The conflicting findings
Assumption #1. Developing countries have greater prevalence of menstrual disorders
Heavy Menstrual Bleeding / Mennorhagia
- An internet based study of 4506 participating women across 5 European countries showed that 27.2% have experienced two or more symptoms of Mennorhagia in the previous year. 304 (30.3%) of 1004 from France reported at least two heavy menstrual bleeding symptoms, compared with 245 (24.5%) of 1001 from Germany, 329 (32.9%) of 1000 from Spain, 222 (22.2%) of 1001 from the Netherlands, and 125 (25.0%) of 500 from Switzerland. Overall, 564 (46%) of the women with symptoms had never consulted a physician. 
- A postal self-reported study in England covering 1861 women over a period of 12 years, found that the baseline responses showed 52% women who reported symptoms of Mennorhagia. The 12-month cumulative incidence was found to be 25%. 
- A London study of Elite and Non-Elite Athletes in 2015 covered 789 participants through an online survey and 1073 face to face interviews. Heavy Menstrual Bleeding was reported by half of those online (54%), and by more than a third of the marathon runners (36%). Surprisingly, HMB was also prevalent amongst elite athletes (37%). Overall, 32% of exercising females reported a history of anemia, and 50% had previously supplemented with iron. 
Hysterectomy (surgical removal of whole or part of the uterus)
- “In the UK, 20% of all women, and 30% in the USA, have a hysterectomy before the age of 60; Mennorhagia is the main presenting problem in at least 50-70%”. 
- Approximately 600,000 hysterectomies are performed in the USA each year, and the procedure is the second most frequent performed major surgical procedure among reproductive-aged women . The estimated proportion of hysterectomies performed for a primary diagnosis of dysfunctional uterine bleeding varies from 6% to 18% .
- A community survey of 8,896 households was undertaken in the Hunter region of New South Wales (Australia) to assess women’s health status. The prevalence of hysterectomy in this sample was 16.9%, with 34.2% of women in their fifties having had a hysterectomy. Most hysterectomies (75%) were performed on women between the ages of 30 and 49 years.
Menstrual Pain / Dysmenorrhoea among adolescent girls
- The MDOT study in Australia surveyed 1051 adolescents between 16 – 18 years and found that 94% experienced menstrual pain, 96% had PMS, 58% reported clots in their menstrual blood (which could mean Mennorhagia) and 30.5% reported irregular periods. 
- A questionnaire based study of girls in grades 11 and 12 in Western Australia showed that 80% suffered from Dysmennorhea 
- A study of 1000 female students in Housten (Texas, U.S), showed that 85% reported Dysmenorrhoea 
- A survey of girls ages 12 – 21 years in Washington D.C (U.S) found that Premenstrual syndrome (PMS) was the most prevalent reported menstrual disorder (84.3%) followed by Dysmenorrhea (65%), abnormal cycle lengths (13.2%), and excessive uterine bleeding (8.6%) 
- A Singapore study of adolescent girls showed that 83.2% suffered from various degrees of Dysmennorhea 
- A study of Japanese adolescents between ages 18 and 25 years found that 63.6% had heavy menstrual flow, 79% had menstrual pain and 63% had irregular cycles. 
- A study of adolescents in South Korea showed that 43.35% reported bleeding quantity as large to very large amount, 74.5% complained of Dysmennorhea and 80% complained of irregular cycles 
- In U.S., menstrual bleeding has significant economic implications for women in the workplace: women who bleed heavily were estimated to work 6.9% or 3.6 weeks less every year. Work loss from increased blood flow is estimated to be $1692 annually per woman. 
- Each year approximately £7 million are spent on primary care prescribing for Menorrhagia in the UK 
Assumption #2. Use of Sanitary Napkins is only 12% in India
Assumption #3. Poor Menstrual Hygiene Management leads to Reproductive Tract Infection (RTI)
The study concludes by stating that“The body of evidence to support the link between poor MHM and other health outcomes (secondary infertility, urinary tract infections and anaemia) is weak and contradictory.”
“It is plausible that MHM can affect the reproductive tract but the specific infections, the strength of effect, and the route of transmission, remain unclear.” 
Assumption #4. Girls in developing countries are dropping out of school due to lack of menstrual products and toilets
“Despite the apparent acceptance in WASH policies that menstrual management affects attendance of adolescent girls at school there is very little high quality evidence associating school attendance or drop-out with menstrual management. The only published study identified found no association between provision of a menstrual cup and school attendance. An unpublished study by Scott et al found significant improvements of 9% to 14%. in recorded class attendance from access to sanitary napkins and/or MHM education but full details of the study methods and results were not available at the time of the review. A systematic review into the linkages between separate toilets for girls and school attendance was inconclusive. The data were analysed without taking account of age with respect to menstruation and MHM provisions in school may have been among the influencing factors. No studies were found which addressed provision of pain medication or other factors that may have a bearing on attendance or drop-out rates. We cannot therefore report that the current evidence indicates improved MHM improves attendance at school.”
“We report two findings. First, menstruation has a very small impact on school attendance: we estimate that girls miss a total of 0.4 days in a 180 day school year. Second, improved sanitary technology has no effect on reducing this (small) gap: girls who randomly received sanitary products were no less likely to miss school during their period. We can reject (at the 1% level) the claim that better menstruation products close the attendance gap. We conclude that policies to address this issue are unlikely to result in schooling gains.”
Why do developed countries have a greater prevalence of menstrual disorders?
- Studies on menstrual cycle irregularities among female workers in Japan  showed that menstrual cycle irregularities were related to stress, smell of cigarettes, age and smoking habits.
- A study in Tehran comparing menstrual problems among day workers and shift workers indicated that Dysmennorhea was 44% among day workers and 66% among shift workers. Similarly, only 7% day workers had irregular periods, while 19.4% shift workers had irregularity in their period. 
- Obesity has been closely linked with various menstrual disorders [85, 87]. 61.9% women in U.S, 57.2% women in U.K, 56.1% women in Australia have a BMI greater than 25; whereas, the percentage of obese women in Nigeria, India, Bangladesh and Nepal are 33.6%, 20.7%, 18.7% and 13% respectively.  The high rate of obesity among women in developed countries could be one of the reasons for the higher prevalence of menstrual disorder.
So how come the developing countries do not have these issues?
Why has the focus been on Menstrual Hygiene and not Menstrual Disorders, in spite of the research and evidence?
(*Proctor & Gamble is the manufacturer of Whisper Sanitary Napkins)“A number of NGOs and sanitary product manufacturers have begun campaigns to increase availability of sanitary products, with a stated goal of improving school attendance (Deutsch 2007, Callister 2008, Cooke 2006). The largest of these is a program by Proctor & Gamble*, which has pledged $5 million toward providing puberty education and sanitary products, with the goal of keeping girls in school (Deutsch 2007). The Clinton Global Initiative has pledged $2.8 million to aid businesses who provide inexpensive sanitary pads in Africa; again, the stated goal is improvement in school and work attendance. In addition to these large scale efforts, a number of smaller NGOs (UNICEF, FAWE, CARE) have undertaken similar programs (Cooke, 2006; Bharadwaj and Patkar, 2004). Despite the money being spent on this issue, and the seeming media consensus on its importance, there is little or no rigorous evidence quantifying the days of school lost during menstruation or the effect of modern sanitary products on this time missed. Existing evidence is largely from anecdotes and self-reported survey data.”
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