Pediatricians’ knowledge, attitudes and practices surrounding menstruation and feminine products

Subjects

A total of 2500 US pediatricians were selected from the AAP’s “Member Directory” using a geographically stratified sampling approach, with 50 pediatricians per state invited to participate. Pediatricians in each state were selected randomly, limiting recruitment to pediatricians who did not belong to AAP Committees, Sections or Councils to specifically target pediatricians providing primary care.

Pediatricians were emailed an explanation of the study and a link to an online questionnaire created through Qualtrics software (Qualtrics LLC, Provo, UT, USA). As an incentive to participate, pediatricians were informed that they would receive a “Feminine Hygiene Fact Sheet” upon completion of the questionnaire. This clinical resource for healthcare providers, developed by the researchers, summarized relevant AAP/ACOG recommendations and provided correct answers to all factual questions in the questionnaire. Two follow-up emails were sent, with the final email offering access to an additional clinical online resource (“ADHD Medication Guide”) to pediatricians who completed the questionnaire [4]. This second incentive was intended to motivate pediatricians who may not have a strong interest in feminine hygiene. All responses were anonymous and no personally identifying information was obtained. This study was approved by the Institutional Review Board of [Northwell Health].

Instrument

The anonymous 5–7 min online questionnaire was developed by the researchers based on AAP/ACOG recommendations and specific concerns raised by a focus group of seven females aged 19–23 years who participated in structured conversations regarding their early experiences with menstruation. The initial questionnaire was pilot-tested on seven physicians (two pediatric residents, five primary care pediatricians including an adolescent medicine specialist) for clarity and content, and subsequently revised to incorporate feedback. The final 53-item questionnaire can be found in the Appendix.

Section Introduction (11 items, 5-point Likert scales) assessed pediatricians’ practices related to the evaluation and discussion of the menstrual cycle, as well as their self-rated knowledge and attitudes regarding the discussion of menstruation. These items were developed based on specific AAP/ACOG recommendations, including: “Clinicians should educate girls and their caretakers (e.g. parents or guardians) about what to expect of a first menstrual period”; “Once girls begin menstruation, clinicians should ask at every … visit for the patient’s first day of her last menstrual period and the pattern of menses”; “Young females … should be instructed on the use of feminine products and on what is considered normal menstrual flow”; and “It is important for clinicians to have an understanding of the menstrual patterns of adolescent girls, the ability to differentiate between normal and abnormal menstruation, and the skill to know how to evaluate the adolescent girl patient” [1], [2].

Section Methods (15 items, 5-point Likert scales) evaluated pediatricians’ self-rated knowledge of feminine products and patient-education practices surrounding these products. Items in this section were developed based on the AAP/ACOG recommendation that young females should be “instructed on use of feminine products” [1], [2]. The first nine items asked pediatricians to rate their knowledge of three feminine products (tampons, menstrual pads, menstrual cups) and their likelihood of discussing each product with patients in early adolescence (12–13 years) and mid-adolescence (16–17 years). These specific products were selected based on their popularity and because they are the three products mentioned on ACOG’s official menstrual-education page, “Your First Period (Especially for Teens)” [5]. An additional six questions regarding pediatricians’ likelihood of discussing specific tampon-related topics identified as important by the focus group were also included.

Section Results (14 items, multiple-choice) assessed pediatricians’ knowledge regarding menstruation and safe tampon usage. Knowledge-based questions about menstruation (eight items) were based directly on information the AAP and ACOG deemed necessary for physicians to properly evaluate the menstrual cycle [1], [2]. Knowledge-based questions about tampons (six items) were developed using alternative sources, as AAP/ACOG recommendations do not specify what information pediatricians should know regarding tampons. Specifically, three questions were based on information identified by the Food and Drug Administration (FDA) as important for consumers to know to safely use tampons (maximum time tampon can be left inserted; safest tampon absorbency; tampon use when sleeping) and three were based on areas identified by the focus group as important (minimum age for tampon use; relationship between tampons and the hymen; tampon use when swimming) [6].

The final section (13 items) solicited pediatricians’ demographic information, including gender, race/ethnicity, state and region of residence and number of years in practice. Pediatricians also reported the setting (private practice, clinic, hospital-based) and surrounding population density (urban, suburban, rural) of their practice.

Statistical analysis

Responses to items in sections 1 and 2 were scored as 5-point Likert items. Distributions of responses were compared across gender using the two-sided Mann-Whitney U test, which has been found to be Type I error robust at an alpha of 0.05 for 5-point Likert items [7].

Responses to menstruation-related and tampon-related items in section 3 were scored on a binary system for correctness. Results for menstruation-related items were summed to create composite scales, as were results for tampon-related items. Differences between genders for these scales were identified using the two-sided Welch’s two-sample t-test. Multivariate logistic regression was used to explore associations between correctness of responses to individual items and gender.

Associations between measured knowledge concerning menstruation/tampons and self-rated knowledge/practices concerning menstruation/tampons were identified using proportional odds logistic regressions, controlling for gender. All analyses were performed using the statistical software R, version 3.5.2 (R Foundation), and package MASS, version 7.3–51.2 (R Core Team, Vienna, Austria; MASS, Springer, New York). p-Values less than 0.05 were considered statistically significant.

The menstrual cycle: clinical practices, attitudes and self-rated knowledge

In total, 75.3% (n = 348) of pediatricians reported that they provide anticipatory guidance surrounding menstruation to “most” or “almost all” pre-menarchal patients, and 62.1% (n = 287) reported that they educate caregivers of “most” or “almost all” pre-menarchal patients about what to expect of menarche. While 70.8% (n = 327) felt this anticipatory guidance was “very” or “extremely” important, the majority (58.2%, n = 269) were “not at all” or only “slightly” familiar with AAP guidelines surrounding anticipatory guidance for menstruation. With respect to post-menarchal patients, 66.9% (n = 309) of pediatricians reported that they discuss menstruation with “most” or “almost all” post-menarchal patients and 78.6% (n = 363) believed it was “very” or “extremely” important to do so. The majority reported that they “very often” or “almost always” ask post-menarchal patients about their pattern of menses (94.4%, n = 436) and the date of their LMP (71.6%, n = 331). Overall, 60.4% (n = 279) rated themselves as “very” or “extremely” knowledgeable about menstruation (Table 2).

Compared to female pediatricians, male pediatricians were less likely to provide anticipatory guidance about menstruation to pre-menarchal patients (3.65 vs. 4.10, p < 0.001) and their caregivers (3.35 vs. 3.76, p = 0.002), and rated the provision of anticipatory guidance as less important (3.65 vs. 3.98, p < 0.001). Similarly, male pediatricians were less likely to discuss menstruation with post-menarchal patients (3.55 vs. 3.97, p = 0.005) and felt that doing so was less important (3.78 vs. 4.13, p < 0.001). They were also less likely to evaluate the menstrual cycle by asking patients about their pattern of menses (4.30 vs. 4.76, p < 0.001) and the date of their LMP (3.61 vs. 4.22, p < 0.001) (Table 3). Finally, male pediatricians felt less knowledgeable about menstruation (3.29 vs. 3.85, p < 0.001), with only 32.0% indicating they felt “very” or “extremely” knowledgeable about menstruation compared to 68.1% of female pediatricians (Table 2 and Table 3).

Feminine products: clinical practices and self-rated knowledge

Many pediatricians reported that there was a “very low” or “low” likelihood they would discuss tampons, pads or menstrual cups with 12–13-year-old patients (respectively, 51.9%, n = 240; 33.5%, n = 155; 91.8%, n = 424) or 16–17-year-old patients (respectively, 34.4%, n = 159; 39.8%, n = 184; 89.2%, n = 412). A substantial percentage also reported that they “almost never” or “rarely” discuss tampon insertion (61.9%, n = 286), how often to change tampons (35.5%, n = 164), risks associated with tampons (36.4%, n = 168), tampon use when sleeping (61.9%, n = 286), tampon use when swimming (50.9%, n = 235), and the relationship between tampons and the hymen (76.6%, n = 354). Only a minority of pediatricians felt they possessed “high” or “very high” knowledge about tampons (43.1%, n = 199), pads (45.7%, n = 211) or menstrual cups (8.4%, n = 39) (Table 4).

Male pediatricians were less likely than female pediatricians to discuss tampons and pads with 12–13-year-old patients (respectively, 2.25 vs. 2.63, p < 0.001; 2.57 vs. 3.09, p < 0.001) and with 16–17-year-old patients (respectively, 2.52 vs. 3.09, p < 0.001; 2.55 vs. 2.85, p = 0.03). They were also significantly less likely to discuss each of the six areas related to tampon usage and safety. No gender differences were noted with respect to likelihood of discussing menstrual cups. Overall, male pediatricians had lower self-rated knowledge scores for tampons (2.53 vs. 3.52, p < 0.001), pads (2.63 vs. 3.62, p < 0.001) and menstrual cups (1.54 vs. 1.95, p < 0.001) (Table 3).

Menstruation and feminine products: measured knowledge

On average, pediatricians correctly answered 66.9% (5.35/8) of knowledge-based questions about menstruation and 66.7% (4.00/6) of knowledge-based questions about tampons. With respect to menstruation, less than half of pediatricians were knowledgeable about the Tanner stage at which menarche occurs, average length of bleeding of menarche, and whether a medical evaluation is necessary if periods occasionally occur more than 90 days apart. With respect to tampons, pediatricians were least knowledgeable about the maximum time tampons can safely be left inserted (47.2% correct) (Table 5). An increase in composite score on menstruation-related knowledge questions was not a significant predictor for an increase in self-rated knowledge about menstruation [adjusted odds ratio (aOR), 1.08; 95% confidence interval (CI), 0.94–1.24], the likelihood of discussing menstruation with 12–13 year olds (aOR, 1.09; 95% CI, 0.95–1.25), or the likelihood of discussing menstruation with 16–17 year olds (aOR, 1.04; 95% CI, 0.91–1.19). However, a 1-point increase in composite score on tampon-related knowledge questions was a significant predictor for higher self-rated knowledge about tampons (aOR, 1.29; 95% CI, 1.14–1.46), higher likelihood of discussing tampons with 12–13 year olds (aOR, 1.27; 95% CI, 1.25–1.43), and higher likelihood of discussing tampons with 16–17 year olds (aOR, 1.14; 95% CI, 1.01–1.28).

Male pediatricians achieved a lower average composite score on knowledge-based questions regarding menstruation (63.7% vs. 67.8%, p = 0.02) and tampons (51.7% vs. 70.7%, p < 0.001) (Table 5).