Through the analysis of both studies, six categories were identified for the analytical framework: 1) Debunking menstrual taboo and stigma through resignifying menstruation and the menstrual cycle; 2) Integrating inclusive and holistic menstrual education in school curricula and mass media platforms; 3) Reframing healthcare services to navigate towards integrative and agentic menstrual consultations; 4) Ensuring the access to menstrual products and menstrual management facilities; 5) Menstruation, productive work and menstrual self-care; and 6) Intersectionality and participatory-based research as the foundation for evidence-based menstrual policies. A summary of policy and community actions based on the analysis of both participant groups is available in Table 3.

Table 3 Proposed menstrual policies by areas of actionDebunking menstrual taboo and stigma through resignifying menstruation and the menstrual cycle

One of the most prevalent claims women and PWM shared was around tackling menstrual taboo and stigma, followed by mentions of menstrual discrimination. They considered speaking up about menstruation imperative to address prevailing taboo and stigma, as well as addressing menstrual taboo and stigma in the workplace, and being able to decide practicing free bleeding without shame. However, as PWPWM1 expressed, participants often navigated between the need for a “menstrual breakthrough” and the ingrained taboo they had internalised themselves:

“Not leaving it (menstruation) as a taboo (…) It is something that happens and that’s it and you do not decide it (…) maybe improving it so that it is further spoken, so that women can express what happens to us […] But of course society is what it is, so… if you are in the street you need to have your tampon, you need to have your pad (…) she’s not gonna be out stained, you’re not gonna go around smelling, like her [referring to the woman in one of the photographs shown in the photoelicitation].”—PWPWM1.

Likewise, professionals considered menstruation and the menstrual cycle to be stigmatised and taboo processes, resulting from patriarchal societal structures. They suggested the need to transform how the menstrual cycle is socially understood, to change menstrual symbolism towards a more respectful and “positive” one. They claimed how this should be done based on a feminist and intersectional perspective (i.e., taking into account different axes of oppression and discrimination) and understanding menstruation and the menstrual cycle as indicators of health in women and PWM. Eradicating menstrual taboos and stigma was also considered imperative. However, one participant offered a reflection on how taboos could have been (and are) protective mechanisms against certain gender role expectations (e.g., women having to be fully responsible for reproductive work):

“The taboo prohibits things, but the taboo also protects you from things. If we look at it from distance, it was also a way for you to get away from hard work of women for a few days. So, even in cultures where there is still no time to take your freedom to rest, taboo is sometimes the only thing that allows you to… ‘I can't cook, I can't…’”—PPA22.

Following the above statement, a participant pointed out that taboos were present in all cultures but in different degrees of expression, questioning the nature of “cultural differences”:

“I think that sometimes we see cultural diversity as something that makes us very different. Here it is mayonnaise and in another place it is 'do not touch the plants [referring to myths around menstruation]. This makes us very equal. The patriarchal society is the same in different degrees of expression. So, a strategy to break the cultural difference would be to make us feel that we are on the same plane”—PPA3.

Ideas that women and PWM shared on how to lessen menstrual taboo and stigma included engaging with social media influencers to normalie menstruation. In line with this, PWPWM24 claimed the need to make menstruation, and the social burden that comes with it, visible in a non-stereotypical way to attain menstrual health. He (PWPWM24 preferred masculine pronouns) explained how menstruation is stereotypically portraited in the media as either discomfort-free or a “cyclical horror”, failing to make visible the wide array of menstrual experiences. His experience was also shared by PWPWM11, who thought the media had a responsibility in not only portraying what could be considered “an idyllic menstruation”. PWPWM24 particularly mentioned the need for all menstrual bodies, in all their diversity (referring to gender non-conforming menstruators) to also be publicly visible, for instance in the media:

“There are a lot of generalisations, speaking about women or speaking about a certain type of women that menstruate in a certain way (…) There are many realities and… I feel that it is important that this gets put on the table”—PWPWM24.

In line with this, professionals considered that menstrual policies should focus on the needs of each population (e.g., people with functional diversity, socioeconomic vulnerable people, migrant populations, and LGTBIQ + communities). Regarding the stability of these policies over time, one participant claimed the creation of internal political structures that ensure the maintenance of menstrual policies:

“To guarantee that the institution maintains this and not depending on which deputies (…) That there is a profile that is mixed between jurists and that has a gender perspective and that can make impact reports. (…) At least, you have the office and if the legislature changes you have it there within the administration”—PPA1.

Besides, as women and PWM exposed, creating spaces to express and make their menstrual experiences visible could lead to getting social support. PWPWM18 and PWPWM30 narrated how addressing menstrual taboo and stigma could have a significantly positive impact on the lived menstrual experiences and emotional health among women and PWM. Further, PWPWM18 expressed that debunking menstrual taboos could lead to:

“Taxes (on menstrual products) to be reduced or that we could get products for free (…) and also discrimination for having our period, or some insecurities, self-esteem problems because of having a period and things like this, that I really believe that happen quite often. And in the end, from my opinion, they come from (menstruation) not being perceived as something natural and the fact that it is something hidden”—PWPWM18.

Moreover, PWPWM29 perceived menstrual taboo to be more deeply rooted among men, claiming that policy strategies should also target men. Involving men and people who do not menstruate (PWNM) in promoting menstrual health and equity was imperative for some to encourage men and PWNM to debunk menstrual taboos, promote empathy, and give social, emotional, and instrumental support to women and PWM:

“So male adolescents should be capable, so that if they see a girl that has stained her pants, tell her, hey do you need anything? Do you want me to go look for something? Instead of “wow!”—PWPWM7.

Integrating inclusive and holistic menstrual education in school curricula and mass media platforms

The need for timely, adequate, and holistic menstrual education was, overwhelmingly, the most predominant claim made by women and PWM. PWPWM17 pointed out that menstrual education should not be relegated to the family context, but to be offered at schools, to ensure and standardize the access and quality of menstrual education. They perceived menstrual education as the first step towards achieving menstrual equity and promoting menstrual health. According to professionals, menstrual education should be integrated into educational spaces (e.g., primary schools, high schools, and universities). They emphasised that menstrual education should go beyond one-time workshops and become an integral part of school curricula:

"If we focus on education, there must be a plan that is not an hour and a half talk because sometimes you open the Pandora’s box of 'How did you experience your first menstruation?' (…) It must be an (educational) program at least two or three times (a year)."—PPA9.

Some professionals referred to the implementation of a health subject in school curricula before menarche, while others suggested addressing menstruation and the menstrual cycle in a cross-cutting manner within existing subjects in school programs. Professionals agreed on the need for a pedagogical intersectionality perspective on menstrual education. While some women and PWM thought of menstrual education within the framework of sexual and reproductive health (e.g., to prevent unwanted pregnancies), others called for critical and feminist-based menstrual education. Based on their narratives, menstrual education should focus on debunking menstrual taboo and stigma. Learning how to manage menstruation, menstrual pain, and understanding the wide range of menstrual products available were other topics that women and PWM believed should be included in menstrual education. PWPWM18 also mentioned that menstrual education should encompass menopause. Besides, they believed that menstrual education should focus on promoting body awareness to identify potential menstrual health problems and include the social sphere of what it means to menstruate:

“And I thought, why don’t they do this at school? (…) now when I read certain things, like the fact that periods aren’t painful, I think ‘what do you mean periods aren’t painful?’ And I think ‘why wasn’t I told this in school?’ Periods aren’t painful. (…) Why did I find out when I ‘m 30 years old?”—PWPWM6.

Menstrual information was perceived by PWPWM27 to be increasingly more available in the last few years, given that there are more books published around menstruation and sexual health, and “red tents” and menstrual workshops are more widely available. However, she also pointed out how these resources were only accessible to those who are motivated and have the financial means. In line with this, professionals mentioned that educational strategies should be inclusive of different menstruating realities (e.g., people with functional diversity, socioeconomic vulnerable people, migrant populations, and LGTBIQ + communities) and that they should incorporate an intercultural approach that acknowledges cultural diversity:

“We did a talk to families at school about this (menstruation and menstrual cycle). Of course, very few (family members) came, the language was a barrier, because of course, we have a lot of immigration there. There were mothers who came with good intentions, but they didn’t understand the message well (…) (It would be) Better if we made it a bit multilingual”—PPA6.

Both women and PWM and professionals agreed on that menstrual education should be designed and implemented regardless of sex/gender, so boys and PWNM should also be targeted for menstrual education actions. Besides, a few women who were mothers shared their concerns about how to educate their children, regardless of their sex but particularly referring to girls, “How will I address it when my girl has it (menstruation)?”—PWPWM33. One participant also mentioned that parents’ concern about teenage pregnancy is the reason why, as a mother, the first thing that will come to her mind to explain to her daughter is that menarche means she can get pregnant “(…) then we will then see if you have polycystic ovaries or you don’t have your period, or you get acne (…)”—PWPWM33. Further, PWPWM34 deduced that menstrual education should also be directed to parents: “Sometimes I think that we should have a course for parents, on how to educate our children or something like that […] To educate. Having children is easy but educating is very difficult”—PWPWM34.

Another demand from professionals was to launch a communication campaign through the mass media and social networks, especially addressed to young people. They explained that these campaigns should have an emphasis on women and PWM rights, disseminate the definitions of “menstrual health” and “menstrual inequity” and inform about menstrual products. Further, PPA19 mentioned that a critical stance on the potential harm of non-reusable menstrual products should also be disseminated to the wider population:

“Tampax tampons and all these brands that say: cotton, polyester, cotton that is not cotton… How is it possible that politics is not there…? If they (products) are harmful products to our health, why isn’t there greater visibility of what we’re putting in?”—PPA19.

Reframing healthcare services to navigate towards integrative and agentic menstrual consultations

Another central tenet for women and PWM was the need to improve the access and quality of healthcare services for menstrual health. According to them, health services should be designed and implemented with the menstrual cycle and menstruation as general health indicators and tools for health promotion in mind. Moreover, women and PWM thought that menstrual health should be addressed in healthcare services in a more holistic (and less biomedical) manner. For instance, using hormonal contraceptives was perceived by PWPWM6 as a barrier to menstrual awareness and body literacy, supporting the need for menstrual health consultations to go beyond medical prescriptions. Demedicalising and depathologisating menstruation (pregnancy and the climacteric) was another of their demands. As PWPWM27 expressed, medicalisation created a sense of disempowerment for her:

“It (medicalisation) creates some sort of disempowerment (…) that perception that makes you feel like something bad is going on and that, also, you have to control it with a pill or something medical. And, why? If it is a natural process for women, right?”—PWPWM27.

Based on the accounts of professionals, healthcare centres are often perceived as hostile spaces, especially for young people and vulnerable populations. Thus, they suggested architectural and design changes to make healthcare spaces more welcoming and facilitate menstrual consultations. They believed that if health centres were seen as health promotion structures and not just as spaces accessible only during illness, they would be more accessible to potential users for menstrual consultations. One participant also commented on how gynaecological services were often were not available for women who were no longer menstruating:

"My mother-in-law, 85 (years), tells me 'oh, my vulva itches, it is dry, but the gynaecologist told me not to return at 65 (…) you are not a woman because you menstruate, but until you die’”—PPA9.

Besides, women and PWM in our study considered it essential to improve professionals’ knowledge and attitudes towards service users and menstrual-related consultations. Some participants also referred to the generalized neglect of menstrual health needs by healthcare professionals, and not feeling listened to:

“I believe that the first thing it to listen to women, right? Whatever happens to her, whatever she explains to you on menstruation, don’t ignore it and if she tells you that it (menstruation) hurts her, well then let’s explore it, right?”—PWPWM12.

PWPWM27 was also critical towards health professionals who made it challenging for women and PWM to take agentic informed decisions:

“With doctors there’s also a lack of clarity. For example, with hormonal contraception they don’t explain to you that, you do not actually have a cycle and that it is a bleeding that is caused by a pill, but you are not going through the same process afterward. All these things are not explained to you clearly, and of course you don’t have the resources to know if you need it (hormonal contraception) or not”—PWPWM27.

To increase awareness of menstruation throughout society, professionals mentioned that university curricula should also incorporate menstrual health and equity into educational, health, social and political studies. In this regard, some participants considered relevant for healthcare professionals to strengthen menstrual health community-based actions, as they found that workload pressures limited their capacity for community health actions. At the same time, offering menstrual health talks by midwives was seen as an appropriate measure to inform to communities. One participant explained that the role of community agents, understood as people who serve as a "bridge" between the healthcare services and the community, could be a powerful resource to disseminate menstrual information to people who do not (or cannot) access primary healthcare centres for various reasons (e.g., language barriers):

“I think that as midwives, it is a high priority to go out, to be more in the street, in neighbourhood associations (…) to be in contact with all the agents in the neighbourhood, because we can get into spaces that perhaps we wouldn't get into if we didn't leave the primary healthcare centre and perhaps reach a population that doesn't come to the primary healthcare centre”—PPA11.

Something else that emerged in the narratives of women and PWM was that access to healthcare should be ensured for those living in socioeconomically deprived situations. Although she did not see it as problematic, PWPWM2 referred to the unequal access to healthcare opportunities:

“Equal conditions for everyone (…) My opinion is that if you (…) (have) money, (you can) pay for it (healthcare) and that’s all […] The person who can’t (afford private healthcare) goes to social security [public healthcare] and that’s it”—PWPWM2.

Besides, PWPWM31, who worked as a cultural mediator in healthcare services, stressed the need to respect women’s decisions regardless of their sociocultural background. She explained a situation she had experiences where a gynaecologist denied a Pakistani woman a consultation when she refused to be seen by a male trainee medical student: “And she got angry and left the consultation there, and she said that she had to leave and get a consultation with someone else”—PWPWM31. The participant explained that the doctor had wrongly assumed that it was the patient’s husband who refused the male student to be present in the consultation, and that the patients’ husband filed a formal complaint. PWPWM31 call for respecting women’s decisions and inferred the need to address cultural and racial discrimination in healthcare services:

“We must respect the person’s opinion. We cannot complain because she does not want to be seen by a man (…) there are also male doctors in Pakistan who do surgeries and all that, and there are women who allow it and other women who do not […] The doctor started to ask, and why don’t the husbands allow it? (…) but if she is here in Spain, she should not allow this. I know that she is in Spain, but it the one who does not want to”—PWPWM31.

Professionals also pointed out the frequent disregard/neglect in healthcare services of the LGTBIQ + community, young people, migrant populations, and socioeconomically vulnerable individuals. For this reason, they suggested creating multidisciplinary teams to guarantee an adequate consultation approach that takes diversity into account:

“So it is very different if there is (in healthcare centres) a person from that community, if there is a deaf person, if there is a person from that culture… People with cognitive diversity.”—PPA21.

Ensuring the access to menstrual products and menstrual management facilities

Women and PWM made consistent claims on the need to improve access to menstrual products, given that they were considered essential goods: “that everyone can access, right? (…) a basic product that all women could access”—PWPWM29. A few participants also expressed their views on promoting the use to reusable menstrual products, such as the menstrual cup, for both the environment and health-related reasons: “they (single use products) have got a lot of chemicals that are hormonal disruptors”—PWPWM21. According to their narratives, access could be enhanced by providing free menstrual products (e.g., in public toilets), reducing their cost (in particular by lowering taxes) or making state benefits available to purchase menstrual products available for socioeconomically vulnerable people. PWPWM18 shared her views on the link between current taxation of menstrual products and social discrimination based on menstruating, as these products were not taxed as essential goods at the time of the interviews. PWPWM21 further discussed feminism and the relationship between political ideologies and people’s attitudes towards subsidizing menstrual products:

“How many women are affiliated to (…) (political party), which is far-right and misogynist (…) because saying this (disagreeing with making menstrual products available for free) means that you disagree with having sexual rights (…) It means being very disconnected from your gender and your sexual identity […] There are many different feminist movements. To me, feminism should simply be that everyone could do whatever the hell they want (…) the important thing is that you are free to choose (…) As long as you are well-informed”—PWPWM21.

Professionals also commented on the importance of taking action around the price of menstrual products to address menstrual poverty, for example, by reducing and/or eliminating taxes on menstrual products. One participant pointed out that a 21% tax was still applied to cloth-made reusable menstrual products, despite the fact that other menstrual products are taxed at a reduced rate. Besides, participants discussed the importance of guaranteeing equal access to all menstrual products, avoiding the imposition of some options over others (e.g., not considering the menstrual cup as the best option). They also mentioned the placement of product dispensers in strategic locations, such as social services, primary care centres, pharmacies, prisons, or food banks, to ensure accessibility to vulnerable and hard-to-reach populations. Above all, they considered that cultural, religious, economic, bodily, and functional diversity should be considered to respect individual choices about the use of menstrual product:

“Everything (menstrual products) should be on the table. (…). We should not go with such an exhaustive mantra about what to do and what not to do, that is, am I not feminist enough because now I don't do this (referring to menstrual cup use). All options must be shown”—PPA9.

Other women and PWM focused on the availability of menstrual management spaces in public settings. They thought adequate menstrual management spaces should also include a washbasin, a waste bin, and a clothes hanger. These toilets should ensure privacy and safety, have a lock, and be clean:

“Well, facilities in public spaces (…) Here in Spain, for example, there are not many public toilets as in other countries. And why not the possibility of a public toilet for women. Or, just as they have divided men and women, the same for people who menstruate. And an equipped toilet, right? In case you’re using a menstrual cup, to be able to clean it or have accessible products for you”—PWPWM14.

Professionals also identified barriers to accessing adequate menstrual management facilities. As a way to minimize these barriers, they suggested the need to adapt public spaces for menstrual management in educational settings (particularly in schools, high schools, and universities), healthcare centres, and workplaces. As women and PWM stated, these facilities should all have access to water and soap, toilet paper, a bin to dispose menstrual products, and even menstrual products available. In school settings, some participants shared the idea of offering spare clothes to students, in case they experienced menstrual blood staining at school. When discussing gender neutral versus sex segregated bathrooms, not all participants shared the same viewpoint. Some participants felt that toilets should be gender neutral to be inclusive of non-conforming menstruators and especially to support people who may experience "gender dysphoria" or other difficult emotional experiences when having to use sex-segregated toilets. Others believed that sex-segregated bathrooms are necessary to ensure the physical and emotional safety of women. However, participants stated that all bathrooms, whether or not they are sex-segregated, should be adapted to menstrual needs:

“Personally, I think that there should be sex segregated bathrooms, for safety reasons. But all bathrooms should be adapted in case there is a menstruating person to change and clean them well.”—PPA11.

Menstruation, productive work, and menstrual self-care

Women and PWM referred to the need for menstrual policies in the workplace, including menstrual leave, having “rest days” available, and ensuring flexible working hours. They explained that these policies should be accompanied by processes to normalize and socially accept the need for rest and adaptation of workplaces to the menstrual needs of women and PWM's, so as not to increase menstrual stigma and discrimination:

“To be able to request a day off if you’re not feeling well and not feel ashamed to say it in fron of anyone, right?”—PWPWM12.

“To adapt society a little so that menstruation is a reality. Hello, it’s happening, and we need so much… support to… live with it in an easier way”—PWPWM13.

Professionals also highlighted the need to adapt workplaces to be respectful of menstrual experiences and needs. They referred to policies such as teleworking or menstrual leave, to support menstrual pain management, although the diversity in working conditions should be considered when developing menstrual measurements in the workplace (e.g., not all jobs offer the possibility of teleworking easily taking bathroom breaks during the working hours):

"In the workplace, bathrooms that are in a good condition (…) this should be part of the idea of optimal working conditions for any job, because in many jobs you can’t even go to the bathroom"—PPA20.

Some professionals also questioned the current social and economic model, based on high productivity and efficiency. Within this system, they discussed how menstrual needs could not be met. For instance, work productivity expectations may not be met when experiencing menstrual pain, or they may be met but at the expense of one’s health. For this reason, some participants believed it was necessary to implement work measures that take menstrual experiences into account and challenge the current hegemonic model of productivity:

“Being able to adapt our work dedication, efficiency based on what we can and cannot do. And if you are not as productive as the system wants, then it’s fine. What it [the system] wants is to be ultra-productive”—PPA3.

Intersectionality and participatory-based research as the foundation for evidence-based menstrual policies

Alongside other actions, several women and PWM and professionals called for the need to generate evidence around menstruation and the menstrual cycle. Professionals emphasized the importance of active collaboration between academia, professionals (e.g., from health settings), and the community, promoting participatory action research. In fact, one woman called for menstrual strategies to be designed based on listening to the needs and demands of women and PWM:

“And they should also listen more to people who menstruate when making decisions regarding people who menstruate, this is a logical thing”—PWPWM9.

In parallel, another participant explained how: “it is always about the government, private companies caring for their employees, and then there’s also the role of civil society, social entities, organisations, etc. to promote equity, let’s say, between those who menstruate and people who don’t menstruate”—PWPWM8.

Besides, one professional shared her views on how academics rarely focus on translating their findings into community actions and policies that could be beneficial to the population:

“It is a world (the academic) that seeks knowledge that does not interest people too much. It’s always the same. Just like in the political world. Many things are done, many actions, but very few reach (people)”—PPA12.

When discussing menstrual research, professionals suggested creating a repository containing research evidence on menstrual health and equity. In addition, this repository could include resources for menstrual education and other useful publications and materials developed by subject matter experts. As inferred from their narratives, research should incorporate a gender-based and intersectional approaches. Inclusion of people with functional diversity and gender non-conforming populations should also be central to menstrual research. Moreover, professionals called for the promotion of research on perimenopause and menopause.