Pediatric clinical engagement on menstrual health: a qualitative assessment

Menstrual health is a critical component of overall health. The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) recommend routine menstrual health screening and care during pediatric visits, yet this topic remains under-addressed in clinical encounters. The study aimed to explore how a diverse group of pediatric-facing providers engage with menstrual health during the pediatric clinical encounter and to identify existing barriers and facilitators for integrating menstrual health into routine care. This qualitative research study included in-depth interviews (N = 46) with pediatric-facing providers across four geographic regions of the United States. Providers were recruited from a range of states, practice settings, urban, suburban, and rural contexts. The interviews sought to understand engagement with the topic of menstrual health within the pediatric encounter, barriers and facilitators to the conversation, and procedures and content when obtaining the menstrual history. Thematic analysis was used to analyze the interview transcripts. Participants represented 22 states across the four major geographic regions of the United States, with an approximately even distribution across practice types. The sample consisted primarily of Medical Doctors (78%), but also included Doctors of Osteopathy, Nurse Practitioners, and Physician Assistants. Roughly half of participants practiced in urban centers, with the remainder divided between suburban and rural settings. Analysis yielded three central themes: (1) formal training and experiential learning shape provider engagement with menstrual health; (2) structural and relational factors influence the extent to which menstrual health is integrated into clinical encounters; and (3) biological, quality-of-life, and condition-specific menstrual health questions affect clinical care. These findings have important implications for the clinical encounter, including potential policy and practice implications to facilitate increased inclusion of attention to menstrual health in pediatric care. Integrating menstrual health questions that address both biological and quality of life issues into the clinical encounter is vital to addressing patient menstrual health holistically.

The field of pediatrics establishes a foundation for lifelong health by focusing on early detection, prevention, and intervention of conditions that affect children's development and long-term well-being (1). Pediatric providers support the mental health and social development of children, recognizing the lasting effects that early stress and stigma can have on health behaviors and intergenerational outcomes (2). By ensuring children can thrive physically, mentally, and socially, pediatric providers help shape healthier, more resilient societies while protecting future populations from escalating health burdens. Menarche is an important developmental milestone in pediatric care that encompasses biological changes around reproductive capacity, marks a social transition towards adolescence, and has implications for overall health and wellness.

Shame, stigma, and lack of education can make it challenging for young people to discuss menstruation (3, 4). Pediatric providers are uniquely positioned to normalize menstrual conversations, offer anticipatory guidance, and evaluate their patients for abnormal patterns and disorders. This foundational health literacy may also enhance patient engagement in their own health. In the United States (US), the average age of menarche has declined to 11.9 years (5), requiring youth to adapt to a changing body at a younger age. For many adolescents, it is often difficult to understand a normal cycle due to lack of information, inadequate tracking, or comfort level sharing concerns. In addition, menstrual cycle variance is common within the first few years, leading adolescents to struggle differentiating what symptoms are expected versus those of medical concern (6). The challenge when speaking with a provider about menstruation is potentially compounded by providers who are also less comfortable asking about and addressing menstrual concerns, due to a lack of training during medical education on the menstrual cycle across the life course (7, 8).

In 2006, the American College of Obstetricians and Gynecologists (ACOG) released a committee opinion, “Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign,” which was endorsed by the American Academy of Pediatrics (AAP). The report has four recommendations, including providing anticipatory guidance and routine assessment of menstrual patterns to identify concerns (see Box 1) (6, 9). Such guidance reinforces the importance of the menstrual cycle as an integral part of general health for adolescents, yet menstruation continues to be an under-addressed topic in pediatric encounters. In one survey of 518 US pediatricians, over half were not familiar with the ACOG and AAP recommendation, a quarter did not provide anticipatory guidance, and even fewer asked about menstrual product use. Notably, male providers had lower self-reported and measured knowledge of menstruation and were less likely to assess menstrual health, highlighting gender differences in clinical practice (10).

• Clinicians should educate patients and their caregivers about expectations for a first menstrual period and the range of cycle lengths considered normal for subsequent menses

After menarche, clinicians should ask about last menstrual period (LMP) and pattern at every preventative care or comprehensive visit

Clinicians should have knowledge of regular menstrual patterns, with the ability to differentiate between regular and irregular, and the skill to evaluate the patients

Identification of abnormal menstrual cycles in adolescence can improve early diagnosis for potential health concerns

Components of a menstrual history vary widely across provider and practice, although assessments generally include the patient's last menstrual period (LMP) date as an initial screening for pregnancy and indicator of cycle regularity (11). However, menstruation is complex, and a more thorough menstrual history might incorporate age of menarche, cycle length, days between cycles, estimated blood loss, and the presence of cramping or clots. These indicators guide the evaluation of patients who fall outside of healthy ranges (12). In adolescence, abnormal frequency of menses may indicate Polyendocrine metabolic ovarian syndrome (PMOS), Cushing disease, and the Relative Energy Deficiency in Sport (RED-S), while abnormal patterns of bleeding may result from platelet function disorders, von Willebrand's disease, clotting factor deficiencies, or other disorders. Heavy menstrual bleeding (HMB) often presents within the first few years of menstruation and approximately 20% of adolescents with HMB have an underlying blood disorder, which underscores its importance in pediatric practice (13). Pelvic pain, which is often dismissed as normal, may indicate early signs of endometriosis contributing to an 8–10-year delay in diagnosis. These risks emphasize the importance of addressing menstrual health early, holistically, and consistently (14, 15).

Given the evidence that suggests menstruation is under-discussed in pediatric settings, the current study sought to understand how a diverse group of pediatric providers across the US engage with menstruation and the barriers and facilitators that might influence expanded inclusion of attention to menstrual health in the clinical encounter.

This qualitative research study included in-depth interviews with a range of pediatric-facing providers across four regions of the US, with the aim of capturing their experiences, perspectives, and recommendations. Columbia University Institutional Review Board (IRB) approved this study (CUIMC: IRB-AAAV0024). The core research team included the Principal Investigator (PI), a PhD-trained staff member on the PI's team, and two Masters-level research assistants (RA). The larger research team included five Co-Investigators (four adolescent medicine doctors and one obstetrician-gynecologist), all with extensive clinical and/or research experience, who provided guidance on the study direction and interpretation of the findings.

Research setting

The research was conducted across four regions of the US (West, Midwest, South, Northeast) given geographic, cultural, and socioeconomic differences across the country (16). There were a variety of healthcare settings in each region including private practices, academic centers, federally qualified health centers (FQHC), and hospitals or clinics.

Sample and recruitment

Purposive sampling was used to identify participants who would represent a diverse group of provider type, institution, geographic location, and urbanicity. Adolescent medicine specialists and pediatric gynecologists were excluded due to their extensive training on menstrual health. Providers with fewer than two years of experience practicing were also excluded to ensure participants had sufficient clinical experience to provide insights on this topic. Participants were recruited through email communications and clinical networks.

Data collection

Prior to data collection, which occurred between August 2024 and January 2025, the core research team engaged in reflexivity exercises to consider their own experiences of menarche, of menstruating more broadly, and the education they received about menstrual health. The aim was to examine how their own biases, experiences, and backgrounds in relation to their or other peoples’ menstrual experiences might shape their interaction with the participants and understanding of the data. Interviews were conducted in pairs consisting of the PI or PI's staff member and a research assistant (RA). The Columbia University Irving Medical Center IRB determined the study protocol to be exempt given its minimal risk and written consent waived. Prior to each interview, an information sheet was shared with the participant about the study details, and all participants provided verbal consent. Interviews were conducted using the video-conferencing platform Zoom.

In-depth interviews (IDIs)

Interviewers used a semi-structured interview guide that explored how the menstrual cycle is incorporated within the clinical encounter, beginning with how clinicians discuss puberty broadly with patients and their families. Interviews then examined the structure and content of clinical visits with regard to menarche and menstruation, and in particular, taking a menstrual history. Interviewers asked participants to reflect on the idea of classifying menstruation as a vital sign, any training that they had received on menstrual health within their clinical education and residency programs, and their recommendations for if and how menstrual health should be expanded within pediatric clinical encounters. See Box 2 for example interview questions. All interviews were recorded with most taking 30–60 min. At the completion of an interview, each participant received a $50 Amazon gift card. Interviews were subsequently transcribed verbatim for analysis.

• Among the population that you serve, what would you say are the top one or two concerns that parents or families bring to you about menstruation?

Can you describe when the topic of menstruation first comes up in your clinical encounters with patients?

We’d like to understand the process you and your colleagues use to document a menstrual history. Can you start by telling me how this is typically done?

The AAP and ACOG have endorsed the idea of menstruation or the menstrual cycle as a vital sign. How do you feel about this framing?

Please describe your medical school education and residency training regarding the menstrual cycle and its role in primary care settings that include adolescents.

What menstruation-related topics do you prioritize during well-child visits and why?

Data analysis

The coding team comprised of three researchers, the PI's staff member and two RAs, who used thematic analysis to analyze the data (17). To begin, analysts read all of the transcripts to become familiar with the data, and subsequently utilized an inductive approach to develop the code book. The team used this preliminary codebook on an initial small batch of transcripts to achieve consensus, refine existing codes and add additional codes. The final codebook was reviewed by the PI and co-investigators who provided additional inputs. The analysis team then used the final codebook to code the remaining interviews individually, with three additional interviews coded by all analysts to ensure consistent coding across the analysis. All interviews were coded using Dedoose software. The team took an iterative approach to data analysis, which included weekly discussions to discuss coding questions, adapt the codebook and code definitions as necessary, and discuss patterns in the data. Codes were ultimately organized into themes, which were shared with the entire research team for further refinement.

The study sample included four types of pediatric-facing clinicians (N = 46), Doctors of Osteopathy (DO)/Medical Doctors (MD), Nurse Practitioners (NP), and Physician Assistants (PA), from a variety of settings (see Table 1). Number of years practicing medicine ranged from two to 35 years.

Three themes were identified that influenced provider inclusion of menstrual health: 1) Formal training and experiential learning shape pediatrician's engagement on menstrual health; 2) Structural and relational factors influence the depth of menstrual health integrated in the encounter; and 3) Biological, quality of life, and condition-specific menstrual health questions affect clinical care. See Table 2 for theme descriptions. Overall, the participants shared positive views on the importance of integrating menstrual health questions into the clinical encounter, despite the variation in their clinical training, type of institutional location, and geographic location. No major differences among geographic regions, provider types, or length of practice were evident, however, some differences arose between institution type and urbanicity in relation to their ability to integrate menstruation into the clinical encounter. Provider gender differences were not assessed due to the relatively small number of male participants.

Formal training and experiential learning shape provider engagement on menstrual health

Providers described two basic forms of education that impacted their knowledge, attitudes, and comfort level discussing menstrual health in the clinical encounter: formal training through school and residency, and informal experiential learning through personal and family or friends’ lived experiences of menstruation.

Most participants remembered learning little about menstrual health during their clinical education, and what they did learn was primarily focused on biological processes and developmental milestones. Many MDs and DOs described their residencies, and particularly their adolescent medicine rotations, as more influential than didactic clinical education due to hands-on educational opportunities with complex patients. Although often short, such rotations enabled participants to experience a wide range of menstrual-related encounters, highlighting the nuances of menstrual health and the most helpful questions for understanding patients’ concerns. As one MD commented on her adolescent medicine rotation:

I always remember that question, like, at least the way they [medical doctor being observed] would always ask is like, ‘how many pads or tampons?’ And then once you've got that, also asking, ‘do you sometimes even have to bring like a change of clothes because, you know, you might bleed through’ or ‘having to wear both at the same time and changing every half hour.’ (Female MD, Northeast, urban FQHC)

These formal learning opportunities through residency appeared foundational for physicians to learn the importance of engaging with menstruation beyond the biological processes learned in medical school.

Many participants credited a mentor in school or residency with helping them understand how to discuss menstruation in a meaningful way. This was especially relevant in understanding what questions to ask and how to create rapport with patients and families around a topic that can potentially create discomfort. Participants also described how mentorship and modelling increased their own confidence level discussing and addressing menstrual health concerns, and some noted an ongoing relationship with mentors from whom they could receive continued support with clinical questions around menstruation.

Participants described how informal learning, shaped by personal experiences and interactions with family and friends who menstruate, increased their knowledge and comfort level engaging with patients on menstrual health. For participants who did menstruate, many described their own heavy or painful periods as a catalyst for including more in-depth menstrual health guidance in their patient encounters. Others described how they used their own experiences to connect with patients and families, normalize menstrual concerns, and put young people at ease when discussing menstruation. A number of providers also noted how their own lived experiences of menstruating sometimes made it easier to relate to the questions posed by their pediatric patients, as illustrated by a female MD who explained:

What if someone, if an 11-year-old says like, “what if I put a tampon in and I can't get it out, right?” Like some of navigating those questions that might just come up in primary care… I think a lot of that is experiential knowledge. (Female MD, Midwest, urban academic center)

Other participants, both male and female, shared how the menstruation-related experiences of others in their lives helped them to understand how to connect with patients and even overcome gender barriers when present. One male MD at a hospital in the West described: “They’re like, ‘What do you know? Come on, you're a guy.’ And I'll say that ‘I have two daughters, and this is what they experienced.’” While not intentionally sought out, exposure to the menstrual stories of others influenced how providers addressed menstrual health with their patients.

In general, most participants found that their formal and experiential learning provided a basic level of comfort with handling a range of aspects of menstrual health, including cramping, pain, heavy bleeding, and irregular periods. For those whose symptoms did not resolve, most participants stated they were comfortable starting an initial work up before referring to a specialist. Referrals were reported to be more challenging in rural areas with limited opportunities. As one male provider in the rural South put it: “You do the best we can with the resources we’ve got.” The lack of specialized providers, such as gynecologists or adolescent medicine specialists, led some rural clinicians to prioritize acquiring extra training on menstrual health care, beyond what was covered in medical school or residency. This ranged from continuing education to increase general comfort and knowledge on menstrual health, to specific skill development such as becoming certified to insert long-acting reversible contraceptives.

Overall, both formal medical training and informal experiential education appeared to shape how providers incorporated menstruation within the pediatric encounter, alongside competing priorities and other developmentally appropriate topics.

Structural and relational factors influence the extent of menstrual health integrated in the encounter

Participants described how structural aspects of the clinical encounter impacted the integration of menstrual health guidance and assessment in practice. This included documentation, time allotted for appointments, clinical flow, referral systems, and other organizational processes. Provision of clinical care was particularly influenced by time constraints, and in rural locations, reduced access to specialists because of limited referral options.

Participants identified a variety of procedures to take and document a menstrual history including templates, drop down menus, and free text. Although documentation processes varied, participants generally indicated relative satisfaction with their existing procedures. In general, participants appeared to feel that it was their responsibility to take a non-judgmental, non-stigmatizing menstrual history regardless of whether a registered nurse or medical assistant had already asked basic menstrual health questions during patient intake.

Appointment duration emerged as the most impactful structural factor that influenced the inclusion and extent of menstruation-related conversations. Participants reported that the amount of time allotted for well-child visits ranged from 10 min to “as long as I want them to be,” which underscores the significant variability in time available to include menstrual health topics. Participants also consistently explained the challenge of incorporating the vast number of topics covered during annual well-child visits while also addressing specific patient concerns.

In particular, participants at FQHCs highlighted the challenges of incorporating menstrual health into their routine visits due to patient volume and time-related pressures. One provider described her prior experience at an FQHC that illustrates these challenges:

When I worked in [city], our well child visits were 20 min, and you had to cover everything …. A lot of times those were patients that did not speak English as well, so everything has to be said twice when you’re using an interpreter, so that was really overwhelming… You might have a well child, they come in and they have zero concerns, the kid looks great, they’re healthy, they’re growing, all the things…. Or you might have a family who doesn't speak English, has three to ten questions to ask you, they are behind on their vaccines, they aren't growing well, and it's just… all that kind of combines to be a really really tough visit. So you definitely really do need that additional time. (Female MD, Midwest, rural clinic)

Another participant at an FQHC echoed the reality of time constraints and competing priorities in clinical care:

I know that there are plenty of times that if we've talked about two or three other things, or if you do have asthma and we gotta go through that, and you're in the context of your well child check that [menstruation questions] gets pushed to the side. So, not really having the appropriate amount of time blocked for a visit means that you cut loose stuff like that. Like, I can't skip your school form, and I can't skip your vaccines, and I can't skip the exam part. (Female MD, Northeast, urban FQHC)

This provider further explained that they have 15 min per visit, regardless of if it is a sick visit, well child visit, initial appointment, follow-up appointment, English speaking, or non-English speaking patient. In contrast, a female participant at a private practice in the South reported “we schedule it for 20 min. But I usually tell patients it's as long as they need.” This sentiment was echoed by a rural provider at a private practice whose explanation illuminated the difference in menstrual care made possible by institutional context:

… we're a private practice so I can self-schedule, right… Like when I know I have my kids coming in for their wellness exams, I book them out for a pretty significant amount of time so I can do all that anticipatory guidance and talk about all these different things. I think when you are limited with scheduling, some of those things might get brushed over or talked over very quickly. (Female NP, Midwest, rural private practice)

Inadequate time led many providers to ask patients to return for follow-up appointments or to see a specialist. Referral systems, both formal and informal, were important structural elements in addressing a lack of time or knowledge about menstrual health issues. For some providers, this was as simple as walking the patient down the hall to another clinician or a health educator; for others it was a formal referral. However, several participants described situations where this was not always possible, particularly in rural locations. One provider shared:

I will usually like for them to get established with an OB/GYN if they can, but I also know and understand it's probably a six month wait. Just for a primary OB/GYN, which is absolutely insane.. And part of it is we used to have some of those services provided by family medicine, but the family medicine practitioners that used to do OB and GYN services don't really exist anymore… And so we really, truly kind of live in a desert. (Male MD, South, rural private practice)

Another rural provider further emphasized the challenge of distance to referral appointments:

We're still in the middle of nowhere and the [university] hospital, like the children's hospital, is an hour away. And, and so they don't necessarily want to go an hour away. And so if they want to go to endocrine, they have to go to the children's hospital. (Female MD, Midwest, rural hospital)

Participants described transportation to cities, including the time and gas required, as barriers for patients to access specialists. Some clinicians suggested telehealth as a possible solution, but that it was not always available and was complicated by unstable internet in some rural communities.

While participants emphasized the impact of structural factors on menstrual health conversations, they also highlighted the importance of cultivating strong relationships with other medical professionals and their patients’ families. In general, participants described relationships with other clinicians as helpful, especially when a provider had reached the limit of their expertise for addressing menstrual health concerns. Such connections also helped when accessible referrals were unavailable, particularly for rural providers. The sentiment of a “curbside consult” and relying on colleagues, friends, and mentors for help with challenging cases was relevant for many participants and is notable, given the limited formal education on menstrual health described by most participants.

Participants underscored the role that trusting relationships play in facilitating comfortable conversations about menstrual health with patients and families. Across interviews, participants described the importance of building rapport, normalizing menstrual health questions and education, and empowering families to talk openly about menstruation. Participants acknowledged that while critical, fostering relationships takes time, which was often limited. A male MD described: “time is the huge killer of joy and huge killer of relationships in medicine right now.” Additionally, gender of provider and caregiver at the appointment, number of family members present, and cultural backgrounds also appeared to impact the conversation flow, sometimes easing and sometimes complicating the discussion. An MD from the Northeast illustrated this point:

I think I'm also very impacted by the families that I take care of. And I again, I take care often of families from outside this country. And so I see a real variety of views on puberty and menstruation and unfortunately sometimes I think I even catch myself not asking as much because I know the families are uncomfortable… And let's just say I've had to learn and overcome the awkwardness. (Female MD, Northeast, urban FQHC)

Participants described varying approaches for these challenges, from pushing through their own discomfort to normalize the topic, to slowly integrating menstrual health education and assessment over many appointments, and on occasion, halting menstrual health discussions if the family preferred not to speak about it. Even in situations where families showed resistance, participants acknowledged the importance of basic menstrual health as a part of a holistic health assessment.

Overall, participants suggested that the quality of menstrual health discussions in a pediatric clinical encounter depends on structural and relational factors. Time as a structural element facilitates relationship building with patients, families, and other providers, which is critical in cultivating a comfortable atmosphere to discuss menstruation and provide clinical intervention when necessary.

Biological, quality-of-life, and condition-specific menstrual health questions affect clinical care

Participants reported varied approaches to obtaining a menstrual history, with no discernible patterns associated by provider type or institutional context, aside from the influence of time constraints. This suggests a lack of consistency in both what is included on the topic and when it is asked.

Many, but not all, participants shared they provide anticipatory guidance with their patients pre-menarche, and additional information post-menarche, focusing on the biological, and sometimes social, experiences of menstruation. Some participants described taking a brief menstrual history and only following up when an issue arose or if a patient/family had specific concerns. Often this short assessment would include questions about menarche, last menstrual period (LMP), regularity, and pain. On occasion, they might explore additional biological questions, or for some providers who described taking a more detailed menstrual history, questions might include experiences related to quality of life, support, or feelings towards menstrual management (see Table 3).

Participants also described the importance of engaging the parent/caregiver in the process, including asking about their own menstrual history if they were willing to share. This enabled the participant to understand what the family believes is a normal way to experience a period, something especially useful for uncovering situations where cramping, pain, or excessive bleeding was normalized, based on the family member's own lived experiences.

In exploring the potential incorporation of the menstrual cycle as a vital sign, participants were asked about their views on the ACOG/AAP recommendation. Most participants were not aware of the position statement, but when presented with the concept, a variety of views emerged. Some participants articulated the value of integrating routine menstrual health questions to normalize and standardize the topic, particularly given competing priorities during a pediatric visit. As one MD explained:

I think it's important because otherwise, unless it's structured as a vital sign, it's not going to get done right? So, once it's like structured as a vital sign, it becomes a routine and you know where to go for where it's standardized. (Female MD, Northeast, urban FQHC)

Other participants were less certain, sharing concerns about how vital signs are defined and measured. One MD described:

I think that vital signs, when you are interpreting them, they need to be very objective, and they also need to have a bell curve of what's normal and what's not normal. That can be age related, but I think that with menstrual cycles, there's so much natural variability both in age and person to person, that it's… I think it would really be hard for that to be a vital sign and have clinical significance. (Female MD, Midwest, rural clinic)

Additionally, some participants expressed concern about inaccurate recall from patients about their menstrual cycles, as other vital signs such as heart rate and blood pressure were objective values measured directly by medical staff. Despite hesitation among some of the clinicians, the general consensus was that regardless of what it is called, asking about menstruation on a regular basis is a critical part of the clinical encounter. Some of this related to participants’ perceptions that asking enough of the right questions around menstruation could uncover health conditions like pregnancy, sexually transmitted infections, endometriosis, or other conditions such as Ehlers-Danlos syndrome, Turner's syndrome, von Willebrand disease, or disordered eating. Participants also noted the relevance of the menstrual cycle to bone growth, anemia, brain health, endocrine functionality, and testosterone levels. A provider at an FQHC in the West emphasized, “menstruation is not in a silo. It's connected to all different things in the body.” A number of participants noted the potential for menstrual cycle information to determine if mood changes were due to pre-menstrual syndrome or other mental health concerns, and to understand the impact of menstruation on school performance, activities, and quality of life.

Participants also mentioned situations where specific sensitivity around menstruation was warranted. For gender diverse children, many clinicians described the need for careful language and training to normalize the biological processes while attending to patients’ feelings of incongruence between their biological sex and gender expression. A few participants also acknowledged the needs of patients with intellectual disabilities, specifically around understanding how they would understand, experience, and cope with menstruation. One MD described:

It's a critically, critically important topic… For menstruating people with significant cognitive delays or on that way less verbal portion of the autism spectrum, there are hygienic issues that nobody talks about… I've absolutely had parents of folks on the autism spectrum: “What can I do to get her to change that pad or to put one in when her cycle starts? I don't know if she started until I’m doing laundry and realized what she's ruined.” (Female MD, South, urban academic institution)

One participant with specialized training highlighted the potential emotional toll of menstruation, especially if the patient also had sensory processing challenges or difficulty verbalizing thoughts and experiences. This translated into behavior changes and challenges when menstruating that could be misunderstood, particularly in school-based settings. She described:

But for patients, the feeling of the period can be a trigger, the cramps can be a trigger, the flow can be a trigger, just that change in your body. And when you have trouble communicating… they have a really hard time finding a word to say, “I don't like the bleeding that's happening.” (Female DO, West, urban FQHC)

Although physical disabilities and related limitations were infrequently mentioned, some participants noted the importance of anticipatory guidance for families with children who have mobility issues, such as those in wheelchairs, to prepare them for coping with menarche.

Together, the various examples and insights from providers highlight the importance of asking the right questions, at the right time, to understand how menstruation connects to overall health and quality of life for patients and their families.

This qualitative study examining clinical engagement on the menstrual cycle among a range of pediatric-facing providers across the US reveals a complex picture of how menstruation is currently addressed. Findings highlight how the level of providers’ menstrual health knowledge and motivation for including it among competing priorities influence both the frequency and extent of its inclusion within a given patient visit. Additionally, structural and relational factors, such as appointment duration or the need for translation services, can influence the thoroughness of a menstrual history. Limited availability of specialists for referrals increases the burden on rural providers to deliver more extensive menstruation-related care. Lastly, there appears to be a diversity of questions, both quantity and quality, included in a menstrual history which affect diagnosis of menstruation-related conditions. Given the critical role of the menstrual cycle in a child's health and development, there is an urgent need to strengthen provider training, standardize care, and implement structural solutions that facilitate engagement on menstrual health to improve patient health and quality of life.

Participants described formal education around menstruation as limited and biologically focused, despite medical recognition of the important sociocultural factors associated with menstruation (18) This aligns with research which broadly indicates that menstrual health education across the life course is limited (8, 19), despite the relevance of the menstrual cycle in many areas of clinical care. Examples illustratively include reproductive health, where birth control may be utilized for menstrual management and pain, endocrinology if a patient experiences delayed menarche, precocious puberty, or other hormone-related issues, and hematology for treatment of conditions such as coagulation disorders, heavy menstrual bleeding, or anemia. This lack of education can lead new providers to feel unprepared to address menstrual health issues with their patients, especially if they are not exposed to other types of learning environments (such as residency rotations or mentors with a particular interest in menstrual health) where the menstrual cycle features more prominently in instruction (7, 8, 19). Research indicates that awareness of physical and emotional changes can lead to greater feelings of empowerment around menstruation for patients (20). This highlights the need for early and sensitive anticipatory guidance, necessitating providers to feel confident in addressing menstruation beyond the biological components. This is especially important when considering how menstruation might impact specific patient populations, such as gender diverse youth, those with sensory processing challenges, or patients with physical or intellectual disabilities. Residency rotations for MDs and DOs were particularly impactful in shaping participants’ confidence in taking a menstrual history and asking questions beyond biological processes; however, adolescent medicine rotations vary widely across the US with differing access to specialists/mentors, length of the rotation, and range of clinical services offered at the training sites. Furthermore, not all pediatric facing providers complete residency as part of their training programs (21).

Increasing menstrual health training for general practitioners is especially important in rural settings, as quick referrals to specialists for menstrual-related concerns are not always accessible. National census data demonstrates uneven geographic distribution of physicians who provide pediatric care. General pediatricians predominantly practice in urban areas, with substantially fewer in rural settings. From 2010 to 2020, the overall number of general pediatricians increased modestly by 6%, though their rural representation declined slightly during this period. Over the same decade, the family medicine physician (FMP) workforce increased by 14%, with rural counties continuing to rely more heavily on FMPs than on pediatricians (22). Despite this growth, 10.5% of US counties had neither a general pediatrician nor an FMP in 2020, highlighting persistent geographic gaps in access (22). This is somewhat mitigated by the influx of NPs and PAs, which expand access in underserved and rural settings (23, 24). Increased training and referral networks (formal and informal) are critical to support providers in rural settings.

Participants highlighted lived experience as a key source of knowledge and empathy that strengthened their ability to address menstruation with patients. Experiential knowledge of menstruation helps build patient trust, which is a core element of a healthy and productive patient–provider relationship, along with loyalty and mutual regard (25). Challenging lived experiences with a clinical topic may also predispose providers to probe for more social aspects of the condition, as opposed to focusing solely on biological factors (26). The pediatric workforce is trending female, regardless of medical training, which may indicate more providers with the lived experience of potential attention to menstruation (23, 27–29). However, lived experience alone is insufficient for clinical understanding and does not ensure that providers will routinely assess menstruation in practice.

Regardless of provider knowledge and training around menstruation, structural factors impacted the extent to which menstruation could be included in clinical encounters. Participants highlighted the importance of having enough time, and organizational pressures to see a certain number of patients per day inherently limits a provider's ability to engage in conversation with patients. While this challenge is well documented across clinical care, time is especially critical for building relationships with families to support discussions of potentially sensitive topics like menstrual health (30–33). This is especially true for providers at FQHCs where time is especially limited, they serve families who do not speak English as a first language, they have patients who present with more complex health concerns, and where Medicaid reimbursement rates are low (34–37). Bright Futures recommends providers begin anticipatory guidance around puberty at age seven or eight (1). ACOG recommends providers incorporate menstrual health anticipatory guidance that includes timing of menarche, that menstruation is a normal part of development, how much blood flow can be expected, the use of menstrual products, and the importance of including families and caregivers in these conversations (6). These discussions take time, as does building relationships, so that the clinical encounter does not feel like a checklist of questions. Until structural changes occur, there may be minimal incentive or practical ability to prioritize expanded inclusion of menstrual health given competing health concerns in reimbursement systems that value quantity over quality.

Participants described a variety menstrual history questions and documenting procedures that include free text and templates in the electronic medical record (EMR). This is consistent with literature on menstrual history taking, indicating a lack of standardization both within and across organizations (4, 11). Evidence suggests that unless specifically related to the health concern or well-visit/annual check-up, menstruation is frequently not included in the encounter (38, 39). Recommendations from the US and other countries include addressing both biological and quality of life questions in a menstrual history (40–43), which are critical to support positive health outcomes for patients through early diagnosis of menstrual health conditions (12, 13). Additionally, menstrual health screening ideally becomes a routine part of the clinical visit, not a one-time acknowledgement of when menarche occurred, documentation of the last menstrual period, or when the patient shares a menstrual health concern. Assessing patterns of bleeding, frequency, and duration of menses over time help determine whether a patient's period is normal based on the irregularity of the first few years of menstruation, or if there are more serious medical conditions to consider (6). Standardizing procedures can enhance menstrual history taking overall which improves screening, documentation, and patient outcomes related to menstruation (44).

Although participants agreed that menstrual health was a critical topic, they expressed mixed views on conceptualizing menstruation as a vital sign, noting the broad range of “normal” menstrual cycles, especially in the first few years post-menarche. Similar hesitation was seen when pain was proposed as the fifth vital sign in the 1990s, as pain is complex with various potential contributing factors. Like menstruation, the introduction of pain as a vital sign illuminated gaps in training about how to holistically screen for and treat pain (45). However, unlike other vital signs such as blood pressure or heart rate, pain is a subjective experience and the American Medical Association advocated for removal of vital sign status (46). Menstruation as a complex experience inclusive of both subjective (e.g., cramp severity) and objective components (e.g., duration of last period). It necessitates a holistic approach to diagnosis and treatment, similar to other areas of medicine, such as mental health. Although not considered a vital sign, screening tools for mental health, such as the PHQ-9 for depression or the GAD-7 for anxiety, have normalized conversations about emotional well-being in routine clinical encounters, with referrals when appropriate. In considering the ACOG/AAP recommendations on menstruation, there are many ways in which this can be operationalized (6, 47). One recently developed mnemonic succinctly addresses biological and quality of life questions on menstruation and can be utilized for adapting EMRs or clinical practice more broadly (48). See Table 4 for full list.

This simple mnemonic (MENSES) could be integrated into provider conversations or pre-screening questionnaires depending on clinic structure and flow or assigned to trained auxiliary staff when available. It would also alleviate the time burden on providers during the clinical interaction but ensure there is a framework for collecting menstrual health information that can be explored further as necessary. Routine assessment of both biological and quality-of-life aspects of menstruation supports children and their families as they navigate menarche and helps identify health issues while improving overall wellbeing.

Given the importance of taking routine menstrual health history to support positive health outcomes for patients, four categories of recommendations are proposed in Table 5.

There are a few key limitations to note. First, the sample recruited was predominantly MDs/DOs. Given the increased number of Nurse Practitioners and Physician Assistants who see children and adolescents in the US, additional research is needed to explore how a broader range of pediatric-facing providers are trained on and engaged with menstrual health during the clinical encounter. Second, the study's small budget limited the recruitment, likely contributing to the study sample including many participants who were already attentive to menstrual health (easier to reach), primarily female, and those who were urban and suburban based. Future research should aim to recruit providers less comfortable or inclined to engage on menstrual health, in addition to more male clinicians, and those based in rural areas. Third, while provider perspectives are essential, more learning about patient and family perspectives around how menstrual health is included in clinical interactions would provide a more comprehensive understanding of what is needed to ensure quality menstrual health care.

This qualitative study explored how pediatric-facing providers across diverse regions and practice settings engage with menstrual health in clinical encounters. Participants described varied approaches to menstrual history-taking with time constraints emerging as the most consistent barrier. Three central themes were identified: the influence of training and experiential learning, the role of structural and relational factors in shaping the depth of menstrual health integration, and the impact of biological, quality-of-life, and condition-specific concerns on clinical care. Findings underscore the need for anticipatory guidance prior to menarche, integration of menstrual health tools into clinical workflows, training for clinicians and ancillary staff, and strategies to normalize menstruation as a routine aspect of pediatric care. Integrating menstrual health screening that addresses both biological and quality-of-life factors is essential for the early diagnosis of menstrual conditions and helps ensure that adolescents feel prepared and confident in managing menstruation as they mature.