Menstrual Health Literacy and Delay in Care-Seeking Among Adolescents with Heavy Menstrual Bleeding

Saba Naz; Madiha Saleem; Maryam Jamal; Dr Monica Punshi; Aisha; Tanzeela Ahmad; Nadia Farooq

doi:10.61919/7weqxp24

Authors

Saba Naz MSN, MPH, MSc Psychology, Riphah College of Nursing, Riphah International University, Islamabad, Pakistan Author
Madiha Saleem MSN, BSN, RM, Lecturer, Dow University of Health Sciences, Karachi, Pakistan Author https://orcid.org/0009-0003-7616-1046
Maryam Jamal FCPS Obstetrics and Gynecology, Federal General Hospital, Islamabad, Pakistan Author
Dr Monica Punshi Consultant Obstetrician and Gynaecologist and Public Health Expert, C.W.M.O. (BPS-19), Dr Ruth K.M. Pfau Civil Hospital; Consultant Gynaecologist, Altamash General Hospital, Karachi, Pakistan Author
Aisha Bahria University of Medical and Dental College, Karachi, Pakistan Author https://orcid.org/0009-0009-2637-109X
Tanzeela Ahmad Consultant, Department of Obstetrics and Gynaecology, Iqra Medical Complex, Johar Town, Lahore, Pakistan Author
Nadia Farooq Doctor of Pharmacy, University of Central Punjab (UCP), Lahore, Pakistan Author

DOI:

https://doi.org/10.61919/7weqxp24

Keywords:

Adolescents; care-seeking delay; heavy menstrual bleeding; menstrual health literacy; mixed methods; school health.

Abstract

Background: Adolescents may normalize heavy menstrual bleeding or lack sufficient knowledge to recognize symptoms requiring professional assessment, resulting in delayed consultation and continued functional impairment. Objective: To assess the association between menstrual health literacy and delayed care-seeking among adolescents with heavy menstrual bleeding and to explore the contextual barriers underlying delay. Methods: A sequential explanatory mixed-methods study was conducted among 186 adolescent girls aged 12–19 years recruited from selected schools, outpatient clinics, and community settings in Islamabad. A structured questionnaire assessed menstrual health literacy, bleeding symptoms, school absence, and care-seeking. Delay was defined as consultation more than 30 days after symptom recognition. Associations were examined using chi-square testing and logistic regression, followed by semi-structured interviews and thematic analysis. Results: Delayed care-seeking was reported by 112 participants (60.2%). Delay increased from 33.3% in the high-literacy group to 57.4% in the moderate-literacy group and 77.6% in the low-literacy group (χ²=22.52, p<0.001). Compared with high literacy, the adjusted odds of delay were greater with moderate literacy (OR=2.18; p=0.031) and low literacy (OR=4.91; p<0.001). Prolonged bleeding, clots, school absence, and weakness or fatigue were more frequent among delayed presenters. Interviews identified embarrassment, normalization of bleeding, family advice to wait, school-related concerns, and discomfort with healthcare consultation. Conclusion: Lower menstrual health literacy was associated with delayed care-seeking, while family, school, and healthcare barriers further influenced consultation

References

1. Hennegan J, Winkler IT, Bobel C, Keiser D, Hampton J, Larsson G, et al. Menstrual health: a definition for policy, practice, and research. Sex Reprod Health Matters. 2021;29(1):1911618. doi:10.1080/26410397.2021.1911618.

2. Babbar K, Martin J, Ruiz J, Parray AA, Sommer M. Menstrual health is a public health and human rights issue. Lancet Public Health. 2022;7(1):e10-e11. doi:10.1016/S2468-2667(21)00212-7.

3. Holmes K, Curry C, Sherry, Ferfolja T, Parry K, Smith C, et al. Adolescent menstrual health literacy in low-, middle- and high-income countries: a narrative review. Int J Environ Res Public Health. 2021;18(5):2260. doi:10.3390/ijerph18052260.

4. Gallivan S, Kelleher S, Foley S. Measuring menstrual health literacy: development and validation of the Menstrual Health Literacy Scale. J Health Psychol. 2026 Mar 23:13591053261423318. doi:10.1177/13591053261423318.

5. American College of Obstetricians and Gynecologists. Screening and management of bleeding disorders in adolescents with heavy menstrual bleeding: ACOG Committee Opinion No. 785. Obstet Gynecol. 2019;134(3):e71-e83. doi:10.1097/AOG.0000000000003411.

6. Munro MG, Critchley HOD, Broder MS, Fraser IS; FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011;113(1):3-13. doi:10.1016/j.ijgo.2010.11.011.

7. Borzutzky C, Jaffray J. Diagnosis and management of heavy menstrual bleeding and bleeding disorders in adolescents. JAMA Pediatr. 2020;174(2):186-194. doi:10.1001/jamapediatrics.2019.5040.

8. Hall EM, Ravelo AE, Aronoff SC, Del Vecchio MT. Systematic review and meta-analysis of the aetiology of heavy menstrual bleeding in 2,770 adolescent females. BMC Womens Health. 2024;24(1):136. doi:10.1186/s12905-024-02921-7.

9. Luiro K, Holopainen E. Heavy menstrual bleeding in adolescents: normal or a sign of an underlying disease? Semin Reprod Med. 2022;40(1-2):23-31. doi:10.1055/s-0041-1739309.

10. Davila J, Alderman EM. Heavy menstrual bleeding in adolescent girls. Pediatr Ann. 2020;49(4):e163-e169. doi:10.3928/19382359-20200321-01.

11. Zia A, Jain S, Kouides P, Zhang S, Gao A, Salas N, et al. Bleeding disorders in adolescents with heavy menstrual bleeding in a multicentre prospective US cohort. Haematologica. 2020;105(7):1969-1976. doi:10.3324/haematol.2019.225656.

12. Cooke AG, McCavit TL, Buchanan GR, Powers JM. Iron deficiency anaemia in adolescents who present with heavy menstrual bleeding. J Pediatr Adolesc Gynecol. 2017;30(2):247-250. doi:10.1016/j.jpag.2016.10.010.

13. Weyand AC, Fitzgerald KD, McGrath M, Gupta V. Depression in adolescent females with heavy menstrual bleeding. J Pediatr. 2022;240:171-176. doi:10.1016/j.jpeds.2021.09.007.

14. Pike M, Chopek A, Young NL, Usuba K, Belletrutti MJ, McLaughlin R, et al. Quality of life in adolescents with heavy menstrual bleeding: validation of the Adolescent Menstrual Bleeding Questionnaire. Res Pract Thromb Haemost. 2021;5(7):e12615. doi:10.1002/rth2.12615.

15. Magnay JL, O’Brien S, Gerlinger C, Seitz C. Pictorial methods to assess heavy menstrual bleeding in research and clinical practice: a systematic literature review. BMC Womens Health. 2020;20:24. doi:10.1186/s12905-020-0887-y.

16. Ko JKY, Lao TT, Cheung VYT. Pictorial Blood Loss Assessment Chart for evaluating heavy menstrual bleeding in Asian women. Hong Kong Med J. 2021;27(6):399-404. doi:10.12809/hkmj208743.

17. Wall KM, Erlandson MC, Gagnon MM. Seeking help for menstrual pain during adolescence: a mixed-methods retrospective survey of treatment experiences and preferences. Womens Health (Lond). 2025;21:17455057251315972. doi:10.1177/17455057251315972.

18. Creswell JW, Plano Clark VL. Designing and Conducting Mixed Methods Research. 3rd ed. Thousand Oaks (CA): SAGE Publications; 2018.