It’s time for the water, sanitation and hygiene sector to hear about the perimenopause
Menstrual hygiene management (MHM) is increasingly on the agenda of the water, sanitation and hygiene (WASH) sector, especially as it concerns young women and girls. But what about the differing WASH needs of women as they reach menopause? On World Menopause Day, Amita Bhakta shares what she learned from her conversations with menopausal women in Ghana.
Watch our short interview with Amita about perimenopause and WASH:
The WASH sector strives towards inclusion for all, leaving no one behind – it is no good only providing services for part of the population. In recent years, menstrual health and hygiene, especially for girls going through puberty and beginning to menstruate, has received much more attention than ever before. But older women going through the menopause have not been considered as much.
The perimenopause, often known as ‘the change’, is the time approaching the menopause – the point in a woman’s life at which periods permanently cease. It is a natural biological process, with symptoms that are often not visible to other people, including irregular, heavy menstruation; hot flushes (sensations of heat starting in the chest and spreading to the face); sweating and incontinence.
The WASH sector has, until now, neglected the topic and its effects on women’s specific needs. WASH professionals have been largely unaware of these issues because, in most societies, regardless of culture or location, women’s reproductive and sexual health issues continue to be surrounded by taboos, stigma or shame, forcing women to meet their menopause-related WASH needs and changes to their bodies secretively.
Talking to the experts gives invaluable insights
When I started my PhD research into women’s WASH needs, I couldn’t find any practical advice for older women. So, I decided to go to the experts – the women having to deal with ‘the change’ with limited access to clean water and decent toilets. This research has begun to explore the WASH needs of women going through the change for the first time.
"When I was about to stop menstruating, I bled very heavily, and it came in clots." – Berta, La, Accra.
In her home in an urban Ghanaian compound, Berta told me how her menstruation changed when she was 45. One month she had heavy bleeding during her menstrual period, then she did not menstruate for several months, then started menstruating again. This cycle repeated several times until her periods finally stopped for good.
This was similar to the experiences of other women living with limited WASH access in the low-income communities of La, Accra and Kotei, Kumasi in Ghana, whose stories I gathered through interviews and maps of the communities that the women drew in groups. The stories gave new insights into the WASH experiences of the increasing number of women going through the perimenopause in the ageing global south.
Adaptating to the menopause can be expensive and limiting
The women I spoke to tried different MHM techniques to manage the substantial volumes of blood flow (up to 80ml, or six tablespoons) they were experiencing during menstrual periods. MHM during the change requires adaptation. Commercial, disposable sanitary pads are expensive, and buying them on a low income is challenging. But thin pieces of menstrual cloth, which are often the alternative, can become soaked very quickly. Fearing leakage and blood-stained clothes, women who could afford to do so used both pads and cloths:
"I had to do that to help soak up the blood. I use both because of heavy bleeding, else the pad alone would have been OK. I changed three times in a day and that was because I supported the pads with the cloth." – Abla, Kotei, Kumasi.
They needed to be prepared for menstruating at irregular times:
"In the third month, I expect to menstruate, so if I have to travel, then I make sure I have my menstrual materials ready. Usually I don’t often go too far from home." – Abla¸ Kotei.
Perimenopause symptoms go beyond bleeding
I learned that managing blood was only a part of women’s hygiene needs during perimenopause. Our conversations identified other blind spots in the WASH sector, particularly a lack of consideration for the need for increased bathing and laundry. Bathing often – to cleanse after heavy bleeding, incontinence and sweating – was critical to the women. One woman bathed three times a day:
"Because of the menstruation...on a normal day when I am not menstruating I bathe once." – Felicia, La.
The women had to shift their routines too. Despite fears for their safety, they began going out to their compound bathhouses to wash in the dead of night:
"I sweat at night sometimes and when that happens, I clean myself with a wet towel and at certain time, I enter the bathhouse to pour water on myself." – Mansa, Kotei.
They also needed to regularly change clothes stained with blood, sweat and urine from incontinence, which increased laundry:
"…when you are menstruating, you can soil your cloth at any time and that increases my laundry." – Efua, Kotei.
"Yes, sometimes when I finish urinating, I feel my panty is wet." – Kisi, La.
Bathing and laundry infrastructure in the communities I visited were not designed to meet perimenopausal women’s needs. For example, disposing of blood-stained wastewater after bathing or laundering onto the open street because there is no drainage, to be seen by all, in a society where menstruation and the menopause are taboo, was not ideal.
The women’s ageing-related joint pains during perimenopause added further challenges to using existing bathing and laundry infrastructure. Facilities lacked handrails and seats and were not user friendly, so were difficult for perimenopausal women with joint pains to use.
How do we work towards inclusive solutions?
It is fantastic to see that MHM has such a high profile now in the WASH sector, but what is suitable for meeting the needs of schoolgirls is not suitable for perimenopausal women. We need to listen to perimenopausal women and raise awareness of their particular WASH requirements, to ensure our WASH work is responsive to and inclusive of people at all stages of their life course.
User-friendly and universally accessible bathing, laundry and toilet infrastructure, covered drainage, a regular and accessible water supply and appropriate sanitary disposal options in household and community facilities could begin to address the different WASH requirements of perimenopausal women – along with the requirements of people with similar needs.
Nobody would disagree that women’s perimenopausal WASH needs should be considered. Yet, even for me as a researcher and a woman, it was challenging to get the stories, and it was hard for women to share their experiences. We need to work to break the silence around the menopause.
Effective communication techniques, hygiene promotion and tailored seminars can both help women to understand the perimenopause and also allow their voices to be heard by the WASH sector, so the required services can be delivered. We need to break the silence and get the WASH sector discussing this issue.
Let’s start the conversation
How have you or the women you know coped with the change? How did you discuss it? Until we start talking about unspoken issues we won’t be able to ensure WASH for all by 2030. Let’s not leave the perimenopause behind.