Menstrual Science: periods, pills, poverty

The England and Wales NHS test and trace app has been - finally - released! This public health tool, designed to assist with coronavirus contact tracing, has been much-touted by politicians but suffered a number of issues during the launch, including problems with QR code scanning at venues, and no way to register a positive COVID test if you got tested at a hospital. The app was originally very similar to Australia’s version, called COVIDSafe, but switched during development to a different model created by Apple and Google; and so it’s useful to compare the two to see what works and what doesn’t. COVIDSafe launched in Australia back in April, and Phil Sansom asked cryptographer Vanessa Teague: how successful has it been?

Vanessa - We're not quite sure. And that's part of the trouble. The federal government, for some reason, refuses to cough up any data at all. We don't know how many people are actually using it. And we don't know what fraction of contacts that it is successfully detecting. They must have that information, right? Because the app interacts actively with an Amazon server at least once a day. So they could easily be telling us, but they've chosen not to.

Phil - Right. So I'm guessing, we're not saying that no news is good news here?

Vanessa - Indeed. One assumes that if 99% of people who had downloaded were still using it, they would probably find it in their hearts to share that information with us.

Phil - Now, can you just explain how different is it to this NHS app that's just been released?

Vanessa - Right. It's actually very, very similar to the earlier British app. COVIDSafe runs a centralised protocol. In other words, the Bluetooth messages that you're sending around, are encrypted versions of your ID. And when you test positive, you upload to the authorities, a list of the encrypted IDs of all the people you've come close to, and they decrypt the ID and notify the person. The information flow is exactly the opposite way round from the decentralised Apple-Google framework, which Britain and most other countries are now using. In the decentralised exposure notification framework, you're doing on your own phone, a computation that tells you whether or not you've come into contact with anybody who has just tested positive for the infection. There's never a need for a centralised authority to learn who's been in contact with whom.

Phil - It's been quite a crucial question, hasn't it? Because the NHS app switched from the centralised to the decentralised. Why is that?

Vanessa - Yes. One of the reasons was that centralised vision just kind of didn't work very well, and COVIDSafe didn't work very well either. You know, it drained the battery. It wasn't as effective as people hoped. It crashed, et cetera. Realistically, that's probably why the NHS app switched over. But I think there's a huge advantage to the decentralised version in that it doesn't build up in a centralised database, a list of which infected person has been near whom. Now, the epidemiologists would say, you also don't get the advantages of scientific analysis of a great big centralised database of who's been near whom, when, and who got infected how, but I'm concerned, at least in the Australian case, about the possibility that that highly sensitive database might potentially be misused, or potentially might just be leaked.

Phil - What about this other factor, that Apple and Google protected this technology that the apps rely on, which is using Bluetooth at really low power?

Vanessa - Right. So long, long before COVID, advertising companies, specifically Google, but plenty of others as well, realised that you could get a very, very accurate picture of where somebody was, if they were willing to turn on Bluetooth low energy on their phone, and scan for Bluetooth beacons that you could carefully put at special locations in shopping malls, or train stations, or something. And so Apple in particular, controlled access to these functions as a privacy feature. Then when COVID came along, somebody had the brilliant idea of using Bluetooth based tracking for connection recording, then Apple and Google had to think of something to do about it. So they responded to this situation by creating this very specific decentralised protocol, rather than just declaring open slather.

Phil - Right. So what you're saying then, is that Australia have essentially stuck to their guns, and they're struggling to get around these privacy restrictions on phones that don't let you use low power Bluetooth easily.

Vanessa - Yeah, that's exactly right. The only slight additional complexity there, is the Australian app initially had a lot of bugs that interfered with the basic workings of the thing. And they blamed Apple for a lot of them, which in fact were just coding bugs in their app.

Phil - Okay. Taking it altogether then who do you think has made the right decision?

Vanessa - Oh, I definitely think Britain has made the right decision. In Australia, we never really had the opportunity to have a real discussion or democratic decision about it. We still have never really got a clear answer on whether the Commonwealth authorities have access to the data, or whether it's only the state authorities, which is actually a big deal in Australia for various reasons. The fact that it was fairly openly and democratically done in the UK, led directly to a good decision to switch.

This is the section of the show where we address your correspondence. Razel is from the Philippines, and is asking about some news about the “white sand of controversy” in Manila Bay - where an artificial beach project using dolomite rocks has been criticised for being an environmental hazard. He asks: “what is the science around Dolomite sand, and does it have health related risks?”

Adam - Well our very own Phil Sansom has been looking into this, and he explained that dolomite is a naturally-occurring type of rock that’s closely related to limestone - it’s a sort of calcium-magnesium carbonate. In this case it’s coming from a large dolomite quarry on a southern Philippine island, and since August has been travelling on ships in crushed form up to Manila.

This is part of a rehabilitation programme to clean up the notoriously polluted bay - or at least, clean up its image. But the Philippines Department of Health have warned of respiratory risks if you inhale aerosolized dolomite dust, and as Bored Chemist pointed out on our forum, people and the waves will probably crush the rocks down to dust over time. Others warn of damage to the bay ecosystem from heavy metals leeching into the water.

There’s limited evidence around dolomite dust’s health or environmental risks in particular, but perhaps this is a relevant point and worth exploring before continuing the project. We’ll be following this story and hoping for some more concrete research soon.

To discuss the relationships between the menstrual cycle and mental health, GP and women's health specialist Hannah Short spoke to Adam Murphy and Katie Haylor. Firstly, Katie asked whether the cessation of periods (the menopause) can have an impact on how someone might feel...

Hannah - Yeah, they certainly can. I think there's two main aspects. The emotional and psychological impact of changing hormones in itself can have an effect because the changing levels affect your brain and so it can lead to symptoms like mood swings and insomnia, anxiety, loss of confidence and irritability. But then there's also the psychological side of it directly by the fact you've stopped your periods. Some women will mourn their loss of fertility or they see it as a sign that they've now passed their youth. And obviously that's particularly problematic for women or girls who have gone through a very early menopause or lost their ovaries as a result of surgery.

Katie - In general, how well do scientists understand the relationship between your mental wellbeing and your menstrual cycle?

Hannah - There's a general appreciation that there is a connection, but to be honest, I don't think it's understood well enough or the severity that can occur is not really fully understood or recognised. I mean, the Royal college of Obstetricians and Gynaecologists have guidelines for PMS, which is premenstrual syndrome. And that's where women will struggle with symptoms in the two weeks leading up to their period. There's a recognition that there's some degree of severity. So for some women it will just be mild unpleasant symptoms and others will be really quite severe. Not everybody's aware of these guidelines. So I think the scientific and medical community needs to do a lot more kind of work around it, but I think it is gaining recognition and understanding.

Katie - Is there a sort of a correlation that we can appreciate between hormonal variation and moods specifically?

Hannah - There's no such thing as typical, I suppose, but often people will associate the first part of the menstrual period - so just the day that your period starts and for the first two weeks of oestrogen rising - their mood tends to improve, their energy tends to be better. Libido is often increased around ovulation. Then the second part of the cycle, when the oestrogen is dropping and the progesterone is rising, a lot of women might feel a bit more irritable, may feel more tearful. Again, this, as I was saying, the severity of that really varies. In about one in 20 women will struggle with very, very severe symptoms. They say it's almost like a switch has been flipped and they're a different person in the second part. And that's when you have something called premenstrual dysphoric disorder or PMDD.

Adam - And, what would you do to advise people to seek help with how they're feeling and what kind of problems can arise for them?

Hannah - Well, I was just saying about the PMDD for the 1 in 20 women, or those who are born female who still have their ovaries, it can be really quite debilitating the symptoms. So they can have suicidal thoughts, it's not just feeling a little bit low. Very severe anxiety. If that's happening, that's obviously not normal and needs help and recognition. Going to see your GP would be the first port of call and keeping a track of your symptoms to kind of show that there's a cyclical kind of nature and that you're not feeling like that all the time. There isn't like an underlying psychiatric diagnosis there.

Katie - What can be done to help? Are there medications that would be appropriate? How do you help as a doctor?

Hannah - It depends on the severity. So women who are having milder symptoms, lifestyle changes like regular exercise, sleep, eating a fibre rich diet can help. Vitamin B6 and magnesium supplements - there's some evidence for those. With people with the more severe symptoms, where they're having to miss school or work or it's affecting their relationships, then things like the SSRI antidepressants can help stabilise the brain and reduce those mood side effects. And things like the contraceptive pill, or HRT can help as well. In some severe cases, having an induced medical menopause - so you have injections to switch off the ovaries - can help. And you're given some HRT to help protect your bones and things like that. And in very severe cases, some women have their ovaries removed, but that's at the very extreme end.

Katie - The menstrual cycle and wellbeing isn't a subject that is talked about loads. As a woman's health doctor, how would you summarise the societal perception of menstruation and mood?

Hannah - I think it's probably still viewed as quite a taboo, I think. Because you've got two kinds of taboos there anyway. I mean, hopefully things are changing, but historically menstruation and mental health are things that people steer away from so when you get that combination I think there's quite a reluctance to talk about it. Unfairly women have often been viewed as quite hysterical, it's probably where the word comes from - stereo and hysterectomy when you're talking about removal of the womb. I think things are getting better, but because it's not fully understood, I don't think women are often believed when people say that their menstruation is really affecting their mental wellbeing. And I'm hopeful that will change as the conversation opens up around it. There's the lack of acceptance really on the societal level, that our moods do change - it's a normal part often of being female. I mean, obviously if it's affecting your day to day life in a very difficult way, that's different. But I think that there's definitely room for society to kind of embrace the fact that women are generally cyclical creatures and not going to feel the same from one day to the next and that's not how we've evolved to be.

Let’s zoom out from the doctor’s office now, to take a broader societal perspective on menstruation. And “Every month, girls in the UK face period poverty: two fifths have had to use toilet roll because they can’t afford proper sanitary products.” That’s a rather damning quote from the charity Plan International in reference to a recent report they conducted, and global campaigns manager Ema Jackson spoke to Katie Haylor and Adam Murphy...

Ema - The term period poverty refers to the inability to afford or access the products needed to manage your period. And this is an issue that's affecting millions of people all around the world and having a huge impact. It's especially acute in places of extreme poverty, as you might imagine. So places where there's little access to water and sanitation facilities. But like you say, it's also an issue here in the UK too, which people are often quite surprised about, given the fact that we're kind of in one of the richer countries in the world. We did a survey with girls in the UK and we found that many were suffering because they couldn't afford to access the products to manage their periods. So we found that 1 in 10 couldn't afford period products and then 42% - so almost half - of girls were saying that they'd been forced to use makeshift items such as socks or toilet roll because they'd been struggling to afford proper products. And our research showed us that period poverty is quite a complex issue that goes beyond simply this affordability of period products. And it's actually made up of what we're calling a kind of toxic trio of three connected and reinforcing issues. So firstly, the high cost of period products. Secondly, a lack of education about what makes a healthy period. And then thirdly, the deep stigma that still surrounds periods all around the world.

Adam - Given that we are in the middle of a global pandemic, what are the consequences for young people now with this?

Ema - There's huge consequences always to this issue. And then we've seen them kind of increase during this lockdown period. So period poverty has a huge and very real impact on girls’ lives. So a key example of this is on education. We see that girls are embarrassed around kind of leaking, or not having access to products, or being bullied. And so they're missing out on school because of their periods. And this is happening all around the world. So we see that 70% of girls in Malawi - a country in Southern Africa - are missing one to three school days per month due to menstruation, which is more than they miss due to malaria. So it is really significant. And period poverty is also putting girls physical, sexual and mental health at risk. So damaging their self image, their self esteem. Because of this kind of period stigma and lack of education, that's meaning that they don't access doctors in the same way and because they're embarrassed. And so it's causing late diagnoses of serious conditions, such as the ones you've been talking about on the programme. So it's brilliant to kind of be opening up those issues.

But then in lockdown, we've seen this compound, particularly around the issue of access to products. So we found that girls are struggling to afford and access the products that they need. We know that families are facing tough financial choices all around the world right now. And it's meaning that more women than ever are having difficulty accessing the products they need. We surveyed girls and found that 3 in 10 girls since lockdown began, had been having issues, affording the period products that they need, which is sad to hear.

Katie - I was talking to a colleague, Ema, earlier in the week about access to toilets as well, not just period products. How are charities like yours trying to support people at the moment?

Ema - Yeah. So there's a whole range of different things that we are doing. So you spoke about toilets there. So kind of firstly, on the global side, we're doing things like constructing girl-friendly toilets in schools and communities, and access to water and sanitation facilities. And trying to support girls so that they no longer need to use unhygienic materials. Also, when an emergency hits like a natural disaster or also COVID, we're providing essential dignity kits, which include period products because these are often kind of forgotten about in emergency response.

And then in the UK, we're doing lots of different things to raise awareness around period poverty and break down the stigma. It's an issue we've been working on since 2015. We did a big research report called Break the Barriers to get more people understanding this issue and getting people talking about it. And then we've done campaigning to the government to call for change around the education curriculum, around access to products. We even secured a kind of period emoji after girls told us that they felt that this would help them better communicate on this issue. So we're kind of trying to tackle it holistically across those three different areas that I discussed in that toxic trio, the access to products, the education and the stigma.

Adam - You mentioned the stigma there. How pervasive is that period stigma, now, in 2020?

Ema - Unfortunately, it's still really pervasive. So it's been there for centuries. But it's still there now. So whilst periods are a normal bodily function and a universal fact of life wherever you live in the world, sadly the shame and stigma still comes with them. So there's a sense that periods are kind of dirty or disgusting or make women weak. They're shameful, they need to be kept a secret. So we've kind of been indoctrinated to think that a perfectly natural bodily function is kind of abnormal in some way. And because it's predominantly affecting girls and women, it's a gender equality issue really. So we know that one in five girls have experienced teasing and bullying because of their period, and that one in five admitted that they didn't actually know what was happening when they started their period, which shows how much this stigma is still pervasive in 2020, because it's not being talked about enough for girls to understand what's happening when they started their period. And it's an issue globally as well. So 48% of girls in Iran believed in a survey that menstruation was a disease. And then there's extreme examples of this period stigma that are still practiced in 2020. So an example of that would be a practice called chhaupadi in Nepal, in which girls and women on their period are considered impure and unclean. And they're banished from the household and made to live for the duration of their period in makeshift huts, outdoors, which exposes them to lots of health and safety risks. So unfortunately, even though we think maybe there's lots of more progressive thought around lots of different health issues in 2020, this is still a key issue. And it's called a lot the final taboo. And it's definitely still there.

Katie - The thing is, better menstrual education and awareness is just better for everyone, whether you have ovaries or not, it's better for society. So what progress do you think, Ema, is being made in terms of access to education around periods, whether you menstruate or not?

Ema - Yes. We've definitely seen a lot of progress on this issue. So there's been a kind of growing and active periods activism movement in the UK and around the world. And from that we saw calls that Plan International UK and others supported to the government to call for the relationships and sex education curriculum to be amended, which we have seen happen. And so there is now discussion around what a healthy period is on the curriculum. And it will be interesting to see how that new curriculum is rolled out, especially in the post lockdown Covid situation that we're in now, seeing how education is prioritised in different ways.

But as you mentioned, it's really important that everyone learns about periods. I think the idea that it's something that just girls should learn about really reinforces a lot of the stigma and the secrecy and it being it kept as something just for girls. And so it's important that in all areas of life and with all people, we're having education on this topic. So it's not just traditional school things. I think this programme has been a kind of really good example of education and information sharing about this issue that can go out to everyone in society. And everyone in society has a role to play in breaking this stigma down.

Katie - Caroline, I want to bring you back in here because of course not all women have periods. And equally, not everyone who has a period is a woman. So how well do health professionals understand the experiences of menstruation for people who don't necessarily identify as women?

Caroline - So I think that the primary duty of a doctor is to the number one care and safety of their patient. And that should be separate to their beliefs. And just bear in mind that our patients come from very diverse backgrounds and beliefs. So I would like to see doctors just taking an open view, taking the lead from the patient and then dealing with those issues as the patient sees them.

Katie - And Ema, does this relate to the issues around access and stigma that we were talking about earlier?

Ema - Yes, definitely. So I think we need everyone in society to be part of that process of breaking down the stigma. And we need to be really inclusive in the language we use and recognise, as you've said, there are trans-men and non-binary people that are experiencing periods as well as lots of women who, for example, for health reasons or being pregnant or post-menopausal, or being trans-women, are not experiencing periods. And sometimes this is where the stigma can be the deepest. So we definitely need to be inclusive in the language that we use and recognise that this is a complex issue. And that no two period experiences are the same.

Katie - So we've mentioned education, we've mentioned stigma, and cost is still a major factor in this problem. Are we going to see the end of the tampon tax, do you think?

Ema - Yep. So the government has committed to ending the tampon tax. That's the tax that sees period products as a luxury item, so there's a 5% tax on them. And so the government in the spring budget committed to the end of that, which is a big step forward in gender equality. And we should see that being removed from January, 2021. But it's important to recognise that won't go that far in tackling period poverty. It saves about 40 pounds per woman over her lifetime. And so we need to see more action towards ending period poverty, even though that is a forward step.

Katie - Caroline, we started the topic of periods by talking to you about some of the basic biology. And now I want to come to you for the close. Is there anything else that you would like to add?

Caroline - Hannah brought up a very good point about periods and the hormonal changes during the month. 90% of women will get some sort of changes in the run up to a period. So we all recognise a bit of breast tenderness, a bit of bloating. PMS and PMDD are just much worse, and often with severe depression as one of the symptoms. So if I had one key message from today, it would be that your periods should be entirely manageable. And if you are running your life around your periods, then your periods aren't normal.