath during menses?

o Yes

o No

4. If yes, how many days do you avoid bathing during menses?

o During the first day

o During the first three days

o During all days

5. Please tick the reasons for taking or avoiding bath during menses

For those who take bath:

o Soothes cramps

o Hygienic reasons

o Feel much better after bath

For those who avoid bath:

o Causes cramps

o Causes irregular flow

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 20 of 29

 o Causes water to fill in stomach

o Advised by elders not to take one

6. Do you avoid washing the groin after urination/ defecation?

o Yes

o No

7. Do you stop doing exercise during menses?

o Yes

o No

o I don’t do exercise regularly

8. Do you have any restrictions of activity during menses?

o Yes

o No

9. If yes, which ones?

o Climbing stairs

o Lifting weight

o Walking

10. What were your feelings when you menstruated for the first time? (you can mark more than one
option)

Scared

o Yes

o No

Guilty

o Yes

o No

Upset

o Yes

o No

Anxious

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 21 of 29

 o Yes

o No

Normal

o Yes

o No

Confused

o Yes

o No

Miserable

o Yes

o No

Shame

o Yes

o No

Excited/Delighted

o Yes

o No

11. Which of these do you use during menstruation to avoid staining your clothes?

o Cloth

o Pads

o Cloth and pads

o Tampon

o Tissue paper

o Cotton

o Menstrual cup

12. For those using cloth, is the cloth:

o Torn from a new fabric

o Torn from an old worn out shirt

13. How many times do you change the menstrual product?

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 22 of 29

 o 4 or more times per day

o 2-3 times per day

o Once per day

o Use 1 for almost 2 days

14. How do you dispose of the menstrual products after using them?

o Bury it

o Burn it

o Flush it in the toilet

o Throw it in waste

o Throw it in sea

o Store it for further use

15. What do you use while taking a bath after your period ended?

o Water only

o Water and soap

o Water and antiseptic

Problems and challenges faced by participants during menstruation

1. Do you abstain from eating certain food items during menses?

o Yes

o No

2. If yes, which of these food items do you abstain from: (you can mark more than one option)

o Guava

o Papaya

o Oily food

o Pickle

o Meat

o Spicy food

o Curd/ Yoghurt

o Caffeine

o Egg

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 23 of 29

 o Milk

o Fish

o Cold drink/ Cold water/ Ice cream

3. Which one of these complains do you have during menses? (you can mark more than one option)

Tension or anxiety

o Yes

o No

Poor concentration

o Yes

o No

Abdominal bloating

o Yes

o No

Change in sexual desires

o Yes

o No

Breast tenderness

o Yes

o No

Crying spells

o Yes

o No

Hair fall or dandruff

o Yes

o No

Acne

o Yes

o No

Mood swings or irritability

o Yes

o No

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 24 of 29

 Joint or muscle pain

o Yes

o No

Constipation or diarrhea

o Yes

o No

Appetite changes or food cravings

o Yes

o No

Headache

o Yes

o No

Nausea or vomiting

o Yes

o No

Trouble falling asleep

o Yes

o No

Fatigue

o Yes

o No

Abdominal pain

o Yes

o No

Social withdrawal

o Yes

o No

4. If you experience abdominal pain during menses, what do you do to relieve it?

o Self-medication

o Consulting a gynecologist

o Herbs/ Homeopathic medicines

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 25 of 29

 o Homemade foods: turmeric milk, tea, hot porridge, soup, hot fluids

o Sleep

o Do nothing

5. Do you avoid taking any medicine during menses? (fear that the menses will stop)

o Yes

o No

6. Regarding going out of your home during periods:

o I avoid going out because I experience a lot of pain

o I avoid going out because I feel my energy gets low during periods

o I avoid going out because I’m scared of the evil spirits/ black magic

o I avoid going out because I’m scared of staining my clothes accidentally

o I go out of my home without any inhibitions

7. Do you feel that you have a bad odor during periods?

o Yes

o No

8. What is the reason for using cloth/ tissue paper/ cotton?

o Pads are uncomfortable to use

o Pads are unavailable in nearby shops

o Pads are unaffordable

o I feel shy to buy pads because the shopkeepers are male

o I feel shy asking my family men to buy pads for me

9. Have you ever had? (you can mark more than one option)

Any reproductive tract infection

o Yes

o No

Foul smelling/ abnormal discharge

o Yes

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 26 of 29

 o No

Painful sores on pubic area

o Yes

o No

Rashes on pubic area

o Yes

o No

Pain or cramps during periods

o Yes

o No

Early period

o Yes

o No

Delayed period

o Yes

o No

Missed/ infrequent period

o Yes

o No

Light flow

o Yes

o No

Heavy flow

o Yes

o No

No issues

o Yes

o No

10. Did you seek any treatment for these gynecological issues?

o Yes

o No

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 27 of 29

 11. Are there sanitary pads available in your institute/ college/ workplace?

o Yes

o No

o I stay at home

Additional Information
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All
authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial
relationships at present or within the previous three years with any organizations that might have an
interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.

References
1. Shoor P: A study of knowledge, attitude, and practices of menstrual health among adolescent school girls in
urban field practice area of medical college, Tumkur. Indian J Health Sci Biomed Res. 2017, 10:249-255.
10.4103/kleuhsj.ijhs_375_16
2. Guide to menstrual hygiene materials . (2019). Accessed: May 26, 2020:
https://www.unicef.org/wash/files/UNICEF-Guide-menstrual-hygiene-materials-2019.pdf.
3. Chandra-Mouli V, Patel SV: Mapping the knowledge and understanding of menarche, menstrual hygiene
and menstrual health among adolescent girls in low- and middle-income countries. Reprod Health. 2017,
14:30. 10.1186/s12978-017-0293-6
4. Hennegan J, Shannon AK, Rubli J, Schwab KJ, Melendez-Torres GJ: Women's and girls' experiences of
menstruation in low- and middle-income countries: a systematic review and qualitative metasynthesis.
PLoS Med. 2019, 16:e1002803. 10.1371/journal.pmed.1002803
5. Das P, Baker KK, Dutta A, et al.: Menstrual hygiene practices, WASH access and the risk of urogenital
infection in women from Odisha, India. PLoS One. 2015, 10:e0130777. 10.1371/journal.pone.0130777
6. Kapoor G, Kumar D: Menstrual hygiene: knowledge and practice among adolescent school girls in rural
settings. Int J Reprod Contracept Obstet Gynecol. 2017, 6:959-962. 10.18203/2320-1770.ijrcog20170564
7. Hennegan J, Montgomery P: Do menstrual hygiene management interventions improve education and
psychosocial outcomes for women and girls in low and middle income countries? a systematic review. PLoS
One. 2016, 11:e0146985. 10.1371/journal.pone.0146985
8. Michael J, Iqbal Q, Haider S, et al.: Knowledge and practice of adolescent females about menstruation and
menstruation hygiene visiting a public healthcare institute of Quetta, Pakistan. BMC Womens Health. 2020,
20:4. 10.1186/s12905-019-0874-3
9. Atif K, Naqvi SS, Hassan Naqvi SA, Ehsan K, Niazi SA, Javed A: Reproductive health issues in Pakistan; do
myths take precedence over medical evidence?. J Pak Med Assoc. 2017, 67:1232-1237.
10. Mansoor H, Salman M, Asif N, et al.: Menstrual knowledge and practices of Pakistani girls: a multicenter,
cross-sectional study. Heliyon. 2020, 6:e03157. 10.1016/j.heliyon.2020.e03157
11. 2017 Census of Pakistan. (2017). Accessed: May 26, 2020:
https://en.wikipedia.org/wiki/2017_Census_of_Pakistan.
12. Monitoring the building blocks of health systems: a handbook of indicators and their measurement
strategies. (2010). Accessed: May 26, 2020:
https://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf.
13. Open source statistics for public health. (2013). Accessed: October 10, 2019:
https://www.openepi.com/SampleSize/SSPropor.htm.
14. Ansari SK: Psychology of beliefs and practices relating to menstrual hygiene of adolescent girls in rural,
Islamabad, Pakistan. Imperial J Interdisc Res. 2016, 2:670-677.
15. Herbert AC, Ramirez AM, Lee G, North SJ, Askari MS, West RL, Sommer M: Puberty experiences of low-
income girls in the United States: a systematic review of qualitative literature from 2000 to 2014. J Adolesc
Health. 2017, 60:363-379. 10.1016/j.jadohealth.2016.10.008
16. Upashe SP, Tekelab T, Mekonnen J: Assessment of knowledge and practice of menstrual hygiene among
high school girls in Western Ethiopia. BMC Womens Health. 2015, 15:84. 10.1186/s12905-015-0245-7
17. Rostami Dovom M, Ramezani Tehrani F, Djalalinia S, Cheraghi L, Behboudi Gandavani S, Azizi F: Menstrual
cycle irregularity and metabolic disorders: a population-based prospective study. PLoS One. 2016,
11:e0168402. 10.1371/journal.pone.0168402
18. Dhingra R, Manhas S, Kohli N, Mushtaq A: A comparative study of understanding of menstrual process
among married women belonging to two ecological settings. J Hum Ecol. 2007, 22:261-265.
10.1080/09709274.2007.11906031
19. Nair P, Grover VL, Kannan AT: Awareness and practices of menstruation and pubertal changes amongst
unmarried female adolescents in a rural area of East Delhi. Indian J Community Med. 2007, 32:156-157.

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 28 of 29

 10.4103/0970-0218.35668
20. Sommer M: Where the education system and women's bodies collide: the social and health impact of girls'
experiences of menstruation and schooling in Tanzania. J Adolesc. 2010, 33:521-529.
10.1016/j.adolescence.2009.03.008
21. Boosey R, Prestwich G, Deave T: Menstrual hygiene management amongst schoolgirls in the Rukungiri
district of Uganda and the impact on their education: a cross-sectional study. Pan Afr Med J. 2014, 19:253.
10.11604/pamj.2014.19.253.5313
22. Mason L, Nyothach E, Alexander K, et al.: 'We keep it secret so no one should know' - a qualitative study to
explore young schoolgirls attitudes and experiences with menstruation in rural western Kenya. PLoS One.
2013, 8:e79132. 10.1371/journal.pone.0079132
23. New Plan International Canada research shows large majority of Canadians support free menstrual hygiene
products in schools and in the workplace. (2019). Accessed: May 26, 2020: https://plancanada.ca/media-
centre/plan-intl-canada-releases-new-menstrual-hygiene-research.
24. Ali TS, Rizvi SN: Menstrual knowledge and practices of female adolescents in urban Karachi, Pakistan . J
Adolesc. 2010, 33:531-541. 10.1016/j.adolescence.2009.05.013
25. Kaur R, Kaur K, Kaur R: Menstrual hygiene, management, and waste disposal: practices and challenges
faced by girls/women of developing countries. J Environ Public Health. 2018, 2018:1730964.
10.1155/2018/1730964
26. Van Eijk AM, Zulaika G, Lenchner M, et al.: Menstrual cup use, leakage, acceptability, safety, and
availability: a systematic review and meta-analysis. Lancet Public Health. 2019, 4:e376-e393.
10.1016/S2468-2667(19)30111-2
27. Garg S, Anand T: Menstruation related myths in India: strategies for combating it . J Family Med Prim Care.
2015, 4:184-186. 10.4103/2249-4863.154627
28. Najafi N, Khalkhali H, Moghaddam Tabrizi F, Zarrin R: Major dietary patterns in relation to menstrual pain:
a nested case control study. BMC Womens Health. 2018, 18:69. 10.1186/s12905-018-0558-4
29. Thakur H, Aronsson A, Bansode S, Stalsby Lundborg C, Dalvie S, Faxelid E: Knowledge, practices, and
restrictions related to menstruation among young women from low socioeconomic community in Mumbai,
India. Front Public Health. 2014, 2:72. 10.3389/fpubh.2014.00072
30. Barnack-Tavlaris JL, Hansen K, Levitt RB, Reno M: Taking leave to bleed: perceptions and attitudes toward
menstrual leave policy. Health Care Women Int. 2019, 40:1355-1373. 10.1080/07399332.2019.1639709

2020 Arshad Ali et al. Cureus 12(8): e9894. DOI 10.7759/cureus.9894 29 of 29