Assessment of the Readiness, Beliefs, and Practices Regarding Menstruation Among Women in Saudi Arabia

Introduction

More than 26% of the world’s population consists of women of reproductive age who regularly experience menstruation. Emphasizing the importance of public education on menstruation and correcting misconceptions and poor practices are necessary to ensure good practices and attitudes toward menstruation.^1–3 The menstrual cycle occurs every 24–38 days, with the flow typically lasting for approximately 3–5 days; however, the range is 1–8 days. Menstruation is caused by a significant decrease in the level of circulating progesterone, which plays a key role in the inflammatory and vascular mechanisms that lead to endometrial shedding, resulting in blood and tissue loss from the vagina.⁴

Globally, there are several myths about menstruation that affect women’s reproductive health and create stigma towards menstruation. Family members are considered the main source of information on menstruation; consequently, several misconceptions and poor practices are communicated.⁵ A descriptive cross-sectional study in Hafer Al-Batin found that among 360 female college and university students, Saudi women had poor knowledge of reproductive health, including menstruation and menstrual hygiene, and this may be related to sociocultural barriers.⁶ Women have believed several age-long menstruation-related practices, regardless of the scientific accuracy of these practices. One of the most important menstrual practices is personal hygiene, which affects an individual’s physical and mental health. According to a study in Saudi Arabia, most participants had average levels of knowledge on personal hygiene during menstruation. The study found that the beliefs and practices regarding menstruation and menstrual hygiene are affected by social, cultural, economic, and religious backgrounds.⁷ Another study showed that some women do not wash or bathe during menstruation.⁸ Moreover, some women change their food habits and restrict their daily activities and exercises during menstruation.⁷

Furthermore, some women experience irregular flow and pain during menstruation; therefore, medications or herbal remedies are commonly used to relieve these symptoms.⁹ Certain types of herbs are used for various purposes owing to several factors, including cultural, traditional, ethnic, and socioeconomic backgrounds. In addition to alternative medicine, some women use pharmacological treatments, such as non-steroidal anti-inflammatory drugs (NSAIDs) and oral contraceptive pills (OCPs), for symptom relief. NSAIDs are the most common over-The-counter analgesics and are becoming a common therapeutic choice for dysmenorrhea (painful menstruation), as they inhibit the enzyme cyclooxygenase, which is responsible for menstrual pain.¹⁰ Furthermore, combined oral contraceptives (COC) are widely used to treat primary dysmenorrhea and infrequent menses in women, as several studies have emphasized reduced prevalence and severity of dysmenorrhea associated with COC use.¹¹

In Saudi Arabia, there is limited research on certain aspects of menstruation, such as misconceptions, types of herbal medications used, and their relationship with various educational and social factors. Besides, there is a lack of awareness among women on available medications; therefore, they refuse to use the medications owing to concern about the side effects.¹² However, these variables are constantly changing and have not been sufficiently examined. This study is important as it evaluates menstruation-related beliefs and practices among women in Saudi Arabia while also examining the sociocultural factors that shape these views. It adds to the limited research on menstruation in the region by offering a comprehensive analysis of hygiene practices, medication use, and herbal remedies. Understanding these aspects is crucial for developing interventions aimed at improving health outcomes and empowering women in managing their reproductive health. The aim of this study was to assess the readiness, beliefs, and practices regarding menstruation and related practices, including hygiene, medication use, and herbal remedies, among women who had experienced menstruation in Saudi Arabia. In addition, the study aimed to evaluate the factors affecting the readiness, beliefs, and practices associated with menstruation.

Materials and Methods

Study Design

This cross-sectional online questionnaire-based study targeted all women in Saudi Arabia who had experienced menstruation, including those who were menopausal.

Study Area/Setting

The study was conducted online in all regions of the Kingdom of Saudi Arabia. We did not restrict the distribution of the questionnaire to Riyadh City alone; instead, we utilized various social media platforms to include all five regions of Saudi Arabia: Northern, Southern, Eastern, Western, and Central.

Study Participants

This study targeted all women in Saudi Arabia who were ≥11 years old and had experienced menstruation.

Sampling Technique

Convenience sampling was used in this study. The study investigators shared the survey link with potential participants (women in Saudi Arabia) via online social platforms such as WhatsApp, Twitter, and Telegram. The initial participants were asked to share the survey link with relatives, friends, and acquaintances to ensure the distribution of the survey to different regions of Saudi Arabia.

Data Collection Methods, Instruments, and Measurements

The authors designed a questionnaire with some questions adopted from previous studies.^13,14 The questionnaire was subjected to face and content validity assessments and subsequently underwent pilot testing prior to its implementation. The online questionnaire was created using Google Forms and comprised the following four sections for data collection:

1. Demographic characteristics: age, nationality, marital status, region, educational level, mother’s educational level, father’s educational level, family monthly income, field of specialty, age at menarche, and severity of menstrual pain. There was one question regarding the source of information about menstruation.
2. Readiness for menstruation: Readiness was assessed by three questions on the participant’s level of preparedness determined by knowledge of what to do before their first menstruation, including their awareness of pad use. Responses were scored as 2 for answering “Yes”, 1 for answering “Kind of”, and 0 for answering “No”. Participants who scored 4 or more points were considered “ready” for menstruation, whereas those who scored less than 4 points were considered “not ready”; therefore, the cutoff point was 66%.
3. Menstruation-related beliefs: This section consisted of 16 questions that evaluated the degree of participants’ agreement with certain menstruation-related beliefs and the corresponding positive or negative effects on menstrual symptoms. These questions were assessed using a five-point Likert scale, wherein the score was calculated as follows: 1=strongly disagree, 2=disagree, 3=neutral, 4=agree, and 5=strongly agree. Participants who scored ≥55 of 80 points were considered to have positive beliefs about menstruation, whereas those who scored ˂55 points were considered to have negative beliefs about menstruation.
4. Menstruation-related practices: This section consisted of three questions that assessed avoidance of any type of food, religious practices, or daily practices during menstruation. In addition, seven questions evaluated pharmacological and herbal medication use during menstruation. The last five questions were related to hygiene during menstruation.

Sample Size

This study assessed the level of knowledge regarding menstruation among women in Saudi Arabia. The menstruation-related knowledge was reported to be 26.6% in a previous study conducted in Riyadh in 2018, which assessed knowledge, readiness, and myths among students of Princess Nourah bint Abdulrahman University.¹⁴ Based on this finding, the estimated minimum sample size required for the present study was 3366, with 1.5% absolute precision and 95% confidence level. Data were collected from participants that received the questionnaire until the estimated sample size (with an additional 15% to compensate for any incomplete survey owing to the online questionnaire design of the study) was reached.¹⁵

Data Management and Analysis Plan

Data were analyzed using the Statistical Package of Social Science (SPSS) software version 26. Means, standard deviations, frequencies, and percentages were used for descriptive statistics. Quantitative data were analyzed using the t-test, whereas the association between categorical variables was analyzed using Pearson’s Chi-square test. Differences were considered statistically significant at P value < 0.05.

Results

In total, 3471 participants completed the survey. Characteristics of the study participants are presented in Table 1.

Table 1 Characteristics of Study Participants (N= 3471)

Table 2 presents details of the factors affecting menstruation-related readiness, beliefs, and use of painkillers among the included participants. Approximately half of the participants were well prepared for menstruation. Participants’ age significantly affected their readiness level, with those aged 11–19 years being the most prepared. Notably, a higher proportion of the women at the school level showed adequate preparation for menstruation compared to women at the university level or higher. Notably, participants with mothers who had higher education were more likely to be prepared than those with mothers who had a school education, and the difference was statistically significant.

Table 2 Factors Affecting the Readiness, Beliefs, and Painkillers Use Among the Included Participants (N= 3471)

Table 3 details the practices of the study participants during menstruation. The most avoided types of food were soft drinks and cold drinks. Regarding hygienic practices, 42.9% of the participants changed their sanitary napkins three to four times a day; 96.1% cleaned the intimate area during a pad change and 72.2% used water for cleaning. There were almost twice as many painkiller users as those who did not use painkillers. Moreover, a small percentage of participants used drugs without a prescription to delay or prevent menstruation. Notably, as shown in Table 2, the use of painkillers during menstruation varied among demographic groups. In addition, some participants used herbal medications during their menstrual cycle to relieve pain or because of common beliefs in the family, whereas others used it to regulate menstruation.

Table 3 Practices of the Study Participants During Menstruation (N= 3471)

Table 4 shows the menstruation-related beliefs of the study participants. Notably, 59.9% of the respondents disagreed or strongly disagreed with the belief that cutting the hair during menstruation affects its growth. In addition, 83.7% of the respondents agreed or strongly agreed that hot drinks could alleviate menstrual cramps. Further, the majority of respondents agreed or strongly agreed that lifting heavy weights could be harmful. A small percentage of participants agreed that the use of large-dose painkillers may cause irregularities; only 519 participants agreed that it may cause sterility. Almost none of the participants agreed that they became nervous if someone mentioned menstruation, and only 5.3% strongly agreed.

Table 4 The Menstruation-Related Beliefs of the Study Participants (N= 3471)

Discussion

The results of this study revealed that more than half of the participants were not well prepared for menstruation. In addition, the participants who were 19 years or younger, unmarried, in school, or had health education had significantly better readiness scores. Furthermore, our findings showed that more than two-thirds of the participants had positive beliefs regarding menstruation; the rate of positive beliefs was significantly higher among participants who were younger, unmarried, or in health-related fields. Regarding the use of painkillers and herbal remedies during menstruation, more than half of the participants used painkillers to relieve their pain; the use of painkillers significantly increased with pain severity and was higher among unmarried participants.

Most participants reported their mother as the primary source of information, followed by social media and the Internet. This finding is consistent with those of previous studies conducted in Pakistan, India, Egypt, and many other countries, which reported that mothers were the main source of information for their participants,^13,16 suggesting that mothers play a crucial role in preparing daughters for menstruation and can help their daughters manage menstruation onset. Menarche period causes significant anxiety among girls living without their mothers.¹⁷ Besides, our findings revealed that the mother’s educational level significantly affected the daughter’s preparedness. Women with mothers with a university degree or higher were more prepared than those with mothers with a school education.

Approximately 53.2% of participants were unprepared for the first menstrual period. The lack of preparedness among the participants could be attributed to sociocultural conservativeness regarding topics such as menstruation.¹⁷ A review in 2017 found that the majority of girls in low- and middle-income countries had limited knowledge and understanding of menstruation before experiencing menarche.¹⁶ Furthermore, the present study found that younger women (aged between 20 and 29 years) were more prepared for menstruation than older women (aged above 30 years). One possible explanation for this difference in readiness levels is the changing sociocultural acceptance of menstruation and increased access to information. A similar study on menstrual knowledge and readiness among Saudi university students showed that younger students (67.9%) were more prepared than older students (59.2%).¹⁸

Additionally, 80.2% of participants had positive beliefs regarding menstruation, with participants in younger age groups of 11–19 and 20–29 years having the highest proportion of women with positive beliefs. This could be owing to increased awareness and education regarding menstruation in present-day society compared to the past. Consequently, more than one-third of the participants strongly disagreed that hair cutting during menstruation could affect hair growth. However, a 2016 study in Saudi Arabia showed that two-thirds of the participants agreed with this belief.¹⁴ This difference could be attributed to differences in age groups between the two studies. The present study had a significant variation in age groups, whereas the previous study focused only on one age group. As expected, participants in a health-related field had a higher percentage of positive beliefs (82.3%) than those in a non-health-related field (80.0%). Another study reported similar results.¹⁴

The results of the present study showed that the women’s beliefs were significantly affected by their eating and drinking habits during menstruation. Most participants strongly believed that hot drinks relieved their menstrual cramps. Multiple studies have shown similar results; one such study was conducted in Yemen and reported that 53% of Yemeni girls believed that hot drinks help relieve pain.¹⁹ Most participants in this study were undecided regarding the belief that eating sour foods and drinking milk or milk products could negatively affect their menstrual symptoms. In contrast, 29.1% of the participants agreed that caffeinated drinks such as soft drinks could aggravate cramps during menstruation. A 2016 study in Nigeria suggested that soft drinks could exacerbate menstrual pain and increase menstrual flow.²⁰ Furthermore, most participants disagreed that exercise had a negative effect on menstruation. In contrast, a study in Yemen showed that 56% of the participants believed that exercises should be avoided during menstruation.¹⁹ Nonetheless, most participants agreed that lifting heavy weights during menstruation had a negative effect, which corroborates the findings of another study among university students in Riyadh, Saudi Arabia.¹⁴ In addition, most participants strongly disagreed that showering during menstruation might affect menstruation.

Furthermore, the present study examined the hygiene practices of menstruating women. We found that 72.2% of the participants used water to clean their perineum during menses and 60.1% changed their pads three times a day. In addition, almost all participants cleaned their perineum when changing the pad. A possible explanation for this is that increased awareness and education about menstruation in society leads to positive hygienic practices. Other studies in Egypt and India showed that a minority of school girls changed their pads while at school.¹⁶ Studies in developing countries have shown that groups with predominantly low-income families, limited education, and unhealthy and unclean environments have insufficient knowledge and poor hygiene practices.^8,21 However, in the present study, no significant relationships were found between the regions, income level, and hygiene practices and beliefs.

In addition, we found that 54.4% of women used herbal remedies for various reasons, including pain alleviation (74.7%), common family beliefs (35.4%), menstrual regulation (33.8%), increased flow (31.6%), better or faster results (16.5%), and ovarian stimulation (11.9%). Moreover, we found that cinnamon was the most commonly used herb (70.0%) during menstruation; this was followed by chamomile (35.9%) and ginger (33.3%). According to a meta-analysis, cinnamon and ginger can reduce the intensity and duration of menstrual pain by inhibiting prostaglandins, thereby decreasing uterine contractions.²²

In the present study, 63% of the participants used painkillers. There was a significant correlation between painkiller use and pain severity. As expected, 83.9% of painkiller users had experienced severe pain. According to the present study, a significant percentage of unmarried participants used painkillers during menstruation (64.2%), whereas 59.7% of married participants used painkillers. There are multiple theories on why unmarried women use painkillers more frequently, one of which is that the use of OCPs in married women may reduce the severity of menstrual pain. A systematic review suggested that the use of OCPs may have a therapeutic effect on menstrual pain.²³ Another theory states that women who undergo childbirth may experience less pain during menstruation. Advocating this theory, a study conducted in Iran suggested that childbirth can alter the severity and duration of primary dysmenorrhea.²⁴ However, there are controversies surrounding these theories.

This study had some limitations. First, this study used a convenience sampling technique to reach a wider population in a short time, but this might affect the generalizability of the results. This concern was somewhat mitigated by utilizing a large sample size of 3471 participants. Second, the study was conducted over a period of 3 months, which is a limited time to collect sufficient data. However, this was overcome by the online data collection tool, which was a useful method for collecting more data from different cities in Saudi Arabia.

Conclusion

This study assessed the readiness, beliefs, and practices of Saudi Arabian women regarding menstruation. Our findings revealed the need for greater preparedness for menstruation among women, as less than half of the participants were ready for menstruation. However, positive beliefs regarding menstruation were observed in most of the study participants. Regarding the participants’ practices, they showed some food restrictions, and most of them preferred the use of herbal remedies for pain relief instead of painkillers.

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