Expert Reviews
Menstruation: science and society

This work was presented at the “Menstruation: Science and Society” meeting, NIH: Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, Sept. 20–21, 2018.
https://doi.org/10.1016/j.ajog.2020.06.004Get rights and content
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Women’s health concerns are generally underrepresented in basic and translational research, but reproductive health in particular has been hampered by a lack of understanding of basic uterine and menstrual physiology. Menstrual health is an integral part of overall health because between menarche and menopause, most women menstruate. Yet for tens of millions of women around the world, menstruation regularly and often catastrophically disrupts their physical, mental, and social well-being. Enhancing our understanding of the underlying phenomena involved in menstruation, abnormal uterine bleeding, and other menstruation-related disorders will move us closer to the goal of personalized care. Furthermore, a deeper mechanistic understanding of menstruation—a fast, scarless healing process in healthy individuals—will likely yield insights into a myriad of other diseases involving regulation of vascular function locally and systemically. We also recognize that many women now delay pregnancy and that there is an increasing desire for fertility and uterine preservation. In September 2018, the Gynecologic Health and Disease Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development convened a 2-day meeting, “Menstruation: Science and Society” with an aim to “identify gaps and opportunities in menstruation science and to raise awareness of the need for more research in this field.” Experts in fields ranging from the evolutionary role of menstruation to basic endometrial biology (including omic analysis of the endometrium, stem cells and tissue engineering of the endometrium, endometrial microbiome, and abnormal uterine bleeding and fibroids) and translational medicine (imaging and sampling modalities, patient-focused analysis of menstrual disorders including abnormal uterine bleeding, smart technologies or applications and mobile health platforms) to societal challenges in health literacy and dissemination frameworks across different economic and cultural landscapes shared current state-of-the-art and future vision, incorporating the patient voice at the launch of the meeting. Here, we provide an enhanced meeting report with extensive up-to-date (as of submission) context, capturing the spectrum from how the basic processes of menstruation commence in response to progesterone withdrawal, through the role of tissue-resident and circulating stem and progenitor cells in monthly regeneration—and current gaps in knowledge on how dysregulation leads to abnormal uterine bleeding and other menstruation-related disorders such as adenomyosis, endometriosis, and fibroids—to the clinical challenges in diagnostics, treatment, and patient and societal education. We conclude with an overview of how the global agenda concerning menstruation, and specifically menstrual health and hygiene, are gaining momentum, ranging from increasing investment in addressing menstruation-related barriers facing girls in schools in low- to middle-income countries to the more recent “menstrual equity” and “period poverty” movements spreading across high-income countries.

Key words

abnormal uterine bleeding
adenomyosis
endometrium
fibroids
menstrual health
microbiome
pelvic health menstrual effluent
period poverty
stem cells
tissue engineering
uterus

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H.O.D.C. has clinical research support for laboratory consumables and staff from Bayer AG and provides consultancy advice (but with no personal remuneration) for Bayer AG, PregLem SA, Gedeon Richter, Vifor Pharma UK Ltd, AbbVie Inc, and Myovant Sciences GmbH. H.O.D.C. receives royalties from UpToDate for article on abnormal uterine bleeding. A.K. receives royalties from UpToDate, Wolters Kluwer for work on the topic hysterosalpingography. E.E.M. consults for Myovant Sciences. K.A.M. is coinvestigator for Bayer Essure longitudinal research study and clinical trial (all funds for this research go to the site of research [W.I.H.] – no personal compensation). K.A.M. is scientific advisor for Myovant (advises on patient questionnaires related to AUB—compensation goes to employer [C.N.E.M.G.]—no personal compensation). K.A.M. has received honoraria from ABOG, ACOG, and NIH for participating in working groups and meetings. K.A.M. is HHS Office of Population Affairs Title X Grant Reviewer (received honorarium). I.M. is employee of Igenomix R&D. C.S. is Head of the Igenomix Scientific Advisory Board. The other authors report no conflict of interest.

Some of the data herein were derived from research grants funded by the Medical Research Council (G0000066, G0500047, G0600048, MR/J003611/1), Wellcome Trust (083908/Z/07/Z), and NIHR Efficacy and Mechanism Evaluation Programme (12/206/52). This work has been supported by the NIH grants P01-HD57877 and R37-HD38691 and by Research Evaluation and Commercialization Hub (REACH), Center for Biotechnology’s NIH award entitled “Establishing a Long Island Bioscience Hub,” and National Heart, Lung, and Blood Institute of the National Institutes of Health-Award Number U01HL127522; The Endometriosis Foundation of America (EFA). J.J.K. is a recipient of NIEHS/NIH/NCATS UG3 (ES029073) and NIH/NCI R01CA243249. J.A.M. is a recipient of Wellcome Trust grant (100646/Z/12/Z), Academy of Medical Sciences (SGCL13). G.P.W. is a recipient of John Templeton Foundation grant 61329; NIH U54-CA209992; WSU19073. L.G.G. received support from NIH U01EB029132-01, The John and Karine Begg Fund, and the Manton Foundation.