Women & Health

ISSN: 0363-0242 (Print) 1541-0331 (Online) Journal homepage: https://www.tandfonline.com/loi/wwah20

“My mama told me it would happen”: menarche

and menstruation experiences across generations

Andrea L. DeMaria MPH, Cara Delay, Beth Sundstrom PhD, MPH, Audrey
Rehberg, Zeina Naoum MPH, Jaziel Ramos-Ortiz, Stephanie Meier & Kristin
Brig

To cite this article: Andrea L. DeMaria MPH, Cara Delay, Beth Sundstrom PhD, MPH, Audrey
Rehberg, Zeina Naoum MPH, Jaziel Ramos-Ortiz, Stephanie Meier & Kristin Brig (2019): “My
mama told me it would happen”: menarche and menstruation experiences across generations,
Women & Health, DOI: 10.1080/03630242.2019.1610827

To link to this article: https://doi.org/10.1080/03630242.2019.1610827

Published online: 25 Apr 2019.

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WOMEN & HEALTH
https://doi.org/10.1080/03630242.2019.1610827

“My mama told me it would happen”: menarche and

menstruation experiences across generations
Andrea L. DeMaria MPH PhD, MSa, Cara Delay PhD, MAb, Beth Sundstrom PhD,
MPH MPH, PhDc, Audrey Rehberg MPHa, Zeina Naoum MPHa, Jaziel Ramos-Ortiz BS
MSd, Stephanie Meier MAa, and Kristin Brig MAe
a
College of Health and Human Sciences, Purdue University, West Lafayette, Indiana, USA; bDepartment of
History, College of Charleston, Charleston, South Carolina, USA; cDepartment of Communication, College of
Charleston, Charleston, South Carolina, USA; dDepartment of Consumer Science, Purdue University, West
Lafayette, Indiana, USA; eDepartment of The History of Medicine, Johns Hopkins University, Baltimore,
Maryland, USA

ABSTRACT ARTICLE HISTORY

The purpose of this study was to understand women’s menarche and Received 17 July 2018
menstruation-related knowledge, attitudes, and behaviors across gen- Revised 29 March 2019
erations. Women ages 18 years and older (Mean = 49.13 ± 14.76 years; Accepted 3 April 2019
Range = 19–78 years) living in South Carolina were recruited to partici- KEYWORDS
pate in semi-structured interviews during May-November 2016. A total Menstruation; menstrual
of 70 interviews were conducted, which were audio-recorded and tran- hygiene; menarche
scribed verbatim. Thematic analysis using open and axial coding tech-
niques from grounded theory provided the framework for data
interpretation. Women described vivid menarche memories; however,
most women had not received proper education or preparation for what
to expect prior to onset. Participants discussed their experiences with
menstrual products, oral contraceptives, and medical procedures to
suppress, manipulate, or manage menstruation. Findings provide prac-
tical recommendations for health professionals to develop further effec-
tive and timely messaging related to menarche and menstruation across
the lifespan. Messaging should inform women about what to expect
with menarche, menstruation management, and health-related impacts,
as well as methods to reduce menses-related myths and stigmas.

Introduction
Most girls experience menarche between the ages of 12 and 13 years (Crooks 2017).
Approximately monthly menses recur for approximately 40 years, constituting over 500 men-
strual cycles during an average lifetime (Crooks 2017). Menstruation management is a global
public health issue, frequently surrounded by social stigma and shame, and often leading to
negative attitudes and misinformation (Crooks 2017; Jackson and Falmagne 2013; Sommer et al.
2015b; Tan, Haththotuwa, and Fraser 2017). Sommer et al. (2015b) discussed the need for
information about puberty (including menarche), menstrual products, and menstrual practices
to enhance health education.
Menstruation can be a frightening experience (McPherson and Korfine 2004). Literature
highlights an overwhelming lack of understanding about menstruation (Hasson 2016;

CONTACT Andrea L. DeMaria ademaria@purdue.edu Public Health Graduate Program and Department of
Consumer Science, College of Health and Human Sciences, 812 West State Street, West Lafayette, IN 47907
© 2019 Taylor & Francis
2 A. L. DEMARIA ET AL.

Sommer et al. 2015b). Negative messaging, such as menstruation being unhealthy, embarras-
sing, and something that should be concealed perpetuates this public health problem (Bennett
and Harden 2014). For some, menarche is a time of celebration, representing transition into
womanhood (Brown 2015; Johnston-Robledo and Chrisler 2013; Newton 2016), while for
others discussions about menstruation are discouraged (Beausang and Razor 2000). Girls in
both developed and developing world contexts report teachers and schools as providing
inadequate menstrual health information, compared to female relatives and friends (Agnew
and Sandretto 2016; Chandra-Mouli and Patel 2017; Cooper, Cooper, and Koch 2007; Stubbs
2008). Some mothers emphasize hiding menstruation (Lee 2009; Tan, Haththotuwa, and
Fraser 2017), which may pass the education responsibility to schools (Costos, Ackerman, and
Paradis 2002). Little research has explored menstruation education (Diorio and Munro 2000;
Kirk and Sommer 2006).
Sexual education curricula have continually addressed menstruation as a pregnancy-
related biological process (Advocates for Youth 2019; Diorio and Munro 2000; Future of
Sex Education Initiative 2012; SFUSD Health Education 2019). Menstruation has generally
been viewed as an illness, and little has been discussed beyond the physiological process
(Beausang and Razor 2000). Emphasis has been placed on hygiene and hiding signs and
symptoms through menstrual products and medications (Costos, Ackerman, and Paradis
2002; Johnston-Robledo and Chrisler 2013). This emphasis perpetuates menstruation as
a negative and shameful experience (Jackson and Falmagne 2013; Lee 2008).
Menstruation may influence contraceptive decision-making (Wiseley, DeMaria, and
Sundstrom 2015). Lakehomer et al. (2013) reported that nearly one-fifth of women surveyed
who used combined hormonal contraception did so to alter their menses. Additionally,
menstrual suppression has become popular among women of all ages, for reasons such as
reducing cramping, controlling endometriosis, and mitigating premenstrual syndrome
(Ferrero et al. 2006; Johnston-Robledo, Barnack, and Wares 2006). Girls and women may
prefer to menstruate less than once per month or to suppress menstruation completely
(Andrist et al. 2004; Edelman et al. 2007; Ferrero et al. 2006; Glasier et al. 2003). One study
found the majority preferred a menses every three months or not at all (Edelman et al. 2007).
Significant literature gaps exist regarding menstruation-related experiences across the
lifespan. Prior qualitative studies have explored menstruation narratives and perspectives
in differing contexts, such as in low-income (Cooper, Cooper, and Koch 2007) and
migrant and refugee women (Hawkey et al. 2017), and European (Brantelid, Nilvér, and
Alehagen 2014) and developing countries (Mason et al. 2013). The present study con-
tributes an examination of menarche and menstruation experiences across generations in
a US-based sample using an interdisciplinary research approach; study protocols and
instruments were designed by a team of Public Health, History, and Health
Communication experts. Our study sought to understand women’s menstruation-related
knowledge, attitudes, and behaviors across their lifespans.

Methods
Participants and procedures
In-depth interviews were conducted with 70 women during May-November 2016.
Eligibility criteria included women aged 18+ years living in South Carolina and able to
 WOMEN & HEALTH 3

be interviewed in English or Spanish. This study was part of a larger reproductive health
oral history research project that provided women with a platform to narrate their health
experiences, which have historically been neglected (Orkin and Newbery 2014).
Qualitative methodology facilitated a comprehensive understanding of participants’
unique experiences and cultural norms. This methodology offers the potential to preserve
narratives of women’s historical practices and traditions, transform lives, encourage cross-
generational communication, recognize and validate experiences, and inspire cooperation
and confidence (Armitage, Hart, and Weathermon 2002). The College of Charleston’s
institutional review board (IRB) approved this study protocol.
Recruitment flyers were placed in libraries, churches, salons, public health buildings, and
local clinics (primary care physician and OB/GYN offices). Targeted social media advertise-
ments helped reach a larger audience. Women were also approached at community events
and in other public places, and participants were asked for referrals (snowball sampling)
(Berg and Lune 2012). These recruitment strategies were designed to recruit a diverse sample,
reflecting the demographics (i.e., age, race, socioeconomic status) of the five targeted South
Carolina counties (Charleston, Beaufort, Dorchester, Colleton, and Richland). Participation
rates are unknown because of the variety of recruitment strategies used; however, all women
who started the interview completed it, resulting in a 100% completion rate. All participants
supplied written informed consent prior to interview audio-recording.

Interviews
In-depth interviews were conducted at locations convenient to the participants and lasted
approximately 60 minutes. Researchers followed a semi-structured interview guide, which
allowed them to build a conversational partnership with the participant and change, add,
or reorder questions (Berg and Lune 2012; Rubin and Rubin 2012). Interviews began by
asking general questions to build rapport and increase comfort. Participants were then
asked a range of questions allowing them to discuss holistically their reproductive health
histories and provide a robust understanding of reproductive health needs and percep-
tions. Though the larger study focused on reproductive health-related experiences, the
current paper hones in on menstruation, using the question “How did you learn about
menstruation and from whom?” While no additional menstruation questions were asked,
many women discussed menstruation while responding to questions about their repro-
ductive history. Interviews continued until data reached theoretical saturation (i.e., no new
concepts emerged) and study concepts were fully developed. Women completed an
anonymous demographic survey upon completing the interview and received a gift bag
totaling no more than $10 as compensation for their research involvement.

Analysis
Interviews, memos, and observer notes were transcribed verbatim and used to highlight
emerging trends (Rubin and Rubin 2012). Although theory development was not our goal,
we used techniques from grounded theory to provide an inductive approach to data
analysis, highlighting participants’ personal experiences and voices (Corbin and Strauss
2008). An iterative line-by-line, open and axial coding process using HyperRESEARCH
3.7 was completed to build conceptual categories and themes (Corbin and Strauss 2008).
4 A. L. DEMARIA ET AL.

Line-by-line coding involves identifying, naming, and categorizing the data as a way to
determine emerging phenomena. Axial coding consists of relating codes into broader
categories and patterns to determine data themes (Corbin and Strauss 2008). Each
researcher coded a subsection of the interview transcriptions, and each coded transcrip-
tion was then checked for quality by the first author, which ensured coding consistency,
with all inconsistencies addressed via consensus. Researchers used a constant comparative
method to identify emerging themes, and frequently met to review data and confirm
emerging theme agreement.

Results
Participant characteristics
The mean age of the 70 participants was 49.13 ± 14.76 years (range = 19–78 years). Participants
self-identified as white (52.9%, n = 37), black (32.9%, n = 23), or Hispanic (8.6%, n = 6), and
16.4% (n = 11) were immigrants (e.g., from Honduras, Mexico, Jamaica, Bulgaria). The majority
of participants had completed a four-year college degree (40.0%, n = 28), a graduate degree
(25.7%, n = 18), or some college (18.6%, n = 13). Most participants were currently married
(48.6%, n = 34) or divorced (20.0%, n = 14). Resulting themes are presented below.

Memorable menarches
“You’re a woman now!:” Differing menarche interpretations. Menarche experience dif-
fered, with some participants suggesting it was a time of celebration. One woman stated
she grew up with a girl whose father “bought her a dozen red roses when she got her
period; it was a big cause for celebration (47 year-old, White).” Another woman echoed
this excitement, “We‘re gonna have a red tent party for [my daughter] when she starts. All
of my friends and her friends are gonna bring her gifts and we‘ll share stories. We‘re really
gonna celebrate that transition in her life. (38 year-old, Black).”
Families represented key influencers in the perception and discussion of menarche,
both positively and negatively. Experiencing menarche was undesirable and unwanted
for others, with one woman stating, “It wasn’t really a big moment or a big thing.
I would have been leery if [my mom] tried to make it a thing (32 year-old, Black).”
Openness within families varied and was potentially off-putting, especially if menarche
“was kind of an unspoken thing, a taboo subject (40 year-old, Black).” One woman
illustrated this, “When [my period] came, I wasn’t really aware…what it was (51 year-
old, White),” suggesting uncertainty stemming from menstruation as “unspoken,”
which was supported by another participant, “I had never heard of [a period] (40 year-
old, Latina).” This often resulted in uncertainty and fear during menarche, including
concerns of “bleeding to death (52 year-old, White).” One participant shared that her
sister thought she was dying and “didn’t even tell our parents for six months (47 year-
old, Asian).”
Little preparation related to normal body functioning resulted in resignation toward an
unspoken illness and, subsequent negative outcome, for which she felt unable to seek
support. Much conversation about menarche included behavioral warnings, as one parti-
cipant remembered being told, “Now you’re a lady and you have to be careful what you do
 WOMEN & HEALTH 5

because now you can get pregnant (66 year-old, American Indian).” These warnings
related to gender separation, “periods mean you don’t mess with boys anymore (55 year-
old, Black)”, suggesting girls were held to different standards following menarche.

Absence or lack of information

“I didn’t learn about menstruation, it just happened.” Some participants noted receiving
little menstruation information. One participant stated, “I didn’t know what was going to
happen until after it happened (58 year-old, White),” suggesting she had not received
adequate preparation. Similarly, another participant said, “There wasn’t a lot of emphasis
on what to expect and how to expect it (32 year-old, Black).” Though she knew about
menstruation, she did not receive experiential knowledge that would have helped her
anticipate and understand her experience. One woman stated, “Nobody ever taught me
anything. I […] started probably around nine years old…It was really interesting because
my mother was a school teacher but she never taught me anything. I don’t ever remember
having anybody sit me down (78 year-old, White).” Inadequate information provision
included other areas, such as school. One participant noted, “There wasn’t really a lot of
education, even though I had taken health class (32 year-old, Black).” These experiences
provided women with an insufficient information foundation, resulting in ill-prepared and
more difficult menstruation experiences.
“You did not discuss private matters like that.” Even if women had learned about
menstruation, many mentioned it was not something openly discussed, with one woman
stating, “I didn’t really talk about it (34 year-old, Black).” Others emphasized associated
silence, suggesting “It’s just one of those taboo topics. Nobody really wants to talk about it
(28 year-old, Black).” Little “discuss[ion] [of] private matters like that (67 year-old,
White)” reinforced menstruation as negative, affecting women and girls’ perceptions
and experiences. One woman suggested her mother “forgot” to teach her:
I went to my mom and she got me some pads and that was basically it… I didn’t know basic
stuff. And I don’t think that was too crude for her, I think she just had forgotten that was
something you need to tell your teenage daughter. (35 year-old, White).

The culture of silence appeared to affect negatively this woman’s understanding of her
period, which also suggested a feedback loop as some women mentioned feeling uncom-
fortable approaching their mothers because of the lack of menstruation-related conversa-
tion. One participant expressed, “Even when I had my first period I didn’t go to my mom,
I went to a friend, because we just didn’t talk about it (49 year-old, White).” She avoided
discussion with her mother altogether due to lack of openness and information sharing.
One woman said, “I felt really awkward, [my mom] made it awkward because she had
never talked about it, it was really weird for me to have to do that because she had never
brought it up (61 year-old, White).” By not preparing girls, families could detrimentally
impact their menstruation experiences and subsequent perspectives. Even when some
participants did inquire into menstruation-related issues, some were met with anger.
One participant described, “I remember asking what tampons were when I was little,
when I saw the commercial, my grandmother yelled at me and told me never to ask that
again (37 year-old, White),” illustrating that attempting to break norms of silence can
result in irritation, rather than improve openness.
6 A. L. DEMARIA ET AL.

Menstruation misconceptions
Participants discussed several menstruation myths and mysteries when recalling experi-
ences. One woman was told she could not enjoy the ocean because she would “attract
sharks (66 year-old, American Indian).” Old wives’ tales remained at the forefront for
some participants when discussing menstruation. Other misconceptions related to preg-
nancy risk and prevention, with one participant suggesting “you can’t get pregnant on
your period (40 year-old, Black).” Some also noted misinformation, such as “when you’re
nursing and don’t have your period you are even more fertile (66 year-old, American
Indian),” despite the opposite being true. Two women were told “not to bathe (61 year-
old, White)” or “wash their hair (38 year-old, White).” Thus, cultural and social norms
may impact how women understand menstruation and what behaviors they engage in.

Menstruation education
Family roles: “My mama told me it would happen.” Immediate family members (e.g.,
mothers, fathers, sisters, and brothers) played a significant role, especially when they
provided relevant and necessary menstruation knowledge. One woman stated, “[My
mom] was very open about everything. She was not one of those typical moms. She
told us the birds and the bees from early on. She was certainly ahead of her time, as
far as those kinds of things (63 year-old, White).” This participant described in-depth
information that assisted her in understanding menstruation and sexual health more
generally. Additionally, participants highlighted the education they received from their
mothers, including “the basics, just the basics (75 year-old, White)” of menstruation as
valuable. Another participant described, “My mama told me it would happen (30 year-
old, Black),” illustrating the role family members played in preparing girls.
Some participants also shared educational experiences they had learning from extended
family members, such as “aunts” (40 year-old, Black), “cousins” (40 year-old, Latina),
grandfathers, and grandmothers. One participant noted, “I learned from my mom and my
aunt, they told us a lot, they didn’t want to shelter us, and they wanted us to know
(32 year-old, Black),” Her family members prioritized knowledge, suggesting they valued
fully-informed menstrual education. Another woman stated, “I went to my other aunt
who was there with her newborn, and I said ‘I think I started my period’, and she gave me
a pad and showed me how to put it on (32 year-old, Black).” The practical knowledge
provided by this family member improved the participants’ ability to manage her men-
struation. Additionally, many grandmothers seemed to have an influence on participants
and their menstrual experiences. One participant described “…[my grandmother] had told
me all about it way before I had a period. She told me if I ever saw something red, don‘t
get scared. It‘s starting menstruation. Just let her know, and she would show me from
there (30 year-old, Black).” This grandmother provided age-appropriate information, with
a focus on allaying common fears expressed by participants’ who had not received
menstruation information. Another woman echoed this, “My grandma taught me it
when I started growing up (34 year-old, Black).” Age-appropriate conversations about
menstruation improved women’s knowledge, comfort, and control when faced with their
own menstruation experiences.
 WOMEN & HEALTH 7

Knowledge from other sources

Teachers and school curricula served as educational sources for participants. One parti-
cipant noted, “When I was in my fourth or fifth year of primary school they started to talk
about menstruation (47 year-old, Black),” emphasizing education to prepare young girls
for menarche. Another participant echoed this, “First, we had a class. I want to say I was
in the fourth grade. They separated the boys from the girls (46 year-old, Latina).”
Beginning menstruation discussions in class at earlier ages suggested curricula meant to
prepare girls for onset. Some classes occurred later, however, with one woman stating, “I
was in the sixth or seventh grade, and we had health teachers that called all the sixth and
seventh grade girls up to the library, and we talked about menstruation, and that’s how we
learned about it (45 year-old, Black).” One participant described her sex education class:
“All the girls in school from 7–12 were pulled into the cafeteria, and we were taught. This
was when our home economics teacher, and our gym teacher gave us the lecture on
periods” (66 year-old, American Indian).

Menstrual management and modification

Women recalled differing menstruation experiences and perceptions of menstruation side
effects, which included having “bad heavy periods (37 year-old, Multiracial)”, “horrible
cramps (63 year-old, White),” and perceiving periods as “a nuisance (47 year-old, White).”
Most women expressed negative experiences: “I had awful menstrual cycles that would
literally put me in the bed for days at a time, and I would feel horrible (45 year-old,
Black).” These negative experiences suggested limited menstrual pain management oppor-
tunities. Another participant said, “My daughter bleeds so much it depletes her body of
iron (68 year-old, White),” highlighting one menstrual health difficulty. Another woman
explained how she would leave school due to her period: “I was like calling my mom every
month, every other month, from 7th to 8th grade, ‘Can you come get me?’ Because I was
having such bad cramps (51 year-old, White).” Though most participants described
menstrual difficulties, one participant expressed the opposite, “I was never really sick
with it or anything like that (38 year-old, White).”
Oral contraceptives were one way participants noted managing menstruation occur-
rence and pain. One woman stated “if you took birth control pills, it wasn’t because you
were sexually active, it was because they were to regulate your period (39 year-old,
Latina).” Another woman expressed her experiences: “I started with Depo-Provera and
that was very bad, hormonally for me. I menstruated a lot […] I didn’t stop. I was on it
for, I think, six months and had my period the whole time (37 year-old, White).” She also
used the NuvaRing, “I ended up going with the pill, and then when they came out with the
patches, I tried those…It just caused me to have a really heavy period, and when they
finally came out with NuvaRing, NuvaRing was perfect.” Thus, bleeding was
a determining factor in her contraceptive choice as it greatly affected her lifestyle.
Another participant noted the menstruation benefits of hormonal contraception, saying
“It was, actually for me it was wonderful, it slowed down my periods, made them a lot
lighter (55 year-old, Black).” Another participant even wished she had considered contra-
ceptives, “I think a good thing in hindsight, maybe some oral contraception would have
made the hormones more regular and lessened some of that pain (51 year-old, Black).”
The effects of hormonal contraceptive on menstruation were important in our sample.
8 A. L. DEMARIA ET AL.

Some women noted medical procedures that altered their menstrual flow, such as
hysterectomies and tubal ligations. One woman mentioned having a negative experience,
“Five women my age that had their tubes tied, our periods went from being a normal
5–7 day to I remember, teaching, standing up in the classroom, and having in a tampon
plus using a pad” (66 year-old, American Indian). These complications led her to choose
a partial hysterectomy, “When I had that partial hysterectomy, it was so nice not to have
a period again. That was one of the best things about having the uterus removed, you
don’t have those periods.” Her reproductive health choices appeared to be influenced by
her desire not to bleed. Finally, participants noted natural options to lessen side effects of
menstruation. Teas were frequently mentioned: “You would drink chamomile tea
(38 year-old, Black),” and sometimes used in addition to other therapies: “Instead, you
know what she did? Brewed me some tea and put Brandy in it and gave me some Tylenol,
and I just napped for a couple hours (51 year-old, White).” Thus, different participants
negotiated various menstrual management tools to improve their experience.

Discussion
This study used an interdisciplinary (i.e., built on co-author expertise in Public Health,
History, and Health Communication) qualitative approach to investigate menarche and
menstruation knowledge, attitudes, and behaviors. Findings revealed participants vividly
remembered their menarches; however, the majority had not received proper education or
preparation. Women who received education primarily received this from family mem-
bers. Aside from menarche, women discussed their experiences with menstrual products,
oral contraceptives, or medical procedures to suppress, manipulate, or manage their
menstruation.
Participants shared the significance of menarche for themselves and their families, often
describing celebrations (e.g., receiving flowers and hosting parties). Findings support
previous research showing some women view menarche as a time of celebration, with
menses representing the genesis of womanhood (Brown 2015; Johnston-Robledo and
Chrisler 2013; Newton 2016). However, difficulties arose when menstruation was consid-
ered “taboo,” resulting in silence. Participants who had not discussed menarche or felt
unable or uncomfortable asking about menstruation demonstrated fear and uncertainty.
This demonstrates a critical need for information beyond biological information (Diorio
and Munro 2000). In particular, women in our sample who were provided with practical
experiential knowledge from trusted sources, like family members, experienced more
positive menstruation perceptions and felt better able to manage their expectations and
experiences. Thus, using women’s narratives to build educational programming focusing
on women’s lived menstruation experiences, including management techniques and men-
struation conversation pointers, may mimic the positive experiences our sample described.
Further, moving away from expert narratives to provide lay information may facilitate
menstruation physiological and psychological understanding, while improving prepared-
ness, which may reduce stigma and negative perspectives (Sveinsdóttir 2016)
In families in which menstruation was rarely discussed, most discussions centered on
the risks, mainly pregnancy risk, supporting prior research that menstruation is discur-
sively framed as a biological function leading to motherhood (Agnew and Sandretto 2016).
Many participants mentioned warnings about pregnancy risk at menarche. These findings
 WOMEN & HEALTH 9

support prior research results that women were aware of sexually transmitted infections
(STIs) and pregnancy, but not the physiologic and psychological aspects of menstruation
(Diorio and Munro 2000). Participants indicated the information provided did not
prepare them for menarche, period maintenance, or subsequent health risks, and, instead,
advocated for behavior change such as reduced interactions with boys. Minimal conversa-
tion resulted in menarche being perceived as unmentionable, supporting prior literature
(Beausang and Razor 2000; Chandra-Mouli and Patel 2017). Discussing menstruation is
important to prepare girls; the topic should be openly discussed with family members, in
school settings, and with clinicians (Hennegan and Montgomery 2016). Clinicians should
incorporate discussions about puberty, menarche, and menstruation with their patients at
a young age, and before average age of menarche. Health professionals can provide reliable
information to initiate menstruation-related discussions within families, which could
include content on average age of menarche, causes and durations of periods, menstrual
product availability and use, and positive menarche and menstruation messaging.
Additionally, clinicians can continually engage in discussions in small chunks over time/
visits with young girls about the human body, reproduction, and menstruation. These
discussions could potentially reduce anxiety and allow girls to be informed over time
about their bodies, including the menstruation process.
Participants most frequently recalled exposure to menstruation information from their
mothers and other family members (i.e., fathers, grandmothers, grandfathers, aunts, and
cousins). These findings echoed previous literature, suggesting close family members often
inform girls about menarche and menstruation (Sommer et al. 2015a). These trusted
sources provide girls with a readily available resource and informed perspective from
someone who has undergone a similar experience. Information from trusted individuals
may be problematic, however, if the information is not accurate or reliable. Girls who
learn about menstruation from close family members are susceptible to believing mis-
information, due to the existing trust and confidence in these individuals (Jain and Anand
2016). One of the goals of oral history is to encourage narrative sharing between genera-
tions, including experiential knowledge about health (Orkin and Newbery 2014). Thus,
promoting community programming to facilitate familial intergenerational communica-
tion about menstruation may provide practical information. Including a health educator
as a facilitator may also clarify common misconceptions, such as those held by our
participants, ensuring correct, non-stigmatized, and usable information, building on
other novel techniques for reducing stigma (Agnew and Sandretto 2016).
Participants engaged in menstruation management through suppression, manipula-
tion, and maintenance. The most frequently reported reason was inconvenience or
discomfortof menses. Participants often described menstruation as worrisome, due to
heavy menstrual flow symptoms (e.g., low energy levels, anemia, cramps). Most
participants described engaging in menstrual modification or suppression through
hormonal contraception and various medical treatments. Managing menstrual pain
and frequency through hormonal suppression was appealing to some participants, and
aligns with evidence suggesting that withdrawal bleeding via contraception is not
medically essential and presents numerous benefits (e.g., alleviating menstrual disor-
ders, improving menstrual regularity, reducing burdens associated with menstrual
hygiene) (Strandjord and Rome 2015; Szarewski and Moeller 2013). Prior research
suggests negative perceptions may stem from over-emphasis of menstruation as an
10 A. L. DEMARIA ET AL.

illness (Agnew and Sandretto 2016). However, as our participants expressed, dysme-
norrhea served as a real and difficult experience, affecting their lifestyle and health
(Sveinsdóttir 2018). Emphasis and education about menstrual suppression could be
a consideration for communication campaigns addressing menstruation and contra-
ceptive use. Messages can be used to improve menstrual management options, while
ensuring menstruation is constructed as healthy, rather than stigmatized. This will
inform and empower women to make the choices best suited to their lifestyles.

Limitations
Qualitative methodologies provide an opportunity for women to share their stories and
experiences; however, recall bias was possible due to the large age range and timing
between menarche, menstruation education, and interview day. Results may not be
generalizable to the US female population due to geographic and demographic limitations
and non-representative convenience sampling. Data presented in this paper were from
a larger study on reproductive health experiences; therefore, information is limited to the
few questions asked on menarche and menstruation. Future research should further
explore menarche and menstruation as a public health topic in diverse community settings
among girls and women across generations.

Conclusion
Menarche and menstruation experiences are diverse and consistent across generations, cultures
and the lifespan. Findings provide practical recommendations to develop effective and timely
menarche and menstruation messaging across the lifespan to inform and empower without
stigma. Messaging should inform about menarche expectations, menstruation management,
and health-related impacts, as well as methods to reduce menses-related myths and stigmas.

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