The invisible pain: why has the research on menstrual health been delayed?

Disclaimer: In this article, “people who menstruate” is used to refer to individuals who experience menstruation, regardless of gender identity.

“I see you’re a bit moody today. Are you on your period?”

Most people who menstruate have heard this question at least once in their lives. It is usually meant as a joke, a shorthand for emotional instability, irritability, or hormonal unpredictability. Yet behind this seemingly harmless remark lies another assumption: that menstruation is something women are expected to go through.

This article is not about one painful period. It is about why experiences remain so broadly shared, and what they reveal about the historical neglect of menstrual health in medical research and clinical practice.

The menstrual stigma

Throughout much of recorded history, menstruation has been surrounded by silence, misconceptions, and social stigma. Although the attitude toward it varied across cultures and historical periods, menstrual bleeding has often been framed as something to conceal rather than discuss, shaping the way menstruating individual’s bodies and, consequently, their pain have been treated and understood.

The menstrual stigma, the set of prejudices and behaviours surrounding an individual’s menstruation, is a concept often set aside, yet it deeply affects the perception of the phenomenon. An interesting study conducted by Roberts, Goldenberg, Power, and Pyszczynski in 2002 presented participants with two scenarios. They either saw a woman accidentally dropping a tampon from her bag or a hair clip, and the results revealed that the ones who saw the tampon falling mainly decreased liking for her, along with a tendency to consider her less competent and avoid sitting next to her. If menstruation cannot be avoided, yet scarce, unreliable information plays a subtle role in keeping the framing of a natural process as such. 

The stigma affects a woman’s everyday life, from work up to family and private life, feeding stereotypes that only boost the normalisation of the menstrual cycle. Generally, when feeling pain is perceived as normal (for example when doing an endurance run, when getting a tattoo), it becomes normalised. The menstrual stigma and all the stereotypes built around it, together with the already cited misinformation, create a reality in which period pain is completely normal, a condition valid both for those who see menstruation from the outside and for those who live it. 

Normalisation clashes with the recognition of pain experience as a legitimate health concern, because with the right acknowledgment individuals, in our case women, gain accountability and consequent “privileges” (such as days off from work or school and targeted medical attention).

When pain is not “normal”

Dysmenorrhea, the medical term for pain associated with menstruation, is one of the most common menstrual health complaints among women of reproductive age. Beyond the characteristic abdominal cramps, symptoms may include nausea, fatigue, diarrhea, headaches and, in severe cases, vomiting or fainting. Clinically, dysmenorrhea is generally divided into two categories: primary dysmenorrhea, in which menstrual pain occurs in the absence of an underlying pelvic pathology, and secondary dysmenorrhea, in which painful menstruation is associated with an underlying condition affecting the reproductive system.

Its prevalence, however, is difficult to quantify precisely. A recent systematic review gathering 336 studies,  estimated a pooled worldwide prevalence of dysmenorrhea of 71.3%, although estimates varied considerably across populations and geographical regions. Prevalence is particularly high in some settings, reaching 89.6% in Central America and 97.7% in Sri Lanka. The review also found substantial differences across population groups, with prevalence reaching 78.4% among university students. Importantly, extremely high heterogeneity was reported, and the certainty of the evidence was considered very low. Nevertheless, the consistently high prevalence reported across different populations points to the substantial global burden of menstrual pain and the need for greater attention to its diagnosis, treatment and wider social consequences.

Usually, individuals who menstruate are taught that pain is normal, that it shall be endured as a natural part of their lives. Endometriosis provides a particularly clear example of the consequences of the normalisation of menstrual pain. 

By affecting an estimated 6–10% of menstruating individuals of reproductive age, endometriosis is a chronic inflammatory condition in which tissue resembling the endometrium grows outside the uterus. This can cause severe dysmenorrhea, along with chronic pelvic pain, painful intercourse and, eventually, infertility. Despite its prevalence, endometriosis remains a difficult condition to diagnose, partly because its symptoms can resemble those of other conditions and partly because severe menstrual pain is still frequently perceived as a normal feature of menstruation. Patients may therefore spend years seeking an explanation for symptoms that are repeatedly dismissed by the medical staff, misattributed or treated without addressing their underlying cause. 

Diagnostic delays may have consequences that go beyond physical health, affecting psychological well-being, quality of life, work and economic security. Endometriosis thus illustrates a broader problem: when menstrual pain is assumed to be an inevitable part of life, the boundary between a common physiological experience and a symptom requiring medical investigation can become blurred.

Insufficient research on menstrual health

The experiences of women with menstrual disorders must also be understood within the broader framing of gender health gap. The persistence of disparities in the way women’s health is researched, diagnosed and treated, may lead women to experience longer diagnostic delays for a range of conditions, while their reports of pain are more likely to be underestimated, a phenomenon often described as “pain bias.” Such disparities are not limited to clinical practice. Women have historically been underrepresented in medical research and clinical trials, with wide gaps in knowledge about conditions that disproportionately or exclusively affect them.

Menstrual health represents a clear-cut manifestation of the problem. Despite menstruation being a recurring physiological process for a consistent part of the population, basic information about menstrual cycles, including length, regularity, duration and intensity of bleeding, is not collected periodically in many healthcare settings nor research contexts. As a result of this missing collection, the menstrual cycle often remains an underused source of information about women’s health. The issue, therefore, is not simply that some menstrual conditions are difficult to diagnose but, plausibly, it is also that the systems designed to study and treat health have not consistently treated menstruation as a relevant indicator of health in its own right.

As of today, the average spending directed toward financing menstrual health accounts for less than 1% of total healthcare expenses globally. The obstacle to reaching a fair economic engagement, lies in the acknowledgement of the phenomenon itself. Up until the moment institutions, social groups, families, and individuals comfortably give a face to the phenomenon, setting aside the shadowing presence of menstrual stigma, slow progress can be made. Acknowledgement empowers, creates responsibilities and new paths toward fairness.

The concrete consequences

The consequences of menstrual symptoms extend well beyond physical discomfort. For many people who menstruate, severe symptoms can interfere with education, employment and everyday activities, creating a social and economic burden often difficult to see. 

An important distinction has to be made between absenteeism and presenteeism. If the former refers to missing work because of symptoms, the latter describes continuing to work despite them, often with reduced capacity or productivity. The latter is particularly relevant when considering menstrual health as it may remain largely invisible.

A consistent study conducted in the Netherlands, published in 2024, found that 13.8% of participants reported being absent from work because of menstrual symptoms, while 84% reported working despite their symptoms and experiencing some degree of productivity loss. Across the year, participants reported an average of 23.2 days affected by reduced productivity. Other researchers similarly suggested that menstrual symptoms may affect work performance, with severe premenstrual and menstrual symptoms associated with reduced relative work performance during the perimenstrual period. Importantly, factors such as work-life balance, working hours and psychological distress were found to influence the relationship between menstrual symptoms and work performance.

Such findings reveal a dimension of menstrual health that is easily and often overlooked when the discussion is limited to medical symptoms. The consequences of severe menstrual pain are not confined to the days on which symptoms occur. Reiterated reductions in productivity, absences from work and difficulties in maintaining employment may accumulate over time. Income can be affected, career progression and the ability to fully engage in social and professional life. The economic costs associated with menstrual symptoms are therefore only one part of a wider burden, one that becomes particularly significant when pain is treated as an inevitable inconvenience rather than as a health issue requiring appropriate attention and support.

Some takeaways

The recognition of the disparities has nevertheless begun to translate into institutional action. Considering as an example the European level, gender equality is increasingly incorporated into health and research policies. The EU4Health programme, for instance, seeks to take into account the different health needs, risks and barriers experienced across genders, while the Horizon Europe programme strengthened the consideration of gender equality within research and innovation. The European Parliament has, likewise, increasingly addressed women’s health, including through resolutions on sexual and reproductive health and research, along with the consultation focused on women’s health launched in 2025 within its Committee on Public Health.

Such developments indeed suggest a gradual shift in how health inequalities are being understood nowadays. Yet institutional recognition does not automatically translate into better diagnosis or treatment, nor in a change of perspective by society. Menstrual health shall be incrementally treated as part of overall health rather than as an exclusively reproductive concern.

Menstruation is a physiological process, but the pain associated with it shall not automatically be considered a physiological inevitability. The distinction is crucial. When pain is repeatedly normalised, the consequences extend beyond the individual sphere: delayed diagnosis, unmet healthcare needs, impact in education, income and more can all be put at stake.

The problem we are presented with, not simply a lack of medical solutions, but it is also an issue of what medicine and society have historically considered worthy of attention. The under-representation of women in research, the limited collection of menstrual data, the persistence of pain bias and the taboo surrounding menstruation contributed to create a system in which menstrual pain can easily remain invisible as it is so common. Recent institutional and scientific efforts suggest that this is beginning to change yet, recognition must be accompanied by sustained research, better clinical habits and greater willingness to listen to who is suffering.

Perhaps, then, the answer to the question “Are you on your period?” should not be a joke about moodiness, but rather a reminder that menstruation is a health experience, that pain shall not become invisible simply because millions of people experience it. No one should have to prove that their suffering is abnormal before it is considered worthy of investigation.