Perspectives of Indian adolescent girls in promoting menstrual health: A qualitative analysis

Abstract

Background:

Menstrual health is a vital indicator of adolescent girls' overall well-being and is shaped by diverse social, economic, cultural, and environmental factors. The menstrual period is often associated with physical and psychological discomfort, which can impact mental health. Early preparedness and a supportive environment are key to promote healthy coping and well-being.

Objective:

To explore the perceptions and experiences of Indian adolescent girls regarding menstruation.

Study design:

Qualitative descriptive study.

Methods:

This study explored menstrual health perception among 20 adolescent girls, aged 11–15 years, from three selected schools of Dakshina Kannada District, India. Data were collected through focus group discussion, transcribed and analysed using the OpenCode software (version 4.02). Thematic analysis was performed using deductive analysis.

Results:

The analysis revealed overarching themes such as preparation, puberty and menstruation, menstrual discomforts, menstrual hygiene and management, menstrual health empowerment, and perceptions about menstruation, reflecting the multifaceted and inter-connected aspects of the participants’ experiences. The findings highlight the need for comprehensive education, policy interventions, and community involvement to enhance menstrual health outcomes for adolescent girls in India.

Conclusion:

This study highlights the multifaceted experiences of younger adolescents regarding menstruation, an area that remains significantly under-researched and emphasises the need for age-appropriate, culturally sensitive interventions to support their menstrual health and empowerment.

Keywords

adolescents menstrual health health promotion school health hygienic facilities school education pubertal changes

Introduction

Adolescence is a critical stage in the developmental process, marking the transition from childhood to adulthood. It typically begins with the onset of puberty and extends into the mid-twenties, characterised by biological, cognitive, psychosocial, and emotional changes.¹ Menarche, the onset of menstruation, typically occurs between ages 10 and 16, with a mean age of 12.4 years.² As this age group typically corresponds with middle school years, the school environment plays a pivotal role in shaping menstrual health knowledge and practices.

Hennegan defines “menstrual health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity in relation to the menstrual cycle.”³ Menstruation is often accompanied by a range of physical and psychological discomforts. According to the National Guidelines 2015, India’s 113 million adolescent girls are vulnerable during their first menstruation due to lack of prior knowledge, inadequate access to hygienic menstrual products, and social stigma surrounding the topic. Nearly half of the girls are unaware of menstruation before menarche. Commercial sanitary pad usage stands at 67% in urban areas and 32% in rural regions, with 24% of girls reporting missing school during this period.⁴

A survey,⁵ involving 2400 Indian women, reported that 60% experienced increased levels of stress, anxiety, and mood swings during menstruation. Studies have also linked body mass index to menstrual irregularities, including primary dysmenorrhoea.^6
–8 Regular monitoring of the menstrual cycle is essential in the early recognition of underlying causes of menstrual disturbances, thereby enabling appropriate and effective management. Promoting safe menstrual health directly supports Sustainable Development Goals (SDG), particularly SDG 3.7 and 5.6, which emphasise universal access to sexual and reproductive health services and reproductive rights.⁹

Recent literature underscores significant variations in menstrual health management across different regions and between urban and rural populations in India. For instance, Sivakami reports that ~22.4% of women in India do not use hygienic methods during menstruation, with substantial disparities based on rural–urban residence and socio-economic status. The study also highlights pronounced state-level and district-level differences, particularly in the north-eastern and Empowered Action Group states such as Assam, where access to hygienic menstrual products and Water, Sanitation, and Hygiene (WASH) facilities remains limited.^10
–13

Menstrual health promotion in India is shaped by a complex interplay of socio-economic and environmental factors. Low socio-economic status, migration, and financial difficulties were some of the barriers to menstrual health promotion reported in the study.¹⁴ Inadequate privacy in schools, WASH facilities, poor waste disposal systems, limited access to appropriate absorbents, and insufficient awareness further hinder menstrual health management.¹⁵ Social challenges, including limited open communication, misinformation from peers, lack of social support, and the high cost of menstrual products, also contribute to these difficulties.^16,17 Additionally, cultural norms and lifestyle factors such as low reproductive and menstrual health literacy, unhealthy dietary habits, and persistent taboos continue to affect menstrual health.^18,19 Addressing these issues requires targeted interventions, encompassing WASH infrastructure, education, healthcare access, and efforts to challenge stigma. These findings reinforce the need for region-specific and context-sensitive interventions.

A study conducted in a less developed state of India in 2025 revealed significant gaps in WASH and Menstrual Hygiene Management (MHM) facilities for adolescents. These include the absence of menstrual hygiene kits, sanitary napkin distribution, educational sessions, changing rooms, separate washroom for boys and girls, water availability, and sanitary napkin disposal mechanisms. These findings highlight the urgent need for targeted interventions in the region.²⁰ While similar challenges exist across India, national data indicate that the implementation of various schemes has gradually improved the awareness and menstrual product usage.

Governmental and non-governmental agencies have taken several initiatives towards the promotion of menstrual health in India. In 2016, the Ministry of Health and Family Welfare, Government of India, launched the Menstrual Hygiene Scheme (MHS) to support adolescent girls aged 10–19 years living in rural areas. Under this scheme, a pack of six sanitary pads were made available at an affordable price of Rupees six.²¹ Presently, this scheme continues in Jan Aushadi Kendras where Suvidha Sanitary napkins are sold at a cost of rupees 1/pad with no restriction on time or quantity of purchase.²² Comprehensive Communication and Engagement termed as a 360° communication strategy was adopted to ensure effective outreach services. These materials help the grassroots level worker, known as Accredited Social Health Activists (ASHA), in effectively delivering menstrual health education. It involves multiple channels and formats such as audio-visual materials (short films, radio messages), printed information education communication materials (posters, leaflets, booklets), interactive sessions (monthly once at Anganwadi centres led by ASHA worker), peer engagement (peer–peer learning), and training for ASHA workers (to effectively communicate and distribute sanitary materials).²¹ ASHA is a female volunteer selected from the community who serves and delivers health information including menstrual health through door to door visit, collaboration with school or Anganwadi centres.^23,24

The Rashtriya Kishor Swasthya Karyakram (proposed in 2011 and ongoing since 2014); the Nirmal Bharat Yatra (2012, one-time programme), a flagship sanitation program that included Menstrual Health and Hygiene; and Samagra Shiksha Abhiyan that included installation of sanitary napkin vending machines and incinerators (significantly expanded in 2023–2024, ongoing), for safe and hygienic disposal – Development of MHM guidelines under the Ministry of Drinking Water and Sanitation (2015, ongoing under Swatch Bharath Mission Gramin), were some of the programs used to promote awareness and accessibility.

These initiatives have significantly improved India’s menstrual product usage from 15% in 2010 to 57% in 2015–2016 and further to 78% in 2019–2021.²⁵ Private initiatives such as Ujass by the Aditya Birla Group in India covering around 25 states,²⁶ and Shuchi-Nanna Maitri scheme by the Government of Karnataka through which sanitary napkins and menstrual cups were freely distributed to school and college students have also contributed to the progress.²⁷

The MHS significantly increased sanitary pad usage by 10.6% and hygienic method adoption by 13.8% points among girls aged 15–19 in Assam and Tripura. Awareness of ovulation improved by 6.1% points, indicating enhanced menstrual health knowledge. However, a 1.8%-point rise is reported in sexually transmitted infections, and disparities based on media exposure and autonomy suggest the need for targeted and informed interventions.²⁸ Currently, there is a lack of comprehensive data to assess whether all the services provided under the governments menstrual health initiatives have been effectively utilised.²⁴

According to the American College of Obstetricians and Gynaecologists, clinicians should initiate educating girls and their caregivers about the menstrual cycle before menarche, around the age of 7–8 years. This education should include what to expect from the first menstrual period and the normal range of cycle lengths that follow. Such guidance helps to reduce misconceptions, supports early identification of abnormal menstrual patterns, and promotes the overall well-being of adolescents.²⁹

Recent studies indicate that Gen Z (born approximately between 1997 and 2012) adolescents are more open to discussing menstruation, have greater access to diverse menstrual products, and are influenced by digital media campaigns that promote menstrual health and challenge stigma. This generation benefits from improved parental communication, higher literacy rates, and school-based awareness programs, contributing to better coping strategies and reduced school absenteeism.³⁰

In contrast, earlier generations such as Millennials (born approximately between 1981 and 1996) and Gen X (born approximately between 1965 and 1980) often experienced menstruation as a taboo subject, with limited access to accurate information and hygienic products. A study conducted in Tamil Nadu found that socio-cultural restrictions, lack of pre-menarcheal education, and maternal discomfort in discussing menstruation contributed to poor menstrual hygiene practices among adolescent girls in southern India.³¹

Furthermore, attitudes towards menstruation were shaped by heteronormative and sexist beliefs, particularly among older generations. Eyring et al. demonstrated that secrecy, shame, and avoidance behaviours were more prevalent among individuals with traditional gender role expectations, which were more common in earlier cohorts.³²

This study aimed to explore menstrual health experiences among Gen Z adolescents, focussing on sources of menstrual knowledge, hygiene practices, emotional well-being, and coping mechanisms. By examining these lived experiences, we seek to understand how current norms shape safer and more dignified menstrual health.

For conceptual clarity, this study uses three related but distinct terms. Menstrual health promotion refers to strategies and interventions aimed at improving overall menstrual well-being, including education, access to products, and supportive environments. MHM specifically focusses on the hygienic practices adopted by girls during menstruation, such as the use of clean absorbents and safe disposal methods, rather than on broader WASH infrastructure. Menstrual literacy denotes the knowledge and understanding of menstrual biology, hygiene practices, and related health issues, which empowers individuals to make informed decisions. These distinctions guide the thematic organisation and interpretation of findings throughout the article.

Methods

Design and participants

This study employed a qualitative descriptive design using focus group discussions (FGDs) to explore adolescent girls’ perceptions related to menstruation. Ethics approval was obtained from Father Muller Institutional Ethics Committee (approval number FMIEC/CCM/640/2023) in November 2023. Three FGDs were conducted in February 2024 across three schools in Mangaluru, Dakshina Kannada District, Karnataka, India. The district was selected for its diverse urban and semi-urban adolescent population. Schools were chosen using convenience sampling based on accessibility, institutional permissions, and willingness to participate. Girls were identified in collaboration with school authorities using convenience sampling. A total of 25 adolescent girls were invited to participate, of whom 20 girls aged 11–15 years voluntarily took part in the discussions. Participants were selected based on the following inclusion criteria: Aged between 11 and 15 years, had attained menarche, were comfortable and able to communicate in English, provided personal assent, obtained parental consent and received permission from the heads of the institution. This approach ensured ethical participation and relevance to the study’s focus on younger adolescents’ menstrual experiences. This study represents the preliminary phase in the development of an intervention module aimed at empowering adolescent girls to promote menstrual health. The selected sample consists of individuals within the same age group as the intended beneficiaries of the intervention. This study involves exploring key thematic areas that are critical for the formulation and refinement of the module.

Instrumentation

The FGD guide was developed based on a review of existing literature and covered key domains relevant to adolescent menstrual health. The content validation of the FGD guide was conducted by a panel of experts comprising one specialist in obstetrics and gynaecological nursing, two professionals in public health/community medicine, and two paediatricians experienced in adolescent health care. Their combined expertise ensured that the guide was age-appropriate, culturally sensitive, and relevant to the health and development needs of younger adolescents. The guide included open-ended questions on the following: preparedness for menstruation, menstrual cycle patterns, pubertal changes, physical and psychological discomforts, management and coping strategies, and support systems. Following each FGD, verbatim transcriptions were carried out. Subsequently, the data were analysed to derive meanings and generate initial codes. Data saturation was considered and achieved when no themes or insights emerged, and redundancy in participants’ responses was observed.

Data collection procedure

Each FGD was guided by an interview guide (Supplemental Material 1) with open-ended questions (Supplemental Material 2). The lead question invited the participants to share their first menstruation experience, followed by sub-questions exploring hygiene practices, emotional responses, and sources of support. FGDs were conducted in English within a private room in the school premises to ensure confidentiality, comfort, and a safe space for open sharing. To maintain privacy and reduce any potential influence or discomfort, no teachers, parents, or other students were present during the sessions. Each FGD was facilitated by the primary author, who is trained in qualitative research and adolescent health, with support from an assistant moderator who managed note-taking and logistics. Both facilitators ensured that the discussions were conducted ethically, respectfully, and in a manner appropriate for the age group. Sessions lasted between 45 min and 1.5 h and were audio-recorded with participants’ consent. Rapport was established prior to the sessions, and participants were briefed on the study’s purpose, ground rules, and confidentiality measures. As a token of appreciation, each participant received a diary and a pen. Data saturation was achieved by the third FGD, with no new themes emerging. No repeat interviews were conducted.

Data analysis

FGDs were recorded using a mobile voice recorder, and transcripts were reviewed for accuracy. The transcripts were reviewed independently by two researchers using a deductive coding approach. Initially, sentences from the transcripts were read thoroughly and condensed into codes that aligned with the study’s conceptual framework. These codes were then systematically grouped into categories, which were further abstracted into overarching themes. The coding process was facilitated using the OpenCode software, version 4.0.³³ To ensure reliability, inter-coder agreement was assessed, followed by consensus meetings, and the coding framework was refined accordingly. This interactive and collaborative process led to the finalisation of themes that accurately represented the participants’ narratives. Thematic analysis was employed to reflect participants’ findings. The steps involved in the thematic analysis correspond with those proposed by Braun and Clarke³⁴: become familiar with the data, generate initial codes, search for themes, review themes, define themes, and write up. Themes derived from narratives were validated by two experts to ensure reliability.

Results

A total of three FGDs were conducted, where the first FGD consisted of seven participants, the second FGD had six participants, and the third FGD had seven participants. Verbatim quotes from participants are presented using FGD and participant codes, for example, FGD1–P1. Direct quotations are attributed to specific participants using the format FGD–P (e.g. FGD1–P1), while multiple identifiers (e.g. FGD1–P1, FGD2–P3, P5, FGD3–P4) indicate that the same theme or statement was shared or agreed by more than one participant across different groups. The placement of quotes was made after checking the appropriateness to the corresponding themes. All FGD Consolidated Criteria for Reporting Qualitative Research checklist was used as a reporting guideline³⁵ (Supplemental Material 3). All the girls were studying between the seventh and 10th standards with an average age of 13.75 ± 1.25 years. Out of 20 girls, 55% were Hindus, 30% were Christians, and 15% belonged to the Muslim religion residing in urban areas. The majority of girls (n = 18) had attained menarche at least 2 years ago, except for two girls who attained within the past 6 months. Baseline characteristics are detailed in Table 1 (Supplemental Material 4).

Table 1.

Baseline characteristics (N = 20).

Variable	Category	Frequency (%)
Age	Mean age (years)	13.75 ± 1.25
Occupation – father	Highly skilled	05 (25.0%)
	Medium skilled	06 (30.0%)
	Low skilled	05 (25.0%)
	Self-employed	04 (20.0%)
Occupation – Mother	Medium skilled	07 (35.0%)
Occupation – Mother	Housewife	13 (65.0%)
Education status – father	High school	06 (30.0%)
	PUC	06 (30.0%)
	Diploma	01 (5.0%)
	Graduate	03 (15.0%)
	Post graduate	04 (20.0%)
Education status – mother	High school	06 (30.0%)
	PUC	04 (20.0%)
	Diploma	02 (10.0%)
	Graduate	06 (30.0%)
	Post graduate	02 (10.0%)
Number of siblings	Only child	05 (25.0%)
	One	12 (60.0%)
	Two	03 (15.0%)

Themes

The perceptions of the adolescent girls were divided into six major themes: “Menstrual preparation,” “Puberty and menstruation,” “Menstrual discomforts,” “Menstrual hygiene and management,” “Menstrual health empowerment,” “Perceptions about menstruation.” Codes relevant to themes and subthemes are described in Table 2, and the conceptual model is depicted in Figure 1 (Supplemental Material 5).

Table 2.

Key themes, subthemes, and codes from FGDs.

Themes	Subthemes	Codes
1. Menstrual preparation	Pre-menarche readiness Source of information	Well prepared and weird experience Close relatives, friends, social media, and school education/textbooks
2. Puberty and menstruation	Age of menarche Menstrual cycle regularity and flow Physical changes Cognitive changes	Fourth to eighth standard and 10–11 years Regular versus irregular and minimal versus heavy bleeding Voice change, breast changes, and hair growth Improvement in thinking, intelligence, and extrovert to introvert
3. Menstrual discomforts	Physical discomfort Psychological discomfort	Leg cramps, back pain, stomach pain, and breast heaviness Mood swings, anger, irritation, sadness, and emotional damage
4. Menstrual hygiene and management	Hygienic practices Sanitary product access and disposal Diet during menstruation Food cravings Physical management	Frequent change of pads and twice bath daily Provision in school, carrying a sanitary pad, wrapping in paper, and discarding burning Avoiding spicy food and consumption of sesame seeds/ragi/turmeric milk Craving for sweets, chocolates, and ice cream Hot water bag, yoga, walking, sleep, and music
5. Menstrual health empowerment	Support during menstruation Boys education Empowerment strategies	Parents, school assistants, and teacher Boys should be aware, respectful, and educated equally Annual education, practical teaching, pain management, and awareness about pad usage
6. Perceptions about menstruation	Attitude towards menstrual cup Self-ideas Peers attitude Societal attitude	Eco-friendly, fear, and parental disapproval Weakness, body weight, hormones, and hereditary Lack of knowledge and discomfort during discussion Lack of awareness, stigma, and cultural views

FGD: focus group discussions.

Figure 1.

Model depicting perceptions of Indian adolescent girls in promoting menstrual health.

Preparation before menarche sets the stage for how girls navigate the physical and emotional changes of puberty, making it essential to understand this transition. As puberty progresses, hormonal and bodily changes often lead to menstrual discomforts, highlighting the need for strategies to manage these challenges. Managing discomforts effectively depends not only on coping techniques but also on proper menstrual hygiene practices, which ensure health and confidence during menstruation. Access to hygiene resources and supportive infrastructure strengthens girls’ autonomy, making menstrual health empowerment a natural extension of effective management. Empowerment initiatives influence how menstruation is perceived, reducing stigma and fostering positive attitudes among adolescents and their communities.

Theme 1: Menstrual preparation

Girls exhibited varying levels of preparedness at menarche, designed primarily by familial and educational influences. While some felt confident and informed, others experienced confusion or surprise, revealing gaps in early menstrual education. Prior guidance from trusted sources helped some girls manage their first menstruation with ease, reducing anxiety. Others described it as a “weird” or unexpected event, indicating emotional and informational unpreparedness.

It was not so bad as I was well aware of all these things priorly. (FGD3–P6). Similar responses were reported by FGD1–P4, FGD3–P1.

Mothers and elder sisters were key educators. A few girls acknowledged their fathers involvement, although most noted limited paternal engagement. Friends often filled gaps left by formal education, serving as informal yet influential sources.

My parents told me about pre menarche like they explained to me what and all happens and what are the symptoms of getting periods. Firstly, they told me that there will be stomach pain before the period starts and after periods end, white discharges will be coming for 3–4 days, then after the 28th day this cycle will be. . . the menstrual cycle will be restarting. (FGD1–P1)

Structured learning through textbooks and health talks provided foundational knowledge.

It was not new to me. I knew about periods as they teach us in religious education. Every girl will get information about it. We have books also related to it. (FGD3–P6)

Social media offered accessible information, although its reliability varied.

I knew about it through YouTube and stuff. . .and then my mother also explained me. My Mom taught about this and my father also supported me. (FGD3–P4)

The findings underscore the importance of implementing menstrual education from an early age, reinforced consistently, and delivered with sensitivity to cultural beliefs. Platforms such as schools, media, and community outreach should play a key role in ensuring that adolescents receive accurate, supportive, and inclusive information, thereby promoting safe and dignified menstrual health.

Theme 2: Puberty and menstruation

This theme explores the biological and psychological transitions accompanying menarche, typically occurring between ages 10 and 11 during grades four to eight.

I got my period when I was in fourth standard. It’s been six years now. (FGD1–P1)

All participants experienced menarche at home due to the COVID-19 pandemic or during holidays, emphasising the need for timely education regardless of setting.

First, I was in grandma’s house, I got there. . .I went there for holidays, little stomach pain. . . fifteen days I had. (FGD2–P3)

Menstrual patterns varied; some girls had regular cycles, while others faced irregularity and variable flow, influencing their comfort and management strategies.

If I get it for one month, next I will get after 2 months. Then my mother took me to a doctor where I was told that I have thyroid issues. (FGD3–P7). Similar concerns about irregular menstruation was expressed by other participants FGD3–P2, FGD3–P3, FGD2–P6.

During puberty, visible changes like voice modulation, breast development and body hair growth occur. These changes often marked the beginning of menstruation. These were accepted positively as a natural physiological change.

My voice has changed a little bit, the development of hair and thinking has improved. (FGD2–P2). Similar observations about physical change was noted by another participant. (FGD2–P6)

Girls reported enhanced thinking abilities and personality shifts, such as becoming more introverted. Although unaware of hormonal influences, many linked physical changes with cognitive growth, reflecting the psychosocial dimension of puberty.

As I have observed, if a girl is extroverted, she will become introverted. Like I have become. I was talkative earlier, after getting periods, I am talking less. (FGD3–P7). Similar reflections on change in personality and behaviour were shared by other participants FGD2–P3. Comparable view on academic performance was expressed by another participant I think my intelligence level has improved. (FGD2–P5)

Theme 3: Menstrual discomforts

This theme highlights the multidimensional characteristics of menstrual discomfort, encompassing both physical pain and emotional strain, and underscores the need for holistic support. All participants reported experiencing pain, with common symptoms including backaches, leg cramps, headaches, breast tenderness, pimples, vaginal pain, and general body aches.

I will have cramp-like pain, back pain, and leg pain, heavy flow during periods. Menstruation time is not comfortable. . .something. . . body is not physically comfortable. As the years increase, all these will increase, but I don’t take any medicines. (FGD1–P3). Similar concerns were shared by participants in FGD1–P1, FGD1–P3, FGD1–P6, FGD2–P6, FGD2–P5, FGD3–P3. Discomfort was noted to increase over time, yet none sought medical help; instead, they relied on home remedies.

Emotional swings were prevalent, with most girls experiencing mood swings, irritability, sadness, and emotional strain. These symptoms were consistent across home and school settings, but no psychological support or counselling was sought.

And when cramps are going on, we have high temper. . . feel like throwing something. Without reason will get angry. (FGD1–P3). Comparable experiences of mood swings and irritability were shared by participants in FGD1–P4, FGD1–P1, FGD2–P5, FGD1–P7, FGD3–P4.

Emotional responses were often ignored or dismissed, highlighting the need for empathy and emotional literacy in menstrual care.

Theme 4: Menstrual hygiene and management

This theme reflects the coping strategies adopted by the girls to manage menstruation, encompassing hygiene, diet, physical care, and emotional regulation. Most participants followed frequent pad changes and twice-daily bathing, with some opting for daily head baths. These routines were shaped by family norms and cultural expectations, aimed at ensuring cleanliness and preventing infections.

I change the pad frequently. (FGD1–P6). Similar practices were performed by participants from FGD2–P5, FGD3–P2.

We must take a bath daily, morning and evening, at least for three days during menstruation (FGD2–P5). Similar response was shared by an participant from FGD3–P2.

Schools provided emergency menstrual supplies, and many girls carried pads in their bags, indicating preparedness and institutional support.

Pads are available in the school office. When we ask, they will give (FGD1–P1). Similar responses were shared by FGD1–P3, FGD1–P5, FGD1–P6.

Disposal methods included wrapping in paper and burning, reflecting both awareness and cultural practices. Repetition of quotes represents the shared practice across multiple participants and groups.

Before disposing, we wrap it in paper, then we will dispose. . . home also there is a bin for disposal (FGD1–P7). Similar practices were reported by FGD1–P4, FGD1–P3, FGD2–P6, FGD3–P4, FGD3–P6, FGD3–P3, FGD3–P1.

Girls avoided spicy foods and consumed traditional remedies like sesame seeds, ragi, turmeric milk, jeera kashaya, and fruits to ease discomfort. These practices were culturally rooted and aimed at promoting well-being.

Normal food only I will take but I avoid spicy foods during those days. My Mother will scold. My grandmother will give fruits and amla’s during periods. And I love oranges eating those days. (FGD1–P6)

Papaya is good for healthy menstruation. I eat papaya regularly and then sesame seeds. . .comes as laddu. . . sometimes ragi, mother prepares a drink from ragi or some herbal drink (kashaya) (FGD2–P4). Similar practices were reported by participants from FGD1–P3, FGD1–P4, FGD2–P5, FGD2–P3.

Hormonal changes triggered cravings for sweets, chocolates, ice cream, and spicy foods. While parents imposed dietary restrictions, girls often lacked understanding of the rationale behind them.

Sometimes there will be a craving to eat some spicy items during those days, but our parents will not allow us (FGD1–P1). Similar experiences were reported by FGD1–P4, FGD1–3, FGD1–6.

Some of them considered strategies like yoga, walking, stretching exercises, and cycling. Some learned techniques from school and others from online platforms.

I get relief when I do regular exercise, but some say exercise increases bleeding, but that is not the fact. I used to practice some asanas from yoga, the Cobra stretch, and other exercises that I learnt from social media. I found it more effective. We will sit in a squat position and then take deep breaths, tummy in, hold the breath, and exhale it out (FGD1–P7). Similar activities were performed by FGD1–P4, FGD2–P3.

Others used hot/cold water bags, music, and pillows for comfort. Music was especially noted for its mood-stabilising effect. Only one participant used prescribed medication; most relied on home remedies or observational learning from siblings, showing a preference for non-clinical coping methods.

My mother was saying not to practice sports during those days. Some say it gets affected with food pattern. But I feel it affects based on each individual’s body reaction, So I go for sports practice except on first day, because I will have stomach pain and more bleeding. (FGD2–P6)

I listen to music; it gives more relaxation (FGD1–P7). Similar responses were added by the participants of FGD1–P3, FGD1–P4, FGD1–P1, FGD2–P3, FGD2–P6, FGD2–P5, FGD2–P4, FGD2–P2, FGD3–P3, FGD3–P4.

I sleep on the pillow (FGD1–P1). Similar practices were reported by the participants of FGD1–P3, FGD1–P7, FGD3–P3, FGD2–P3.

Theme 5: Menstrual health empowerment

This theme emphasises the importance of supportive environments and inclusive education in empowering girls during menstruation. Girls felt more comfortable with school assistants than teachers, as they provided practical help like sanitary materials and support during emergencies. Support from parents, peers, and community members was also seen as crucial in boosting self-esteem and confidence.

In school, we have aunties (school assistants), who will help us a lot. Teachers also help, but we don’t talk to them; we ask Aunty most of the time (FGD2–P5). Similar experiences were reported by FGD2–P4, FGD2–P6, FGD2–P3.

Participants advocated for combined sessions for boys and girls to foster understanding, respect, and reduce stigma. Educating boys was seen as essential, especially for those without sisters, to prevent teasing and promote empathy.

Yes, every year they must be educated. Not only the girls but also the boys should know and classes need to be taken together. They should remain friendly during those days. Boys also should know because it’s not something uncomfortable, it’s a natural process, so everyone should know about it. Boys are not taking it seriously; they should understand our problems (FGD2–P4). Similar opinion was shared by the participant from FGD1–P1, FGD3–P4.

Different empowerment strategies suggested by girls were as follows: annual awareness programs to reinforce menstrual knowledge, practical demonstrations about pad usage, hygiene practices, pain management education to address physical discomfort, and guidance on pad disposal to promote hygiene and environmental care.

Mainly about pain, how it starts, because nobody will have knowledge about it. Also, the use of pads, like those who live in slum areas, they lack that knowledge, and it is scientifically said that cloth is allergic to that area. So, awareness needs to be given. (FGD1–P1)

Many members come here to teach us, but what they do is just show some slides and explain, but practically they don’t teach . . . so it is not benefiting us much (FGD2–P3). Similar note was made by the participant from FGD2–P4.

Theme 6: Perceptions about menstruation

This theme explores how personal beliefs, peer dynamics, and societal norms shape girls’ attitudes towards menstruation and menstrual products. While all participants used sanitary pads, some were aware of menstrual cups through school sessions. Despite recognising their eco-friendliness, usage was hindered by parental disapproval and fears about insertion and hygiene, reflecting cultural taboos and misinformation.

We are using sanitary pads. (FGD1–P1). Similar responses were reported by all the participants from FGD1, FGD2, and FGD3.

When I asked my parents about a menstrual cup, they said it would expand the vagina. It will not be good for the future. Pads are only better. (FGD1–P1)

My elder sister is using that menstrual cup. that is good for nature. it will not destroy our plants and trees and all. but I don’t want to use it, I am scared to use/. (FGD2–P6)

Participants had misconceptions linking menstruation to body type, personality, and heredity. For instance, some believed that thinness or weakness affected flow or that sports should be avoided to prevent excessive bleeding. These beliefs were unquestioned, indicating a gap in scientific understanding.

I am thin so for thin people menstruation happens lately. (FGD1–P5)

Every person’s body is different, even hormones also. . . even parents genes also may have influence on menstruation. (FGD3–P6)

My mother was saying not to practice sports during those days. Some say it gets affected by food patterns. . .I feel it affects based on each individual body reaction. (FGD2–P6)

Peer discussions were limited due to shyness and confidentiality concerns. Girls often hesitated to seek help or share experiences, highlighting a lack of openness and the need for safe spaces for dialogue.

Some girls do not feel comfortable. They think that we are sharing that information with others. So, it becomes very difficult for them to make it understand (FGD3–P3, P4). Similar responses were received from participants in FGD2–P5, FGD2–P1.

I am not getting regular menstruation but I don’t want to discuss all these things with doctor, I don’t feel comfortable also. . . (FGD2–P6)

Practices like wrapping pads in newspaper at medical stores reinforced stigma and secrecy. Participants called for community education to normalise menstruation and challenge outdated norms, despite ongoing government efforts to promote menstrual health.

Sometimes when we go to buy in the medical store, they wrap in a newspaper and give it like hiding. They are still like in the old concept (FGD3–P3). Similar experiences were reported by the participants of FGD3–P4, FGD3–P6.

Educating on this topic will help many uneducated people. (FGD3–P6)

Based on the derived themes and codes, a conceptual diagram linking themes and subthemes to elicit perceptions of Indian adolescent girls about menstrual health promotion is developed and is presented as Figure 1 (Supplemental Material 5).

The conceptual model presented in Figure 1 is a multidimensional framework for examining the perceptions, experiences, and challenges faced by Indian adolescent girls in relation to menstrual health. It identifies six interrelated domains that collectively shape menstrual health outcomes, with empowerment positioned at the core of the model.

Menstrual health empowerment

Empowerment is central to menstrual health and is fostered through inclusive education, particularly by engaging boys to promote empathy, reduce stigma, and cultivate a supportive environment. Key strategies include peer-led interventions, access to menstrual products at school and home, and availability of adolescent-friendly healthcare services. Institutional support and policy-level initiatives further reinforce empowerment.

Perceptions about menstruation

Girls’ perceptions of menstruation are shaped by peer dynamics, cultural norms, and community beliefs. Supportive peer environments enhance openness, while stigma can lead to silence and discomfort. Internal beliefs, body image, self-esteem, and receptiveness to sustainable menstrual products also influence how menstruation is experienced and discussed.

Menstrual preparation

Preparation prior to menarche is critical for a positive menstrual experience. Emotional readiness and accurate information, often provided by family, peers, and media, play a pivotal role in shaping girls’ understanding and attitudes towards menstruation. Early and age-appropriate education is essential to foster confidence and reduce anxiety.

Menstrual hygiene and management

Effective MHM encompasses access to sanitary products, safe disposal practices, and awareness of dietary habits during menstruation. Dispelling myths and taboos related to hygiene and nutrition is vital. Infrastructure, such as clean toilets and water supply in schools, also significantly impacts menstrual health.

Menstrual discomforts

Menstruation is often accompanied by physical symptoms (e.g. cramps, fatigue, headaches) and psychological challenges (e.g. mood swings, anxiety). These discomforts can affect girls’ quality of life and school attendance. Empowering girls with coping strategies, including pain management techniques and emotional support, is essential.

Puberty and menstruation

Biological and emotional changes during puberty, including age at menarche, menstrual cycle patterns, and bodily transformations, affect how girls adapt to menstruation. Mental and emotional development during adolescence further influences their coping mechanisms and overall menstrual health experience.

Discussion

This study offers valuable insights into the perceptions and experiences of adolescent girls related to menstrual health in an urban Indian context. The findings underline the key role of family support, specifically from mothers, in preparing girls for menarche and guiding them through coping strategies during their menstruation journey. The findings align with systematic review results¹¹ and research from Nigeria and Ghana, where mothers and teachers were identified as primary sources of menstrual information, contributing to positive attitudes and hygienic practices.³⁶As many young girls consider menstrual education a sensitive issue, peer education can be used as a strong tool to educate them.^37,38

Adolescents in this study demonstrated commendable hygienic practices and awareness of menstrual management as they were supported by access to sanitation facilities and resources at school settings. Higher rates of hygienic practices were noted in the southern and western parts of India due to the presence of better toilet facilities, disposal systems, availability of sanitary napkins in the school, and subsidised sanitary napkin distribution programmes.^11
–13,39

The use of reusable products and safe disposal practices contributes to promoting safe environmental health.¹³ A study reported in Karnataka showed 4.5% of the healthcare students held a negative attitude towards the use of the menstrual cup.⁴⁰Whereas non-useability by family member (24%), fear of insertion, and difficulty in using^41,42 were the contributing factors for this negative attitude. However, the study revealed limited awareness and acceptance of menstrual cups, often hindered by misinformation. Although they were interested in trying new menstrual materials, the response they received from their parents was poor. This indicates a critical gap in menstrual product education, as also observed in studies from Kerala and Spain.^43,44 Moreover, misconceptions related to diet, fear of menstrual cups, and stigma around discussing menstruation necessitate the need for targeted educational interventions. Studies from Rajasthan and Haryana also emphasised the importance of peer education and curriculum-based menstrual health literacy.^36,45Addressing these gaps, our findings suggest that practical demonstrations and community engagement could enhance menstrual autonomy and sustainability.

The physical and emotional discomforts reported by adolescents, including cramps, mood swings, and irritability, were primarily managed through home remedies and non-pharmacological strategies such as yoga, music, and dietary adjustments.^46,47 Systematic review and meta-analysis conducted using 29 randomised controlled trials involving 1808 participants among adolescents with primary dysmenorrhoea and who were practising relaxation exercises, strength training, aerobic activity, yoga, mixed exercise, and kegel manoeuvre found to be more effective. In spite of the pervasiveness of discomfort, none of the adolescents reported school absenteeism,^11,48 suggesting resilience and effective informal support systems. Similar types of physical symptoms, coping strategies, and no absenteeism were noted in the current study as well.

Hormonal fluctuations during a normal menstrual cycle, particularly changes in oestrogen and progesterone, can significantly influence mood, emotional regulation, and mental health. The premenstrual phase is often associated with increased vulnerability to symptoms such as irritability, anxiety, and low mood, while the follicular phase may bring improved emotional stability.⁴⁹

A study at Dehradun proves that the relationship between stress score and menstrual cycle phases occurs due to altered hormonal levels exhibiting premenstrual symptoms such as mood swings, anger, fatigue, and depression. Timely management and family members’ support would be the most beneficial ones.⁵⁰. Availability of counselling support could further enhance adolescent well-being, as evidenced by research conducted among teachers in South Africa.⁵¹ Similar symptoms were noticed among present school-going children, but no record of seeking any assistance from healthcare providers or teachers. None of the physical or psychological discomforts during menstruation caused school absenteeism or reduced academic performance, and healthy food habits were observed among these adolescents.

Interestingly, recent research suggests that oral contraceptive use may enhance certain aspects of psychological well-being, including sexual desire, relaxation, and improved sleep quality during the pre-ovulatory phase. Additionally, rising levels of oestradiol during this phase also contribute to mood and vitality. This reinforces the idea that hormonal changes can positively support well-being, creativity, and social engagement instead of causing discomfort.²³

Dietary beliefs also played a role in menstrual experiences. Adolescents were of the opinion that spicy foods need to be avoided as they increase the menstrual flow and lead to menstrual irregularities.^46,52,53 It was evident in the study that the majority of girls had a craving for spicy and sweet items during their periods, but the cause was not known to them; still, they followed a healthy food pattern as their family members restricted the spicy food items during menstruation.

A study conducted in the rural schools of Malawi shows that after the implementation of the MHM program, the knowledge scores of boys have improved from 45% to 75% advocating for co-educational sessions to foster empathy and reduce stigma.^54,55 Males need to be aware of this to overcome the problems, as most of us live in a patriarchal society.^50,51 The call for inclusive education, specifically including male adolescents, was a recurring theme in this study. Such inclusive approaches are necessary for dismantling patriarchal cultural norms and promoting gender equity in health education.

The findings of this study reinforce the broader public health imperative of recognising menstrual health as a human rights issue. Period poverty, stigma, and lack of access to accurate information and resources continue to marginalise menstruating individuals, particularly in low-resource settings.^56,57Menstrual health must be integrated into national health agendas to ensure dignity, equity, and access for all, especially critical for marginalised populations, including those in rural areas, tribal communities, and socio-economically disadvantaged groups, who often face compounded barriers to menstrual health.

Addressing these challenges requires a multi-sectoral approach involving schools, families, healthcare providers, and policy makers. Interventions must be age-appropriate, culturally sensitive, and inclusive of all genders. Only then can we move towards achieving SDG related to health, education, gender equality, and environmental sustainability.

Strengths and limitations

This participant-centred approach provided a unique perspective on adolescents’ views on menstruation, as FGDs created an open platform for them to share their opinions with peers of the same age group within the Indian context. This study offers a foundational understanding that will inform the development of a menstrual health promotion module, making it a unique contribution to adolescent health research.

Researchers recognised certain limitations in this study, including the absence of cultural practices, prevailing taboos, and restriction of setting to an urban place. The study was limited to one district with a limited number of participants. Conducting repeated FGDs with the same participants could have provided deeper exploratory insights as repeated interactions are known to enhance rapport and trust between researcher and participants, which in turn facilitates open communication, adding to the richness of the data. Despite these constraints, we are confident that our findings offer a comprehensive overview of contemporary adolescent perceptions related to menstrual health.

Conclusion

This study highlights the complex nature of menstrual health among Indian adolescent girls, revealing both strengths and gaps in awareness, practices, and support systems. While participants demonstrated commendable hygiene habits and resilience in managing physical and emotional discomforts, the persistence of misconceptions, stigma, and limited access to accurate information underscores the urgent need for targeted interventions. To address these challenges, the following actionable recommendations are proposed: integration of menstrual health into school curriculum, training teachers and school staff, engagement of parents and guardians, inclusive education for boys, improving access to menstrual products and sanitary materials, empowering adolescent girl as educator, collaborating with healthcare providers and NGOs, establishing feedback mechanism and evaluating the menstrual health initiative programmes would serve as an effective strategy. These multi-sectoral approaches will enable all Indian adolescents to move closer to achieve safe and dignified menstrual health.

Supplemental Material

sj-docx-1-whe-10.1177_17455057251407846 – Supplemental material for Perspectives of Indian adolescent girls in promoting menstrual health: A qualitative analysis

Supplemental material, sj-docx-1-whe-10.1177_17455057251407846 for Perspectives of Indian adolescent girls in promoting menstrual health: A qualitative analysis by Precilla Dsilva, Mitchelle Shilpa Lewis, Baby S. Nayak, Sudhir Prabhu, Prajna Kumari and Shreedhara Avabratha Kadke in Women's Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057251407846 – Supplemental material for Perspectives of Indian adolescent girls in promoting menstrual health: A qualitative analysis

Supplemental material, sj-docx-2-whe-10.1177_17455057251407846 for Perspectives of Indian adolescent girls in promoting menstrual health: A qualitative analysis by Precilla Dsilva, Mitchelle Shilpa Lewis, Baby S. Nayak, Sudhir Prabhu, Prajna Kumari and Shreedhara Avabratha Kadke in Women's Health

Supplemental Material

sj-docx-3-whe-10.1177_17455057251407846 – Supplemental material for Perspectives of Indian adolescent girls in promoting menstrual health: A qualitative analysis

Supplemental material, sj-docx-3-whe-10.1177_17455057251407846 for Perspectives of Indian adolescent girls in promoting menstrual health: A qualitative analysis by Precilla Dsilva, Mitchelle Shilpa Lewis, Baby S. Nayak, Sudhir Prabhu, Prajna Kumari and Shreedhara Avabratha Kadke in Women's Health

Supplemental Material

sj-docx-4-whe-10.1177_17455057251407846 – Supplemental material for Perspectives of Indian adolescent girls in promoting menstrual health: A qualitative analysis

Supplemental material, sj-docx-4-whe-10.1177_17455057251407846 for Perspectives of Indian adolescent girls in promoting menstrual health: A qualitative analysis by Precilla Dsilva, Mitchelle Shilpa Lewis, Baby S. Nayak, Sudhir Prabhu, Prajna Kumari and Shreedhara Avabratha Kadke in Women's Health

Supplemental Material

sj-docx-5-whe-10.1177_17455057251407846 – Supplemental material for Perspectives of Indian adolescent girls in promoting menstrual health: A qualitative analysis

Supplemental material, sj-docx-5-whe-10.1177_17455057251407846 for Perspectives of Indian adolescent girls in promoting menstrual health: A qualitative analysis by Precilla Dsilva, Mitchelle Shilpa Lewis, Baby S. Nayak, Sudhir Prabhu, Prajna Kumari and Shreedhara Avabratha Kadke in Women's Health

Footnotes

Acknowledgements

The authors thank all the participants for their active participation in this study.

ORCID iDs

Precilla Dsilva

Baby S. Nayak

Sudhir Prabhu

Prajna Kumari

Shreedhara Avabratha Kadke

Ethical considerations

Ethics approval was granted by Father Muller Institutional Ethics Committee (approval number: FMIEC/CCM/640/2023) in November 2023.

Consent to participate

Written informed consent is taken from parents, heads of educational institutions, and participants. Consent to share participants' experience in anonymised quotations was obtained prior to participation in the study.

Author contributions

Precilla Dsilva: Conceptualisation; formal analysis; methodology; writing – original draft; writing – review and editing.

Mitchelle Shilpa Lewis: Formal analysis; writing – original draft; writing – review and editing.

Baby S. Nayak: Conceptualisation; methodology; supervision; writing – original draft; writing – review and editing.

Sudhir Prabhu: Formal analysis; methodology; supervision.

Prajna Kumari: Conceptualisation; writing – review and editing.

Shreedhara Avabratha Kadke: Supervision; writing – review and editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The data used in this study are not available for public sharing. Data sharing rights are reserved with the corresponding author.

Supplemental material

Supplemental material for this article is available online.

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