Menstruation Nation

Some notes: While I’ve tried very hard to include a variety of issues and perspectives regarding menstruation and the ways it happens in our lives, this zine is hardly comprehensive. Whether this zine answers any questions you had, or prompts new ones, I encourage you to explore the other resources mentioned throughout and at the end.

The use of appropriate language is also important to me as a person learning to communicate health information, and so while occasional mentions to “female” anatomy or biology are hard to avoid, generally the langauge is purposefully neutral. In case you didn’t already know: not all women menstruate, and not all people who menstruate are women.

Contents Author’s note: How I came to love periods Introduction: Menstruation basics

• What is menstruation?

• What is in menstrual blood?

• What other animals menstruate?

Representation: Hollywood thinks your period is scary Anecdote: ...And sometimes it actually is

Your body, yourself: Getting to know your period

What can disrupt your menstrual cycle?

• Hormonal contraception Let’s talk about birth control!

• What was the Dalkon shield?

• What happened to Norplant?

Anecdote: My last trip to the gynecologist • Pregnancy • Abortion • Breastfeeding • Menopause How can you manage your period?

• Tampons and pads • Sea sponges • Menstrual cups • Period pants Anecdote: “What it’s really like to free bleed during your period”

Other bodies, other voices: Learning about what other people have been doing & saying about periods • • • •

Free to Bleed, You and Me More about Menotoxin Public Service Announcement Period Policy • Novel Idea: What if we actually researched whether menstrual products are safe to use • Clinical Trials on Trial: Medical studies still exclude women and people of color to dangerous degree

Glossary References and resources

Author’s note: How I came to love periods This zine is the result of an outpouring of energy and enthusiasm, reserves of interest and dedication I didn’t realize I had: evidently I love learning and talking about periods. I love talking to people about their menstruation: how they manage it, how they figure out what’s weird and what’s not. I love helping people learn more about their bodies and figure out new ways to engage knowledgeably with the different things their bodies do. But while this is true of 27-year-old me, it was not of true of many younger versions of myself.

I don’t remember specifically my first period, but I remember I was in seventh grade, 14 years old. But even as I write that, it sounds wrong to me: I must have been 13 and maybe still only in sixth grade. I’m convinced that a lot of my inability to recall these moments—which for many people are indelible memories—is due to the much larger crisis of my mother dying over the course of three years of my adolescence. At some point during that time, I started getting my period, and I read a lot and was very observant, so I knew basically what to do, and I did it and it was done.

I do remember distinctly my mom asking me once if I went swimming in gym class during my period. (I did, and was always in awe of the girls who would sit out during swimming, fully clothed in the corner of the pool deck. I just could not fathom the bravery of admitting to the entire class, plus the teacher, that you were on your period.) I lied to her about using tampons, said I’d worn a pad, a lie that was pretty ridiculous to me then but is truly hilarious to me now: what a blessing that my mom did not press me.

Why I was afraid to tell her I was using tampons, I have no idea; I think maybe I was scared that only mature girls were supposed to use them.

It’s about a decade later, and even though I’m much more eager to talk about menstruation, I admit I’m still pretty shy when it comes to announcing I’m On My Period. So I’ve

settled into a passionate ambivalence about periods: I’m here to listen to you if you want to talk about them, maybe help answer some questions, but I respect any antipathy or frustrations you may feel vis-à-vis your own menstruation.

Right now I’m here for people who want to know more: maybe you want to know more about your own body or the body of someone you love, maybe you want to learn about different strategies for managing your bleeding, maybe you’re just curious about this biological phenomenon that regularly and repeatedly occurs in the bodies of millions of people every day. Wherever and whoever you are, welcome.

I think the thing that so compels me about periods is that menstruation is both everywhere and nowhere. A lot of us experience it, most people who don’t still know that the rest of us do, ads for menstrual products are everywhere, and any display of disagreeable behavior is grounds for being accused of being hormonal/PMS-ing/on your period, and thus unreasonable.

Everyone knows of periods, but who actually knows about them? For one thing, periods aren’t a time when the vagina is bleeding, that’s just where the blood is coming out of.

Menstrual blood comes from the inner lining of the uterus, the endometrium, which is shed once an egg has been released by an ovary and not fertilized. But anyways, I’m getting a bit ahead of myself.

My point is that, similar to the ways that menstruation is both public knowledge and taboo, it is also thoroughly medicalized but glaringly under-studied and underresearched. It’s a natural, evolved biological process that we’ve managed to mostly control, even if we don’t completely understand how. And there’s a third paradox: when a person has a healthy menstrual cycle, they are also likely to suffer any number of ailments. And because we’re not encouraged to talk about the details our of periods—whether we’re wary of providing ammunition to people who would dismiss us because we’re “hormonal,”

or we’re shamed because it’s ‘TMI’—we learn to endure in relative silence, grimacing with a heating pad or a bottle of ibuprofen or a warm cat.

And thus, a general culture of silence around menstrual pain / female pain thrives. For an example of the disastrous consequences of this culture of silence, consider ovarian cancer. Ovarian cancer is not so much a silent killer as it is not listened to. So many symptoms of PMS—fatigue, nausea, cramps, diarrhea, bloating—are also symptoms of ovarian cancer. Now, ovarian cancer mostly kills older (post-menopausal) women, but this is largely because it is often not detected until its later stages—and why is it not detected? Because most people don’t know to take seriously any symptoms that seem menstrual, because we’re taught that they’re normal. And, in kind, most doctors don’t take seriously any symptoms that seem menstrual. History indicates that for centuries doctors have found ways to simultaneously pathologize and dismiss women’s pain.

Introduction: Menstruation basics (Source: Rupi Kaur)

INTRODUCTION: MENSTRUATION BASICS What is menstruation?

The menstrual cycle is, as the name suggests, a process that repeats itself, about every 28 to 36 days.

The uterus prepares to receive an egg by creating a cushiony lining made mostly of blood and cervical mucus.

One of two ovaries releases an (unfertilized) egg—also called an ovum—which travels through the fallopian tube toward the lining of the uterus (or the endometrium). This process, which lasts about three days, is known as ovulation and is the time a person is most likely to get pregnant if sperm are introduced to the environment. If the egg is fertilized, it will implant itself onto the lining of the uterus, which will continue to grow.

If the egg does not become fertilized, it travels through the fallopian tube and is then expelled by the body over the course of several days, along with the lining of the uterus.

This is the bleeding a person experiences during what is generally called a “period.” The number of days in a person’s cycle is counted from the first day of one round of bleeding until the first day of the next round.

ovary travels through the fallopian tube

(meanwhile, the uterus has been preparing for a fertilized egg, building a lining of blood and nutrients) the egg and uterine lining are expelled from the uterus, through the cervix and vagina

an egg is released from an ovary

What is in menstrual blood?

(Source: Gross Science) Sure, there is a fair amount of blood comprising the fluid that comes out through the vagina during menstruation—but there are also immune and uterine cells as well as vaginal secretions (basically, cervical mucus or what you might know as “discharge.”)

Do animals other than humans menstruate?

(Source: Gross Science) Yes, but only a few; namely, some kinds of primates, bats, and the elephant shrew. These animals are unique in that their uterus develops a protective lining in advance of pregnancy, whereas most other mammals only develop a uterine lining once an egg has been fertilized and thus pregnancy already begun.

Why does this happen? Well, in humans at least, the reason could be our egg cells, which appear to be pretty aggressive burrowers. If there was no nice blood-rich cushion lining the endometrium, after fertilization an egg cell could burrow itself directly into to the uterine wall—making it difficult for a person to give birth or get pregnant a second time. Repeat pregnancies and deliveries would be essentially impossible if the uterus weren’t able to develop a lining in advance of fretilization, which is shed with each menstrual cycle if fertilization does not occur.

The first time you get your period is called MENARCHE! You can have a party to mark this occasion if you’re so inclined. Might I recommend playing the song “Crimson Wave,” by Tacocat?

The age at which a person experiences menarche is influenced by: • Biology, diet and weight: a person needs about 25% body fat (compared to total weight) in order to begin or continue menstruating • Environment: a person exposed to endocrine disruptors (chemicals that interfere with genetic or hormonal signals in a person’s body) in things like plastics and pesticides might get their first period earlier than they would have without that exposure • Family history, race and ethnicity: a person can expect to start menstruating at about the same age as other people to whom they’re biologically related—but of course, there are many factors (like those listed above) that can lead to earlier or later menarche than those of relatives And of course, periods do not always happen according to expected patterns: • Never bled = Primary amenorrhea: this term applies to people who have not yet experienced a menstrual period by their late teens (most people with a healthy, functional set of reproductive organs should experience menarche by age 17 or so) • Stopped bleeding = Secondary amenorrhea: this term describes conditions in which a person has undergone menarche, but for some medical reason is not currently menstruating • Irregular bleeding = Oligomenorrhea: this term describes a menstrual cycle characterized by periods that, instead of occurring in a typical 28- to 36-day cycle, are irregular and unpredictable

REPRESENTATION: Hollywood thinks your period is scary (Source: Ali from Autostraddle) We all know that Hollywood makes a mountain out of a molehill when it comes to bleeding from your snatch, but Dr. Lauren Rosewarne at the University of Melbourne says that the media has so consistently turned periods into horror stories that it’s traumatizing teenage girls.

According to Rosewarne’s website, this study “examines and categorizes representations to unearth what they reveal about society and about our culture’s continuingly fraught relationship with female biology” by analyzing hundreds of representations of menstruation in film and television. The analysis includes television shows such as Madmen, The Big Bang Theory, Friends and Grey’s Anatomy along with movies such as Annie Hall and Anchorman.

The conclusion? Hollywood sucks at representing Aunt Flo. “The regularity, normalcy and uneventfulness of real life menstruation is rarely portrayed on screen. Instead, it’s treated as traumatic, embarrassing, distressing, offensive, comedic or thoroughly catastrophic,” argues Rosewarne.

Carrie won for most traumatizing portrayal, but it is far from the only sensationalized example. And in her new book, Periods and Pop Culture, she says such representations of girls may be unnecessarily scared about first experiencing their first shark week. “There is this issue of girls feeling anxious about it or even over-estimating things like how much they will bleed,” she said. “And when men are actually asked about menstruation they assume it’s a Niagara Falls of blood, because it’s not something men necessarily know much about and our culture doesn’t encourage them to.”

Considering that our culture doesn’t encourage men to know much about our periods, they sure do a lot of writing about it. The examples that have been made public before the book’s release were overwhelmingly written and produced by men, who probably don’t have an idea of what a period is/

feels like/looks like. In fact, most stuff in Hollywood is pretty much dominated by men, and only by one kind of man. So yes, having an entire locker room full of terrible girls throwing pads at a character when she gets her period is much more dramatic than what actually normally happens, which is you just getting your period and going about your day like a normal human being. But the other thing that makes for a nice, dramatic story is your mom taking you out of school for a holiday when you bleed from your hoo-ha to bake you a womanhood cake and make you feel awesome. Why don’t we see any stories like that on television? Oh, that’s why.

And as a result, “girls in real life are viewing menstruation as a hassle, women are happily filling prescriptions to make it go away, men are mocking it, loathing it and rarely understanding it,” according to Rosewarne. And we need a whole study, analysis, and book about it because it’s so entirely normal for us to do so. How many women do you hear berate their period, dread it, complain about it, tell horror stories? How about we take today, in honor of not making a Friday the 13th out of our panty carnage, and combat the bad rep with some good solid Menstruation Information. The less we fear and loathe our liquid womanhood, the more we understand Dr. Rosewarne when she makes the assertion “TV is seen as being some kind of mirror on society. When it comes to menstruation, it is not.”

ANECDOTE: ...And sometimes it actually is

(Editor’s note: I’m including this not because I want to perpetuate a culture that laughs at menstruating people, but because I want to encourage people to look out for those in need and educate the young and old people you know to prevent these kinds of humiliations. There are plenty more stories online.)

No More Teacher’s Dirty Looks (Source: The Most Horrifying Period Stories You’ve Ever Heard, Jezebel) In middle school I had the. worst. periods. They were often so heavy that I bleed through both a super tampon and super pad (was wearing the two simultaneously) in an hour in a half on more than one occasion. Between the hemorraging and the cramp-induced vomiting, I missed several days of school per semester. Now, when I was in middle school I was also drastically underweight and as a result had very irregular periods that started with no warning.

One day I was sitting in homeroom when I suddenly felt incredibly nauseated and dizzy. I was too dizzy and disoriented to make it to the bathroom and so I threw up in my backpack. That’s when the horror dawned on me: there was more to come because I was starting my period. My homeroom teacher was an epic douche who seemed to get off on punishing me in particular so my desk was crowded in a corner that obscured me from the view both she and my classmates.

I deliberated with myself for about 10 minutes (while the vomit dried in my backpack) and decided the only thing I could do was call my mom. As I mentioned, this teacher was a total douche and so I then wasted 10 more precious minutes steeling myself to ask to use the phone. Let’s take stock: at this point I’m now cowering in the hidden corner, bleeding profusely through my sundress, clutching a backpack full of vomit and running a fever (the fever part happened often with my period as well). I HAD to get home.

Me: Ms. Blake, um, I’m not feeling well. May I please call my

mom?

Ms. Blake: You may only make phone calls with a note from the office.

Me: So um, Ms. Blake, may I please go to the office?

Ms. Blake: Not unless you have a note from the office.

Normally I would just go along with the game and loudly protest how stupid she was being, but I was in no position to do so because I was too dizzy and too embarrassed to make a scene in front of the class. I pleaded with her again and again to either let me call my mom from her classroom or else let me go to the office. Each plea was met with a resounding “you need to go to the office.” It had been about 30 minute since I vomited at this point, and I was shivering with blood beginning to drip down my leg. I suddenly snapped.

I shot up suddenly from my desk and got in her face. I was 7 or 8 inches taller than her so I must have been pretty imposing. Even if my sheer height wasn’t intimidating, the long trail of blood down the back of my dress must have been. I yelled directly into her face.

Me: Ms. Blake, as you can see I got my period unexpectedly and now I’m kind of sick. See, I puked in my backpack (I showed her the mess). I can’t make it to the office and I need to go home, so may I PLEASE call my mother?!

The sheer look of horror on her face made the entire spectacle worth it. She quickly assented and unlocked the closet where she kept the phone and let me talk as long as I wanted. I was so scary though, no one dared laugh, not even the 13 year old middle school boys who lived for that kind of thing. In fact, the whole scene was never mentioned by any of my classmates or teachers ever again as far as I can tell.

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What can disrupt your menstrual cycle?

Some causes of amenorrhea and oligomenorrhea are: • Current or recent use of hormonal birth control methods* • Pregnancy (whether it ends in delivery, miscarriage, or abortion)* • Breastfeeding* • Menopause* • Emotional factors and stress • Heavy athletic training • Excessive dieting, anorexia, or starvation • Use of some medications, including chemotherapy • Obstruction or malformation of the genital tract • Hormone imbalance and chromosomal conditions • Cysts or tumors • Chronic illness *These are the ones we’re going to talk about

Hormonal contraception

(Source: Our Bodies, Ourselves website) • Most forms of contraception work by preventing an egg from being released from an ovary, preventing a sperm from fertilizing an egg, or some combination of both.

• With most short-term hormonal contraception methods (the pill, the patch, and the ring), you can control the timing of your bleeding. This monthly bleeding is not a “true” period because the contraception works to prevent eggs from being released from the ovaries, but it resembles a monthly period in most other ways. You may hear this kind of bleeding referred to as “withdrawal” bleeding.

• Some IUDs, as well as the arm implant, can lighten or suspend your menstrual cycle after you’ve had the IUD for about a year; menses resume within a few months of IUD removal. Other IUDs release a slightly lower amount of hormones and will likely lighten your menstrual bleeding, but will probably not suspend bleeding altogether. With all of these LARCs (or longacting, reversible contraception), you can become pregnant immediately after removal.

• Generally, after menarche, the amount of estrogen your body produces increases until menopause, at which point estrogen production slows considerably.

• Given this, the more you menstruate, the greater the amount of estrogen your body is exposed to—and as a result, the higher your risk of developing estrogenreceptive breast and/or ovarian cancer.

• So if you hear claims that hormonal birth control can reduce your risk of breast cancer, this is the scientific basis for that claim: contraception inhibits ovulation and menstruation, thus decreasing the overall amount of estrogen your body produces over time and so lowering your risk of developing hormone-receptive cancers.

LET’S TALK ABOUT BIRTH CONTROL! Birth control is a unique medication for a few reasons.

First, it can be prescribed without any need for a diagnosed disorder or disease—meaning, basically, that it’s a drug for healthy people. On one hand, this helps illuminate the ways that even ‘normal’ or ‘healthy’ bodies or bodily processes are medicalized and thus exploited for profit by private pharmaceutical companies.

But think also of how people are denied insurance coverage for this basic drug that is widely available over the counter throughout the world (to learn more, visit www.FreeThePill. org, a great resource for information on which countries do and don’t require prescriptions for birth control pills).

The thing is, there are millions of people who take advantage of hormonal contraceptives to manage their menstruation in a variety of ways for an even bigger variety of reasons, and the development of an array of contraceptive methods since the introduction of the Pill has benefited countless people. Just one example: Relatively “invisible” methods of contraception such as the Depo-Provera injections, the arm implant, and IUDs can be life-saving for people with partners who interfere with their birth control plans.

The United States is one of the few countries in the world to require a prescription be written in order for a patient to obtain hormonal contraception. This is something I learned anecdotally from international patients who end up at the sexual health clinic where I work. I verified it with some research and I’ve come away convinced that birth control pills should be available over the counter: I see patients who struggle to afford the annual appointment necessary to obtain a birth control prescription.

One thing that is worth mentioning about birth control, too, is that during its development in the 1950s and 1960s, the United States generally excluded women from clinical trials in order to safeguard their fertility. Due in part to this culture and also to racist/classist/misogynistic attitudes and protocols, these experiments were exported to Puerto Rico.

(This is not so unusual in the the long history of science and medicine exploiting women of color in the US and other countries. For an example, watch the PBS documentary No Más Bebés.)

United States medical professionals also performed nonconsensual sterilizations on Puerto Rican women (on the island and the continental US), as well as many other poor white, Latinx/Hispanic, and black people throughout the US. Much of the contraceptive variety enjoyed by people of all races and ethnicities today comes to us courtesy of several instances of medical abuses committed against too many marginalized people.

There are just a few examples in here of interesting moments in the history of menstrual management and reproductive health, moments when institutions and members of the public collided due to tragically misaligned motives. I encourage you to do your own research!

The history of menstrual management is long and brutal, and much bloodier than it should be.

What was the Dalkon shield?

(Source: MedScape and the New York Times magazine) The Dalkon shield was an early intra-uterine device (IUD) introduced to the market in the 1970s. It was a uniquely shaped device, with grooves that stuck out from the sides in order to keep it inside the uterus. This made removing the IUD difficult, so a string was added to aid in the process.

About 2.5 million shields were used, and about 200,000 of the people who received those shields filed complaints with the manufacturers complaining that the string caused infections that led to pelvic inflammatory disease (PID). PID is a painful condition that can lead to ectopic pregnancy and infertility. As a result, Dalkon shields were quickly removed from the market, and for years IUDs were warily regarded as unnecessarily dangerous. IUDs today are much safer, easier to remove, and less likely to cause PID.

What happened to Norplant?

(Source: Los Angeles Times)

Introduced to the public in the 1990s, Norplant was a contraceptive arm implant consisting of six subdermal rods that released a progestin. At first hailed as an innovation in birth control, Norplant soon caused thousands of users to complain of headaches, weight gain, persistent menstrual bleeding, hair growth or loss, ovarian cysts, anemia and depression. Many doctors contintued to insist that Norplant was safe, dismissing users’ concerns. Removing the six rods often proved more difficult than had been originally anticipated, and some insurance and Medicaid plans covered the insertion only. Norplant is no longer available in the US, although it is used widely abroad. Current arm implants in the US consist of a single rod that release a different progestin, and produce less extreme side effects.

Anecdote: My last trip to the gynecologist I have a Nexplanon implant in my arm. In terms of size and shape, the common comparison is to a matchstick, and that’s about right. It’s a slender piece of plastic that a nurse slid under my skin using a pre-packaged device that has a large, beveled needle for pushing the implant through. I’ve found a few studies showing that Nexplanon has helped some people suffering from pain related to conditions like endometriosis. The implant releases a low dose of hormone throughout my body constantly, and the idea is that it will relieve my sometimes debilitating menstrual cramps. At first I had neear-daily spotting, and now I do generally get a monthly “period,” but it’s lighter and the cramps are not nearly as bad as they were before.

My own introduction to endometriosis came when I began bleeding between periods, something I’d generally never experienced. (The important thing to keep track of in terms of your own menstrual cycle is the pattern your body develops: don’t worry if your cycle is longer or shorter than other people’s, or if yours seems more or less painful. Focus instead on irregularities of your own cycle.) I did notice that for the past few years my periods had become increasingly painful, the cramping in my uterus sending me buckled over with a sore and aching back. I started buying ibuprofen in 500-pill bottles. And now I was bleeding a few days in between each period, for several months in a row.

I went to the gynecologist, hoping she could help me find some answers. I listed my symptoms and asked about endometriosis, she performed a basic pelvic exam, and then referred me for a vaginal ultrasound. The ultrasound was unpleasant not only because a plastic wand with a lubricated condom was probing my vagina, but also because the technicians were only supposed to record the images and take measurements—my doctor had to see the pictures and interpret them before anyone could tell me what was going on. So the ultrasound tech just silently probed as I

lay there in the dark, my tights at my ankles as I craned my neck toward a black and white screen I couldn’t understand.

I few days later I went back to the doctor, after she had reviewed the ultrasound. Basically the verdict went something like: we can’t really tell why you’re bleeding but it seems like everything’s okay. From what I remember, my gynecologist said that in order to properly be diagnosed with endometriosis, I would have to undergo laparoscopic surgery to have endometrial tissue removed.

This gynecologist announced that since such a diagnosis might lead to insurance companies refusing to cover fertility treatments due to a pre-existing condition (endometriosis can cause infertility because of the development of scar tissue in and around the uterus), she recommended against a diagnosic procedure. I was too surprised to remind her that we had never discussed my desire to get pregnant (nonexistent), or that she was failing to take into account what we had discussed, namely my long-term monogamous sexual relationship with a cisgender woman. Nonplussed, I nodded silently and then asked if there was anything that could be done in the meantime, absent a diagnosis.

She again made an announcement that caught me off guard: Since this was “not greatly interfering with my life,” there was nothing to do about it now. I was confused; the whole reason I had gone to a doctor was because this had begun interfering with my life. Desperate for some sign that my concern was valid, I asked if it was okay to to take 10-16 200mg tablets of ibuprofen every few weeks. She said it was safe as long as I didn’t do it every day, and that was the end of the appointment.

It was disappointing having this experience, but the memory of those interactions have guided me in my current job as a medical assistant. I try to remember that when people come to the clinic, they’re often scared or concerned. As much as they want treatment, they also want recognition, empathy, and respect, and it’s my role to provide that as best I can.

What can disrupt your menstrual cycle? (continued) Emergency contraception • Emergency contraception (“EC”) works similarly to regular hormonal contraception, releasing hormones to prevent fertilization. (This is a distinction from socalled “abortion pills,” which end and expel existing pregnancies rather than prevent pregnancies from occurring).

• Because EC can prevent the release of an egg from the ovary, prevent fertilization of the egg by sperm, change the lining of the uterus, or some combination of all three, it can briefly disrupt your menstrual cycle. As long as EC works to effectively prevent pregnancy, your menstrual cycle should resume its regular schedule within a month or two.

• Importantly, EC cannot work to end a pregnancy. If you have had unprotected intercourse that has resulted in the fertilization of an egg, EC will not harm or affect the pregnancy at all. The only medications that can safely abort an early pregnancy are mifepristone, misoprostol, and methotrexate. (For more information on medication abortion, I recommend the Planned Parenthood and Women on Waves websites.)

Pregnancy • While you might experience bleeding during pregnancy, this bleeding is not a period—as long as your uterus contains a fertilized egg, your body should not ovulate.

• Human chorionic gonadotropin (hCG) is a hormone produced during pregnancy—hCG, among other things, triggers the production of progesterone, which suspends the menstrual cycle by inhibiting the release of further eggs from the ovaries

Abortion

(Source: Planned Parenthood of Mid and South Michigan website) • Human chorionic gonadotropin (hCG) is a hormone produced during pregnancy and is what is tested in urine- and blood-based pregnancy tests.

• In the weeks and months following abortion, it is common to experience bleeding and elevated hCG levels—this can make it difficult to determine when your body has resumed its normal menstrual cycle.

• Because of this, it is important to know that you can become pregnant at any time before your next period if you have unprotected intercourse.

• You can expect to get your period about 4-6 weeks after the abortion, unless you are using hormonal contraception.

Breast-feeding

(Source: Australian Breastfeeding Association) • If you breast feed, during the first six months postpartum (after the baby is born), you’re menstrual cycle may not resume for several months because you’re producing prolactin, a hormone that triggers the production of breast milk and also inihibits ovulation.

• Some people breast feed according to a schedule, which can be a reliable form of short-term contraception: this is called the lactational amenorrhea method (LAM).

• LAM is based on three simultaneous conditions: • It has been less than 6 months postpartum, • You haven’t yet gotten your period, • You’re exclusively breast feeding, on demand.

• As long as you breastfeed frequently enough to maintain sufficiently high prolactin levels, you will suspend your body’s ovulation process and so not menstruate.

Menopause

(Source: NIH MedlinePlus and the National Library of Medicine) • Menopause indicates the time in a peron’s life after their period has stopped. It usually occurs naturally, most often after age 45.

• Menopause happens because the ovaries stop producing estrogen and progesterone. The remaining eggs in the ovaries are generally absorbed back into the ovarian tissue.

• The official medical designation for menopause is the point after which a person has not menstruated for a year. Changes and symptoms can start several years earlier.

How can you manage your period?

Tampons and pads • To avoid bleached or synthetic products, you can find all-cotton and all-organic cotton, chlorine-free tampons in health food stores and online, and even at drug and grocery stores.

• You can also buy or make your own reusable cloth pads—look around online for patterns.

Sea sponges • Natural sea sponges work like tampons, and they are relatively inexpensive and reusable.

• Just be sure to follow cleaning directions for before and between uses.

Menstrual cups • These kinds of products collect rather than absorb menstrual fluid.

• Reusable menstrual cups are elongated cups made of rubber or medical-grade silicone that are inserted into your vagina.

• You can wear one for up to 12 hours and keep it in while swimming and other physical activities (you’ll need to remove it before intercourse or other insertive sex).

• There are both disposable and reusable versions, and one that is inserted higher than the other menstrual cups (over the cervix) so it’s possible to keep in during insertive sex.

Period underwear • These come in a range of thicknesses and styles, to suit different flows and preferences.

• Some underwear are made of superabsorbent fabric, while others have a pocket for tucking in a resuable pad.

ANECDOTE: What It’s Really Like to Free-Bleed During Your Period (Source: Lane Moore for Cosmopolitan) I’m not a big fan of tampons or pads. This is not a very original feeling, but the more I read about how tampons can be harmful, combined with the fact that they’re expensive as hell, I knew I needed to find another option. (Pads just always fall out of my underwear like it’s their job, so.) Then my email started flooding with promotions for special period underwear — that is, underwear you wear without a pad, tampon, or cup while you have your period. Basically, the underwear has extra-reinforced material that absorbs liquid.

I thought they were worth a shot. I clearly did not think it through.

I got a variety of period underwear by Googling all the different kinds, like an appetizer sampler but with stuff you can bleed on. There aren’t actually that many, but the ones I found that didn’t look like you were wearing a blood-covered disco ball were actually cool-looking. The ones I ordered ranged from ones that looked kind of like fancy lingerie, ones that looked like little boy’s superhero underwear, and ones that just looked like Victoria’s Secret underwear that you buy on sale in bulk so you never have to buy underwear again in your life.

I knew the first day would not be fun. I stared at all these pairs of underwear and thought, So I’m just going to freebleed into you and my clothes will remain unstained and I won’t feel like I’m wearing a sexy diaper? OK, I’ll believe you. Let’s go, because it is a very normal thing to talk to your underwear first thing in the morning like it’s a classroom at a school you work at.

I went with the fancy lingerie pair first, not just because I enjoy fancy lingerie but because it also looked the sturdiest aka the way you’d go and select a horse at a farm. The fabric was thicker and the coverage was better, so I figured it was a good bet for a Day One situation.

The whole day I was super aware that I was free-bleeding (which is a term I keep using that I heard somewhere at some point) and it felt a little weird. You know that gush you feel during your period sometimes and you think, My tampon’s got this? Well, this time, my tampon did not got it and I felt the puddle land in my underwear in a way that made me queasy. And I hate that it made me queasy! I want to be cool with my period, man. I don’t think periods are gross (because they’re not) and I don’t think women’s bodies are weird (because they’re not). But gushing blood into my underwear felt like jumping out of an airplane without a parachute. Still, at a certain point, I just accepted that this was a weird thing I was doing and that it would be fine one way or another because it felt too stressful to worry about it every single second.

By the middle of day one, I’d already had to do that thing I used to do when I was 16 where you roll up toilet paper to make a makeshift pad in your underwear because the underwear were totally soaked (I know, I know, even I’m repulsed by this) and had started staining my pants and it felt like a defeat. Because it was. What was the point of wearing underwear I could bleed in if I was just going to have to make DIY pads all day? And they weren’t even going to be good ones because I do not have time to become the Martha Stewart of menstrual products, so they just looked like wadded-up garbage shoved in my underwear.

The second day was pretty much the same deal in terms of a glass of blood-wine being dumped into my pants throughout the afternoon, but I went with a different brand, which were even worse. The fabric wasn’t that thick and I bled right through it (I don’t want to brag, but I’m, like, really good at having my period) and stained my jeans yet again. It probably only took a few hours for that to happen and by the time it did, I just kind of rolled with it because I didn’t feel like going to buy tampons because I hate them. So DIY pad it was. The third day, I went with the cute superhero underwear but almost immediately ruined them with my lady blood

because they were no match for it.

The subsequent days were almost like a joke because my period is usually so light then that asking a pair of black underwear to catch a little bit of blood without staining is like asking a clown to be creepy: They were going to do that anyway.

I was hesitant to write about the experiment because honestly, I think period underwear is a badass idea and so many of the pairs were hella cute and comfortable (some of them I would’ve worn even if I didn’t have my period, which is an achievement because I have high underwear standards), but I just don’t think they’re there yet. Or maybe it just makes sense to wear period underwear on your light days, because that worked across the board. You’d still save a bunch of money and wouldn’t be putting potentially harmful tampons into your body, which I will always recommend.

The experiment wasn’t that weird for me, maybe because my long-time menstrual cup usage made me more at ease with my period, and maybe because I think periods are cool.

And yeah, painful as hell sometimes, but I don’t think they’re awful and disgusting and not to be talked about. The idea of blood in my underwear seemed really normal and “who gives a shit” to me, so on that level, I didn’t mind it.

But the thing that got me was, was I supposed to be switching out the underwear multiple times a day like a fullbutt pad? And if so, how the hell was I supposed to do that at work? Just go into the stall and take off all my clothes so I can change into a fresh pair of underwear like a kid who had an accident at school?

Yeah, I’ll just stick to my hippie-ass menstrual cup forever, thank you.

OTHER BODIES, OTHER VOICES: LEARNING ABOUT WHAT OTHER PEOPLE HAVE BEEN DOING AND SAYING ABOUT PERIODS

Free to Bleed, You and Me: Considering attitudes on menstrual management, with a specific look at the reactions to the concept of “free bleeding” The other day I was browsing photos using Instagram’s explore function, and stopped on a picture of someone lifting their skirt hem to reveal blood on the crotch of their underwear and smeared on the tops of their inner thighs.

The original caption said something like “bae looking cute and free bleeding,” but the re-poster was far less enamored, and the comments were overwhelmingly negative. Most aimed to shame this person for practicing a “stupid,” “unhygienic,” and “dangerous” method of menstrual management.

The comments gave me pause: this photo had been reposted by user with “feminist” in her name and she, like many of the others, regarded this as the nadir of selfish “white feminism.” Some distinctions were attempted, by one or two users in the comments, to separate the menstruating person from the products of menstruation, but I wasn’t convinced by this feeble defense—and even those commenters often added that irrespective of this separation between a body and its contents, this reckless bloodletting was gross and impolite.

I wasn’t convinced—to me all the haranguing sounded a whole lot like the same myths we’ve been fed for centuries about the dirtiness of menstruation and the destructive powers of “menotoxin,” a pseudo-scientific concept describing toxins specific to menstrual blood that were thought to (among other things) make flowers wilt and wine turn sour. Because we live in a “developed” nation, and because we have access to fancy plastics tampons, many of us seem to think we are a people beyond such primitive superstitions.

And yet, while menotoxin is mostly a relic of overtly patriarchal medical practice, the idea that menstrual blood is a uniquely dangerous or disgusting substance produced

by our (designated female) bodies continues to circulate among American cultural discourse at a variety of levels.

Tr*mp, while scarcely an examplary human, is the leader of this whole damn country, so let’s remember when he ranted that Megyn Kelly performed poorly as a debate moderator because she had blood coming out of her eyes and her whatever.

Horrific, yes. Uncommon? Not really.

“Science” is frequently employed as an apparatus to sanitize conversations and advertisements for menstrual management supplies: My favorite ads are those for tampons and maxi pads featuring technical-looking diagrams, highlighting different engineering strategies intended to guard against an onslaught of leakage emergencies. There’s no mention of the substance we’re so desperately hoping won’t leak, nor are we told from whence this leakage comes. What we get instead, of course, are the commercials and print ads employing those hilarious vials of blue liquid used to demonstrate how much “moisture” the products can absorb.

So in this case my point is: in Band Aid ads, we get to see scraped knees or bumped elbows. In Kleenex ads, people are sneezing and sniffling; even ads for hemorrhoid cream or diarrhea medication feature people squirming with uncomfortable expressions, their movements exaggerated to demonstrate rectal or G.I. distress. And sure, okay, maybe a lot of us aren’t too keen on watching someone hunched over a toilet removing a blood-soaked tampon in a Kotex ad, but I wouldn’t mind seeing more ads with explicit reference to menstruation; i.e. any indication this product is meant to manage blood coming from a uterus through a vagina, and that we wear these products in our vaginas or underwear. I would like some public recognition for having a human (and not a monstrous) body that excretes a variety of fluids, which sometimes stain my clothes.

But even that humble request seems too much to ask of a culture that would really rather not talk about periods, if that’s

all right with us. So many people who get their periods dread it, avoid it, do their best to be as discreet as possible when managing it—and my argument is not that we should all hold monthly celebrations for our periods. I understand that menstruation is physically painful for a lot of us, or emotionally exhausting, or psychologically unbearable.

But I also think that a lot of people who have basically “average” or “normal” periods, according to current biomedical trends/scientific knowledge/etc, are unnecessarily antagonistic toward their periods to the point of ignorance or neglect of their own bodies. If we are repulsed by our menstrual blood, or we dread getting our periods and deal with them negligently, then we risk failing to observe important symptoms or patterns evident in our cyclical discharge (I know, it’s the worst word). If we don’t keep track of what’s happening with our bodies, it’s hard to know if the things we’re putting in and on them are more helpful than they are harmful.

But, as I’ve mentioned, the problem with the available science on menstruation is that the selection is limited, and it’s hard to find quality research about the safety and efficacy of various menstrual management strategies. And it’s harder still to figure out a clear and unbiased answer to the question: Is “free-bleeding” actually dangerous for anyone?

I’ve spent the past few days on the internet trying to figure this out. I just wasn’t convinced that this practice, regardless of the number of practitioners, was quite the public health concern people were so quick to characterize it as. Much of what I found concerned itself with one of three things: (1) Free bleeding is a hoax, something no one actually does but is perpetuated by people who frequent sites like Reddit and 4chan to malign Feminism, (2) Free bleeding is a gross/unhygienic/stupid/dangerous/ obnoxious thing that radical white feminists, who are by the way the worst, have decided to start doing,

(3) Kiran Ghandi ran the London Marathon while free bleeding; isn’t she the worst/maybe kind of cool/so gross/ etc.

However, by looking at a few published research findings— regarding the transmission of viral infections (e.g. HIV, hepatitis) through needle sticks as well as through menstrual blood during sex, the composition of menstrual blood versus venous blood, and the best hygiene practices to employ while menstruating—I’ve established a better foundation for questioning claims that free bleeding is dangerous, either for the people who do it or those who could potentially come in contact with menstrual blood.

Now, I understand the importance of properly managing one’s bodily fluids in public and private spaces, for reasons related to comfort, hygiene, courtesy, and health. When I sneeze I try to do so in my elbow and find tissues if I need them; on the unpleasant occasions when I get a bloody nose in public I do my best to quickly get to the nearest bathroom and clean up any blood I’ve left in my wake. But sometimes I wipe my nose on my sleeve or the back of my hand, or I chew off a hangnail while waiting for my coffee to be served, or sweat heavily on the bus, or, yes, stain my underwear and pants with blood because I can’t really predict my endometrial bleeding.

And sure, okay, yes: It’s rude to fail to take necessary precautions when given the opportunity to, say, sit on someone else’s furniture, or wear their clothes, or swim in their pool, or whatever. You might take off your shoes when you get to someone’s house, or wear a mask if you’re contagious and sitting the waiting room of a hospital, or apply clean dressings to a large open wound before going out. No matter where in or on your body it’s coming from, it’s your responsibility to try not to get your fluids on other people and their stuff. Fluids can stain, transmit disease, and freak some people out. But unless you’re bleeding into or on another person’s mucous membranes or any open wounds, it’s seem rather unlikely that this kind of possible

exposure to blood could transmit viruses—they just can’t live outside the body for very long, and are even less likely to be transmitted by surface contact or ingestion.

So as long as someone is keeping their bleeding in check, such that it’s not staining other people’s stuff or pooling in their seat or at their feet, I don’t see how it could really be considered a concern from a hygiene or public health perspective. It’s true that menstrual blood can be an irritant for some, and spending much of the day in damp underwear can cause chafing or general discomfort—but these are minimal risks and generally borne by the bleeder, not the unwilling public.

Many of the voices on the anti-free-bleeding camp vehemently point to the danger of exposing unwitting bystanders to the thousands of bacteria contained in the medical waste produced by menstruation. Now, let’s be clear: there are indeed about 7000 different kinds of bacteria present in menstrual blood, many of which are unique to that environment (which makes the uterine microbiome pretty cool). But of course, as we’ve learned from years of yogurt ads, some bacteria are actually good for us. Again, there isn’t much quality research about menstruation in healthy people, but we know that these bacteria are not the menotoxin; they won’t hurt us if we’re exposed to them.

After all, people who menstruate are exposed to these bacteria for several days every month or so for decades, and no harm is wrought from that exposure.

Still, though, fear of menstrual blood remains, and so much of it appears largely irrational (and predictably misogynistic): when commenters argue that menstrual blood is dangerous because it is full of bacteria, they are tangling together misunderstandings about bacteria, toxicity, and immunity with assumptions regarding the cleanliness and hygiene of menstruating people. The result is a specious claim about the potential dangers of contact with another person’s period blood.

The real dangers, in terms of exposure to menstrual blood, seem to lie mostly in terms of sexual contact: performing digital, oral, or penile sex on someone who is menstruating.

This is mostly because, as mentioned, sexual contact is a known and likely cause of transmission of viral infections like HIV and hepatitis B/C between people. The best protection against contracting these viruses (other than avoiding sexual contact altogether) involves non-permeable barrier methods like latex gloves, condoms, and dental dams.

There’s further evidence to suggest that people are more prone to contracting even sexually transmitted illnesses that aren’t present in the blood (such as gonorrhea or chlamydia) during period sex, as compared to people having non-period sex.

But none of this really supports the claim that free bleeding is “dangerous” or “unhygienic.” If people don’t mind staining their pants every so often—because they don’t or can’t track their periods, or they aren’t satisfied with any available menstrual management products, or their vagina is sore from wearing tampons or a cup for days, or whatever their reasons may be—then I have no problem with that and I’m frustrated by people who feel justified in calling free bleeders “stupid” or “disgusting.” Everybody bleeds, and a lot of us do so regularly, and we are entitled to choose the ways we manage this. It’s important for us all to be mindful of the ways our bodies (and their fluids) exist in space with others, but I’m tired of people being told that menstruation should be hidden from public and private sight as much as possible; that even staining the crotches of our own clothes is open to criticism and taboo.

For too long menstrual management has been regulated and advertised and engineered and legislated and commercialized by so many people who have never menstruated, that even those of us who do are ready to employ some “common sense” reasoning as a means of attacking somebody’s bodily autonomy. It is not “common

sense” or “basic science” that says menstrual blood is dirty; it’s people comprising a centuries-long culture of misogyny and medical control and dismissal of women as linked to the body and all its indignities. All of womankind was punished with birthing pains because Eve was tempted by the prospect of knowledge and self-awareness. It’s absurd that we’re allowing biblical symbolism to guide our attitudes about menstruation. Periods happen, all the time, to all kinds of people, and if we have to be confronted with this information every so often with a glimpse of bloodied shorts, then all the better.

More about menotoxin: Menstruation is just blood and tissue you ended up not using (Source: Kate Clancy for Scientific American) I love science, and I love the scientific method. I think that the scientific method is one of the most useful ways of knowing out there. I have devoted my life not only to the study of the science of human evolution and female reproductive physiology, but to increasing science appreciation and literacy in the general public.

So why am I always criticizing it?

Two reasons. First, the process of science can be biased by who performs it.

Second, the results and implications of scientific research can be biased by who tells it.

To demonstrate this, I’m going to tell you a little story about a menstruating nurse.

Dr. Bela Schick, a doctor in the 1920s, was a very popular doctor and received flowers from his patients all the time.

One day he received one of his usual bouquets from a patient. The way the story goes, he asked one of his nurses to put the bouquet in some water. The nurse politely declined. Dr. Schick asked the nurse again, and again she refused to handle the flowers. When Dr. Schick questioned his nurse why she would not put the flowers in water, she explained that she had her period. When he asked why that mattered, she confessed that when she menstruated, she made flowers wilt at her touch.

So, rather than consider the possibility that the nurse was offended that her skills and expertise were being put to use to put someone else’s flowers in water, Dr. Schick decided to run a test. Gently place flowers in water on the one hand‌ and have a menstruating woman roughly handle another bunch in order to really get her dirty hands on them:The flowers that were not handled thrived, while the flowers that

were handled by a menstruating woman wilted.

This was the beginning of the study of the menstrual toxin, or menotoxin, a substance secreted in the sweat of menstruating women.

This story begins far before Dr. Bela Schick and his menstruating nurse. Because the kind of bias that produces a doctor who can believe that menstrual toxins exist, and launch a field of study on them based on some wilted flowers (if the story really did happen the way he tells it), did not come from one man alone. The cultural conditioning that has produced the idea that women are dirty, particularly during menses, is quite old. The Old Testament of the Bible claims that women are unclean when they menstruate, and menstrual huts exist in some cultures to separate out menstruating women from the rest of their group.

But some mark the beginning of our misunderstandings of female physiology in European-derived cultures with one book in particular written in the thirteenth century – De Secretis Mulierum, The Secrets of Women. This book was written by a man who claimed to be the monk Albertus Magnus, but was most likely an impersonator (which is why most call the author of De Secretis Mulierum pseudoAlbertus Magnus, or pseudo-Albert).

So here are some winning quotes from this book, which was considered a premier text for several centuries, even though it is likely pseudo-Albertus Magnus never treated women and based much of his work on having dissected a female pig: “Woman is not human, but a monster.”

Menstruating women give off harmful fumes that will “poison the eyes of children lying in their cradles by a glance.”

Children conceived by menstruating women “tend to have epilepsy and leprosy because menstrual matter is extremely venemous [sic].”

De Secretis Mulierum went through at least eighty editions over several centuries (Rodnite Lemay 1992). While it was not a strictly medical text, it is clear that it was both popular

and influential. Do doctors refer to De Secretis Mulierum today? Of course not. But this book, to me, represents a broader cultural understanding that menstruation is dirty, that women are powerful, mysterious, dangerous, and subhuman.

So back to those menotoxins. Dr. Schick decided there was something nasty in the sweat of menstruating women.

Others took up the cause. Soon, people were injecting menstrual blood into rodents, and those rodents were dying (Pickles 1979). Others were growing plants in venous blood from menstruating women to determine phytotoxicity; the sooner the plants died, the higher the quantity of menotoxin assumed in the sample.

What’s worse, the presence of the menotoxin in the female body began to expand beyond menstruation. Any woman who was post-menarcheal and pre-menopausal could be found to have the menotoxin in her system. She could not escape it: some reported that the menotoxin could be found in a woman’s menstrual blood, but also venous blood, sweat, and breastmilk. One case study reports that a mother gave her child asthma because she was menotoxic during pregnancy (Perlstein and Matheson 1936), and several contended that colic was caused by menotoxin in breastmilk (Ashley-Montagu 1940; Perlstein and Matheson 1936).

Not only did the idea of the menotoxin become a ubiquitous menace around any reproductively-aged woman, it began to explain pathology. So the menotoxin, which first was an explanation for the presence of menstruation in women, became a way of diagnosing women as ill… and again, since now all reproductively-aged women could secrete it from any bodily fluid at any time, the state of being female essentially made one pathological.

Soon the idea that the menotoxin indicated specific illnesses began to take hold.

“Dr. Schick and I discussed the possibility that the adult female diabetic out of control, the depressed adult female

psychotic, and the adult female in the premenstrual phase secreted some common substance in their sweat.” (Reid 1974) Here, you see premenstrual women compared directly with two pathological conditions: diabetes and psychosis.

And all of these relationships, between menstruation and colic, asthma, wilted flowers, are largely observation, case reports, or poorly controlled experiments. When studies do not support the idea of the menotoxin, as with Freeman et al (1934) and two studies cited by Ashley-Montagu (1940) that were not in English, each get dismissed as outliers (even though in Labhardt’s case from Ashley-Montagu, the sweat of men was often as toxic as that of menstruating women).

And this is where I bring it back to my first two points about bias, that science can be biased by the cultural conditioning of those who perform it, and those who tell it. The people who studied the menotoxin really, really wanted to believe in it, to the point that they would ignore negative results and overstate the power of their anecdotes and case studies.

The study of the menotoxin spans at least sixty years, maybe ninety depending on which references you consider legitimate, debated in Lancet letters to the editor, and published in several medical journals.

I wish I could say that the menotoxin was dead. But several contemporary hypotheses about the evolution of menstruation still in some way reflect the thinking that menstruation, if not women, is dirty and serves the purpose of expelling toxicity. Clarke (1994) proposed menstruation as a mechanism to expel unwanted embryos. Margie Profet (1993) argued that menstruation helped to expel spermborne pathogens, which made men the dirty party. This is why it’s important to recognize that many ideas that seem intuitive to us at first derive from cultural conditioning and bias. (My favorite book on the topic is Emily Martin’s The Woman in the Body [1980].)

Thankfully, the most accepted idea is that menstruation

did not evolve at all, but is a byproduct of the evolution of terminal differentiation of endometrial cells (Finn 1996; Finn 1998). That is, endometrial cells must proliferate and then differentiate, and once they differentiate, they have an expiration date. Ovulation and endometrial receptivity are fairly tightly timed, to the point that the vast majority of implantations occur within a three-day window (Wilcox et al. 1999). So it’s not that menstruation expels dangerous menotoxins, but rather that menstruation happens because the endometrium needs to start over, and humans in particular have thick enough endometria that we can’t just resorb all that blood and tissue.

It’s time to dump the idea that menstruation is dirty. It’s blood and tissue that you ended up not using to feed a baby, and that’s all. *I want to credit one of my favorite courses from college for much of the content related to pseudo-Albertus Magnus: Women’s Studies 106a, Bodies and Boundaries, taught by Prof. Katherine Park at Harvard University. I have no idea if it’s still taught (*cough* it’s been ten years *cough*), but if you are a student there, you are missing out if you don’t take a class with her. **If you are a historian of science and would like to talk over this material with me, let me know! It would make for a great paper.

References Ashley-Montagu M. 1940. Physiology and the Origins of the Menstrual Prohibitions. The Quarterly Review of Biology 15(2):211-220.

Clarke J (1994). The meaning of menstruation in the elimination of abnormal embryos. Human reproduction (Oxford, England), 9 (7), 1204-7 PMID: 7848450 Finn CA (1996). Why do women menstruate? Historical

and evolutionary review. European journal of obstetrics, gynecology, and reproductive biology, 70 (1), 3-8 PMID: 9031909 Finn CA (1998). Menstruation: a nonadaptive consequence of uterine evolution. The Quarterly review of biology, 73 (2), 163-73 PMID:9618925 Freeman W, Looney JM, and Small RR. 1934. Studies on the phytotoxic index II. Menstrual toxin (“menotoxin”).

Journal of Pharmacology and Experimental Therapeutics 52(2):179-183.

Martin E. 1980. The woman in the body. Beacon Press, Boston.

Perlstein M, and Matheson A. 1936. Allergy Due to Menotoxin of Pregnancy. Archives of Pediatrics and Adolescent Medicine 52(2):303.

Pickles VR (1979). Prostaglandins and dysmenorrhea: Historical survey.Acta Obstet Gynecol Scand Suppl 87:7-12.

Profet M (1993). Menstruation as a defense against pathogens transported by sperm. The Quarterly review of biology, 68 (3), 335-86 PMID:8210311 Reid HE (1974). Letter: The brass-ring sign. Lancet, 1 (7864) PMID:4133673 Rodnite Lemay H. 1992. Womens Secrets: A Translation of Pseudo-Albertus Magnus’ de Secretis Mulierum with Commentaries: State University of New York Press.

Wilcox AJ, Baird DD, & Weinberg CR (1999). Time of implantation of the conceptus and loss of pregnancy. The New England journal of medicine, 340 (23), 1796-9 PMID: 10362823

PUBLIC SERVICE ANNOUNCEMENT: YOU PROBABLY WILL NOT GET TOXIC SHOCK SYNDROME (Source: Our Bodies, Ourselves website) Toxic shock syndrome (TSS) is a serious but rare condition caused by bacterial infection, most often by staph bacteria but also by strep bacteria. Anyone can develop TSS if they develop a staph or strep infection—you don’t have to use tampons to get it.

However, using superabsorbent tampons and/or leaving in a tampon for longer than eight hours can increase your risk of TSS. (If used according to the directions on the package and changed regularly, though, tampons are safe.) The story behind the link between TSS and tampons dates back a few decades, before which TSS was basically unheard of in ERs or doctor’s offices.

TSS became a big deal as a result of a specific brand of tampon (Proctor & Gambel’s Rely) that was introduced to the market in the 1970s. The tampon was created to be superabsorbent, featuring synthetic materials that, it turned out, absorbed so much blood and other secretions that (when inside a warm, moist vagina) it became the perfect breeding ground for bacterial infection.

This becomes especially dangerous if people have staph or strep bacteria in their blood, organisms which thrived in the microbiome of these tampons. Inevitably, there were some high-profile incidences of toxic shock syndrome. Eventually this particular tampon was taken off the market, and today many tampons are made with safer materials that are less likely to lead to infection.

As a precaution, however, there is now a regulation that requires all tampon manufacturers to include information on TSS with their products. (It’s kind of annoying that rather than conduct studies about the actual safety of individual tampon brands and styles, the FDA chose to require every

manufacturer to issue identical warnings.) Because it is still possible—though unlikely—to develop TSS with any kind of tampon, it is best to avoid keeping a tampon in for longer than 8 hours and to only use the least absorbent tampon you can at any given time (meaning, for example, only use a superabsorbent tampon on when you have an especially heavy flow; otherwise opt for regular or light tampons and aim to replace every 4-6 hours).

Period Policy: News from the intersection of menstruation and legislation Novel Idea: What if we actually researched whether menstrual products are safe to use (Source: Helen from Autostraddle)

Think about your favorite—or not so favorite—menstrual hygiene product commercial. Usually some racially ambiguous person who presumably menstruates floats across the screen in a lily white dress, enjoying their life until “Mother Nature” ruins everything. The protagonist loses all hope in ever smiling again now that their period has arrived.

Luckily, some Playtex™, Kotex™, Always™, or Stayfree™ product saves the day with a promise of “incredible protection and all-around comfort.” Oh yeah!

Menstruation products are a big deal with respect to the U.S economy, with over $2 million spent on menstrual hygiene products every year. The average person who menstruates uses about 300 to 420 tampons and/or pads a year, spending anywhere between $100 and $225 solely on their period. That’s a lot of money and a lot of hygiene merchandise! However, the welfare of people who menstruate has proven less important to the companies who profit from these goods and to the government given that little research has been done to determine how safe menstruation products really are. Even though so many people in the United States use menstrual hygiene products, the businesses profiting from this population do very little to inform menstruating consumers about what they are putting into their bodies At the end of May, Congresswoman Carolyn B. Maloney (D-NY) introduced a new version of proposed legislation that would require further research into the health effects of menstrual hygiene products. The bill, named The Robin Danielson Act of 2014, “would require the National

Institutes of Health (NIH) to research whether menstrual hygiene products that contain dioxin, synthetic fibers, and other chemical additives like chlorine and fragrances, pose health risks,” according to a press release issued

by Maloney’s campaign. The Robin Danielson Act would also demand that the FDA publicly disclose the list of contaminants in menstrual hygiene products. This latter portion of the legislation is really important because many of these companies that sell menstruation products keep the public unaware of the chemicals used in the bleaching and fragrances of pads and tampons.

Alexandra Scranton, Director of Science and Research for Women’s Voices for the Earth and author of the report Chem Fatale, explained the importance of knowing what elements are used in menstruation products. Scranton insists, “A number of different chemicals of concern may be found in feminine care products, but there simply has not been sufficient research to determine the effects of these chemicals on one of the most sensitive and absorptive areas of a woman’s body.”

Given that little research has been done on these potential toxins, we have no way of knowing if there is any connection between menstruation products and cervical cancer, or any vaginal/uterine health issues. That type of scientific ignorance is medically and socially irresponsible towards people who have periods and rely on hygiene products like pads, tampons, cups, liners, and sponges.

For people to make informed choices about their health and hygiene, there must be more information about menstruation products. People who have periods have already been down this road of insubstantial research and unsafe marketing.

In 1979, Proctor and Gamble released Rely, marketed as a super absorbent tampon made with compressed beads of polyester and carboxymethyl cellulose that could absorb up to 20 times its weight in fluid. Rely entered the menstrual hygiene product scene although there were no federal guidelines as to what materials were safe to insert into a

vagina. Because Rely could hold so much moisture — more moisture than what is generally present in a vagina — if the product remained inside the body for long enough, it would dry the vaginal walls and lacerate the user’s vagina as it was removed. Furthermore, when researchers finally looked into Rely, the product was found to filter the bacteria that cause toxic shock syndrome and many people were ill or died because capitalistic ventures took precedence over people’s vaginal health.

I like my menstruation products. But, do you know what I like even better? I like the idea that what I put inside, outside, or anywhere near my vagina is safe enough to be in the immediate vicinity of my uterus. The blatant disregard that the government and consequently scientific research has demonstrated towards people who menstruate is but an extension of our society’s institutionalized misogyny. For example, a few groups have been doing studies on how Viagra affects people with penises, even though the pill was approved by the FDA in 1998, but Congresswoman Maloney is proposing her legislation for the government to step up its menstrual hygiene product regulations for the sixth time.

Since 1999, the United States government has rejected attempts to make better provisions for menstrual hygiene management. The government and sanitary products companies’ attitudes suggest that when the health of people who have periods is at stake, their wellbeing is less than a major priority. We should not have to beg the government to make the necessary provisions to keep our bodies safe.

People who menstruate cannot afford unsafe standards or provisions for hygiene products.

Update: Maloney is still working to get the Robin Danielson Feminine Hygiene Product Safety Act passed. According to a Newsweek article from April 20, 2016: “Since [1997], she has reintroduced the bill eight times; it’s currently sitting with the Energy and Commerce Subcommittee on Health. ‘It is

very difficult to get a bill passed, especially when it concerns women’s health. The safety of tampons is not something that is on the minds of many members of Congress,’ says Maloney, speaking through a spokesperson. ‘I believe one day we’ll get this legislation passed.’”

Clinical Trials on Trial: Medical studies still exclude women and people of color to dangerous degree (Source: Laura Mandanas from Autostraddle)

If you consider yourself a feminist — or even if you don’t like the label but do like equality — the Health Equity and Accountability Act is a thing that you should care about.

Not familiar? Here’s the rundown: • As you’re no doubt aware, per the patriarchy, the “default” population our society caters to is white men.

• When this pattern is repeated in medical research, we wind up with clinical trials that primarily focus on white, cisgender male bodies and fail to consider the physiological differences in other populations.

• Without adequate medical research on different types of bodies, women and racialized people unnecessarily face worse health outcomes when the results of this medical research roll out full scale.

These problems are well documented, and women’s health advocates have been pushing to improve this situation for several decades. An important victory was won in 1993 with the National Institutes of Health Revitalization Act, a law mandating the inclusion of women and racial/ethnic minorities in clinical trials funded by NIH. The Food and Drug Administration also issued its “Guidelines for the Study and Evaluation of Gender Differences in the Clinical Evaluation of Drugs” that year, informing the pharmaceutical industry on how to evaluate data on women included in drugdevelopment trials. In 1998, the FDA required that anyone

enrolled in clinical studies be identified by gender, age and race, and that safety and effectiveness data be evaluated to identify differences based on these categories. Yet despite some progress, women and racialized people are still vastly underrepresented in clinical study data.

Last year, Ambien became the first and only prescription drug on the market with different recommended dosages for men and women. Although the sleeping medication had been approved and in use for over two decades, a series of high profile incidents led investigators to discover that the active ingredient, zolpidem, metabolizes differently in male and female bodies. By this time, thousands of women had received inappropriately high dosages — almost double what most female-assigned bodies need! — putting them at higher risk for adverse reactions such as “sleep driving.” In spite of this, the FDA still does not require sex- or race-specific analysis in the drug approval process, even when making dosage recommendations. They merely offer guidelines.

Alarmingly, the Ambien dosage debacle is just one example among many in which marginalized populations were exposed to significantly greater risk. Even for diseases which disproportionately affect women (such as lung cancer, heart disease, Alzheimer’s and depression), the only available medical treatments have largely been tested on men. For example, even though lung cancer is the top cause of cancer deaths among women and women now account for almost half of new cases and deaths, only 32% of lung cancer trial patients are women. And even though African Americans smoke less, they develop lung cancer at higher rates than white people — yet still represent less than 2% of lung cancer trial participants.

As is often the case in STEM, the exclusion of women and POC from studies may relate, in part, to the demographics of investigators. Yet disparities between different stages of clinical trials and a closer look at the history of such studies reveals a much more complicated picture.

Modern scientific methods for clinical trials — including the use of placebos, blinding and comparison of effects between groups of individuals — were developed using new statistical methods during the 1930s and ’40s. Corresponding ethical guidelines, however, were not formally established for another few decades. During this period, numerous experiments were carried out without the knowledge or consent of participants. While this is far from an ideal situation for anyone, the results were particularly devastating for racialized populations, whose lives and bodies were often viewed as expendable pieces of public property.

The Tuskegee Syphilis Study, for example, has become an infamous example of racist and unethical medical experimentation. Beginning in 1932, the United States Public Health Service began providing free “health care” to 600 African American men from rural Alabama, 399 of whom had syphilis. The men were never told that they were infected, nor were they ever treated, even after penicillin was established as a standard, effective treatment for the fatal disease in the mid ’40s. During the course of the study, researchers regularly lied to participants about what they were doing, and even orchestrated placebo treatments so as to continue unimpeded observation as the disease progressed. This continued until 1972, when a leak to the press turned the project into a public scandal.

Outcry prompted new federal regulations, such as the creation of institutional review boards to govern the ethical conduct of research on human subjects. Interestingly, ethical principles outlined included justice, specifically in fairly distributing the benefits and burdens of medical research.

(Clearly, it’s still a work in progress.)

One unintended consequence: broad interpretation of these guidelines meant that female-assigned people of childbearing age were excluded outright from clinical trials.

This included people using contraception, as well as those who stated that they were not having sex with male-assigned people. For researchers, the “vulnerable population” in need

of protecting was not women, but fetuses and potential fetuses. (That women’s health would suffer on the whole seemed not to be an issue.)

Today this legacy continues, with women vastly underrepresented in Phase I clinical trials. It is during this phase that dose-ranging activities take place, with researchers determining the optimal amounts that will provide the most benefit without unacceptable toxicity.

Meanwhile, underrepresentation of people of color is most prominent during later stages. Although the most prevalent explanation for this is widespread distrust among POC communities, studies have shown that this is less of a factor today than in the past. While it is true that some POC may (reasonably!) feel wary based on knowledge of past medical atrocities, accepting this as an immutable fact places blame on the wrong target. Clinics can overcome such barriers by focusing on building strong patient-clinician bonds and providing transparency.

In fact, there is already a high willingness among POC patients to participate in clinical research when asked — many are simply never made aware that studies are going on. For one thing, POC are less likely have access to health insurance, which is a prerequisite for gaining access to many medical facilities and some Phase III clinical trials (the stage at which patients undergo long term testing in blind, controlled studies). Due to economic oppression, POC are more likely to be seen by a variety of physicians who are unfamiliar with them (such as emergency room doctors), and who are therefore unlikely to enroll them in clinical trials. Even when POC have consistent primary care physicians, biases about racial groups may leave physicians less likely to suggest POC for clinical trials out of belief that they will not comply with difficult therapeutic regimens over long periods of time. (This in spite of the fact that “perfect” adherence is significantly more important in Phase I and II trials.)

Yet even when clinical trials include appropriate numbers of women and racialized people, a recent report by the FDA revealed that shortfalls remain in meaningful subgroup analysis. In other words: although data about women and POC may have been collected, the results were not separated out. Without subgroup analysis, medical professionals are not able to understand the full extent of effects or efficacy of products on different population groups.

The best they can do in these situations is to either assume that the results are equally representative for everyone, or make an educated guess otherwise.

So what’s being done about this?

As required by section 907 of the 2012 Food and Drug Administration Safety and Innovation Act, the FDA is currently assembling an Action Plan to provide recommendations on how to improve women and minority representation, subgroup analysis, and the availability to accurate information to doctors and consumers. The report will be released within the next month. However, given the limited resources the FDA has for enforcement, legislative action is critical to drive action.

On July 30, Representative Lucille Roybal-Allard introduced a bill called The Health Equity and Accountability Act, which provides a strategic plan to eliminate health disparities across racial, ethnic, ability, language, and gender groups. It would make federal resources available to target inequitable health care access, create federal guidelines for data collection and reporting, increase culturally and linguistically appropriate health care availability to communities of color, and even increase access to comprehensive sex education.

Although it takes a long time for the results of clinical trials to be realized, the NIH Revitalization Act passed over two decades ago, and our health care system is still far from equitable. When population groups are excluded from clinical studies, they are exposed to harm that could easily be avoided through more inclusive practices. Lack

of information makes it impossible for women and people of color today to make fully informed decisions about their health, and denies them the right to advocate for what happens to their bodies. In 2014, this should no longer be acceptable.

The HEAA is supported by multiple POC advocacy groups, including the Congressional Hispanic Caucus, the Congressional Asian Pacific American Caucus, and the Congressional Black Caucus. For opportunities to get involved, check out #HEAA2014 on Twitter.

Update: According to GovTrack.us, the bill was introduced to the 113th Congress, from 2013-2015, but died in session and was never enacted.

GLOSSARY Estrogen (Source: Hormone Health Network) • Estrogen is a hormone that triggers puberty, leading to breasts development, hair growth, and—you guessed it—menstruation • Most estrogen is released by the ovaries, and the amount of estrogen released changes throughout the menstrual cycle (estrogen levels are highest during ovulation and lowest during a person’s period). There are three types of estrogen produced by the body, released during different times in the lifecourse: • Estradiol – the main estrogen released in a postmenarcheal person • Estriol – the main estrogen released in a pregnant person • Estrone – the main estrogen released in a postmenopausal person Etonogestrel (Source: NIH MedlinePlus, and the websites for the Nexplanon implant & NuvaRing) • Etonogestrel is a progestin that prevents pregnancy by changing the lining of the uterus, thickening the cervical mucus, and preventing ovulation • Etonogestrel works alone as contracpetion in the arm implant • Etonogestrel works as contracpetion in combination with ethinyl estradiol in the vaginal ring, making it “combination hormonal contraception” (abbreviated CHC) • Contraception with etonogestrel: • Nexplanon arm implant • NuvaRing vaginal ring Ethinyl estradiol (Source: NIH MedlinePlus) • Ethinyl estradiol is a synthetic estrogen used in the vaginal ring (in combination with etonogestrel, a progestin) and the transdermal patch (in combination with norelgestromin, a

progestin) • In combination with progestins, ethinyl estradiol works as contraception by preventing ovulation, changing the lining of the uterus, and thickening the cervical mucus Human chorionic gonadotropin (Source: NIH MedlinePlus) • Human chorionic gonadotropin is a hormone produced by an embryo following implantation onto the uterine lining • The presence of hCG is often what is detected in urine- or blood-based pregnancy tests • In the weeks following the end of pregnancy (whether by delivery, miscarriage, or abortion), a person’s blood can contain sufficient amounts of hCG to produce a false positive pregnancy test • It is unlikely but still possible to get pregnant during the time immediately-postpartum Levonorgestrel (Source: NIH MedlinePlus, and the websites for the Mirena/Skyla & Liletta IUDs) • In a class of syntheic hormones called progestins (which act like progesterone in the body) • Used in both hormonal intrauterine devices (IUDs) and emergency contraception • In IUDs, levonogestrel prevents pregnancy by doing some combination of: changing the lining of the uterus, thickening the cervical mucus, and preventing ovulation • As emergency contraception, it is used to prevent pregnancy after unprotected sexual intercourse (UPIC • “Unprotected” in this case means: penis-in-vagina sex without any method of birth control or with a birth control method that failed or was not used properly (e.g. a condom that slipped or broke, or birth control pills that were not taken as scheduled) • EC should be taken within 72 hours of UPIC to work effectively

• As EC, levonorgestrel should not be used to prevent pregnancy on a regular basis • IUDs with levonogestrel: • Mirena • Sklya • Liletta • EC with levonogestrel: • Plan B One-Step • Next Choice One Dose Medroxyprogesterone (Source: NIH MedlinePlus) • In a class of syntheic hormones called progestins (which act like progesterone in the body) • Works to prevent pregnancy by preventing ovulation and changing the lining of the uterus • Also used to treat endometriosis, a condition in which the endometrium (the tissue lining the uterus) grows in other areas of the body, causing pain, heavy or irregular menstruation, and other symptoms • Hormonal contraception with medroxyprogesterone: • Depo-Provera • Lunelle (also contains estradiol, a type of estrogen) Mifepristone (Source: Our Bodies, Ourselves wesbite) • A medication used to terminate a pregnancy by blocking progesterone, leading the embryo to detach from the uterine lining Misoprostol (Source: Our Bodies, Ourselves wesbite) • A medication used to terminate a pregnancy by softening the cervix and causing uterine cramps, expelling the embryo

Norelgestromin (Source: NIH MedlinePlus) • Norelgestromin is a progestin that, in combination with ethinyl estradiol, is used as hormonal contraception in the transdermal patch • The patch, which sticks to the skin, releases both an estrogen and a progestin, making it “combination hormonal contraception” (abbreviated CHC) • Patches which contain noerelgestromin in combination with ethiny lestradiol: • Ortho Evra • Xulane Progesterone (Source: Hormone Health Network) • Progesterone triggers the thickening of the uterine lining during each menstrual cycle.

• If a pregnancy occurs, progesterone is produced in the placenta and levels remain elevated throughout the pregnancy.

• If a pregnancy does not occur during the cycle, progesterone levels fall and the uterine lining is expelled • Progesterone is also used in hormone replace therapy (HRT) for people who have undergone menopause. HRT often includes estrogen, and progesterone helps prevent the uterine lining from abnormal thickening, which can be caused by estrogen.

Progestin (Source: NIH MedlinePlus) • A class of synthetic progesterone hormones, often used in contraception • Progestin works by preventing ovulation, thickening cervical mucus, and changing the lining of the uterus

Prolactin (Source: NIH MedlinePlus) • A protein secreted from the pituitary gland that, in humans, is best known for its role in enabling milk production Prostaglandin (Source: NIH MedlinePlus) • The prostaglandins are a group of lipids made at sites of tissue damage or infection that is involved in dealing with injury and illness • Prostaglandins are involved in the control of ovulation, the menstrual cycle and the induction of labor

REFERENCES Ali. “Hollywood Thinks Your Period is Scary.” Autostraddle.

13 July 2012.

Clancy, Kate. “Menstruation is Just Blood and Tissue You Ended up Not Using.” Post, Context & Variation blog, Scientific American. 9 Sept. 2011.

Cohen, Sharon. “Norplant Lawsuits Flourish along with Women’s Reports of Problems.” Associated Press, The Los Angeles Times. 8 Oct. 1995.

Grindlay, Kate, Britt Wahlin, and Daniel Grossman. “Free the Pill.” Free the Pill. Ibis Reproductive Health. 2016.

Helen. “Novel Idea: What If We Actually Researched Whether Menstrual Products are Safe to Use.” Autostraddle. 2 June 2014.

Jones, Abigail. “The Fight to End Period Shaming is Going Mainstream.” Newsweek. 20 Apr. 2016.

Kolata, Gina. “The Sad Legacy of the Dalkon Shield.” The New York Times. 6 Dec. 1987.

Labbok, Miriam H., MD, MPH. “The Lactational Amenorrhea Method (LAM) for Postpartum Contraception.” Australian Breastfeeding Association. July 2013. Web. 29 Apr. 2016.

Mandanas, Laura. “Clinical Trials on Trial: Medical Studies Still Exclude Women and People of Color to Dangerous Degree.” Autostraddle. 11 August 2014.

MedlinePlus. Bethesda, MD: National Library of Medicine (US). 2 May 2016.

Moore, Lane. “What It’s Really Like to Free-Bleed During Your Period.” Cosmopolitan. 3 June 2015.

No Más Bebés. Dir. Renee Tajima-Peña. Independent Lens, 2016. PBS Documentary.

Planned Parenthood. “Menstruation at a Glance.” Planned Parenthood Federation of America. 2014.

Rothschild, Anna. “Three Facts about Periods.” Gross Science. WGBH for PBS, Boston, Massachusetts. 2016.

Stewart, Dodai. “The Most Horrifying Period Stories You’ve Ever Heard.” Jezebel. 22 Nov. 2011.

Zeldes, Kiki, ed, with the Boston Women’s Health Collective.

Our Bodies, Ourselves: A New Edition for a New Era. 2nd ed. New York: Simon & Schuster, 2011.

For some further reading and learning pleasure!

Ehrenreich, Barbara, and Deirdre English. For Her Own Good: Two Centuries of the Experts’ Advice to Women. 2nd ed. New York: Anchor, 2005.

“Gross Science: Three Facts about Periods.” PBS. WGBH, 10 February 2016. Web. 18 April 2016. http://www.pbs.org/ show/gross-science/ Gubar, Susan. Memoir of a Debulked Woman: Enduring Ovarian Cancer. New York: W.W. Norton, 2012.

Jamison, Leslie. The Empathy Exams: Essays. Minneapolis: Gray Wolf Press, 2014.

Our Bodies, Ourselves Revised and Edited. New York: Simon & Schuster, 2011.

Roberts, Dorothy E. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York: Pantheon, 1997.

US National Library of Medicine, National Institutes of Health, MedlinePlus. https://www.nlm.nih.gov/medlineplus/ Washington, Harriet A. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. New York: Doubleday, 2006.

Resources

Great websites and places for information about sex, sexuality, and sexual health: • Scarleteen website (great stuff even if yr not a teen) • Planned Parenthood clinics and website • Your local library!