Menstruation is the visible manifestation of cyclical, physiological uterine bleeding due to shedding of the endometrium[1]. It starts during puberty and stops permanently at menopause[2]. The first menstruation –menarche- occurs between 9 years and 16 years. Menstruation is the physiological process in a girl’s body and is an indication of normal growth and development[3]. In recent years, a trend toward earlier 

onset of menarche has been observed, sometimes as early as nine years. Therefore, sympathetic guidance and appropriate support for young girls experiencing menstruation are of paramount importance. Even though menstruation is a normal biological process, it is surrounded by cultural taboos and misinformation in many communities. Also, lack of awareness and poor menstrual hygiene can lead to health problems like reproductive tract infections (RTIs) and social consequences such as school absenteeism[4]. Inadequate menstrual hygiene management (MHM) practices among adolescent girls in underdeveloped and developing nations continue to pose challenges for girls themselves, their families, broader society and public health authorities. Menstruation related problems are widespread among adolescent girls in India. Menstrual abnormalities and disorders are frequently linked to physical, mental, social, psychological and reproductive issues[5].

Research has shown that there is a strong association between practices during menstruation and prevalence (reported symptoms) of RTIs. The prevalence of RTIs was more than 3 times higher among girls having unsafe and unhygienic menstrual practices[6] and various surveys suggest that poor management results absenteeism in school, distraction in studies and disengagement in other activities[7]. Effective MHM is vital to enable women and girls to participate in daily life with dignity, comfort and confidence[8]. It encompasses Hardware intervention which includes the provision of absorbents or improved water sanitation and Software interventions which address deficit in knowledge of menstruation and management by providing education[9]. According to a study, although initially only 34% girls were aware that menstruation is a normal process, the number increased to 80% after giving them health education[10]. This observation highlights the importance of Health Education Programs in schools focusing mainly on menstrual hygiene and reproductive health among both adolescent girls and boys.

Thus, the present study aims to assess the awareness and practices related to menstrual hygiene among school going-girls aged 12-18 years in Sindghudurg district, Maharashtra. The findings are expected to identify existing knowledge gaps, behavioural patterns and their implications for health and education, thereby informing strategies for improved MHM in school settings.

Study design: A cross-sectional observational study.

Ethical approval: The study was approved by the Institutional Ethics Committee.

Study population: This study was conducted among the young school going girls from 7th to 12th grade mainly in the age group 12-18 years attending government or private schools in Sindhudurg district of Maharashtra, who have attained menarche and who are willing to participate in the study. 

Inclusion criteria

Exclusion criteria

Sampling procedure

A two-stage cluster sampling method was employed: First, the accessible schools (both government and private) in Sindhudurg district were selected by simple random sampling and then the eligible girls (aged 12–18 years who have attained menarche) within selected schools were chosen by simple random sampling from class lists.

Sample size

As per one study [11], taking the prevalence rate of satisfactory menstrual hygiene practices to be 80%, using the formula Z²P(1 -P)/D² with 95% confidence limit, 5% absolute error, and 10% non -responsive rate, the sample size came to be 284.   

Data Collection

After obtaining permission from the principal and with the consensus of class teacher, time and date of data collection was planned accordingly. Informed consent was obtained via school authorities and assent from participants. Data was gathered using a predesigned and prevalidated questionnaire that included questions about menstrual awareness. Each interview was started with greetings and explanation of the questionnaire which was made available in both Marathi and English (or regional language when required).   All the data collected were kept fully anonymous and privacy was maintained while conducting the interviews. A health education session was also conducted on menstrual hygiene and its significance after collecting the data from the required participants. Data of all the participants was kept confidential.   

Statistical analysis

The collected data from the interview was entered in an Excel sheet and analysis was done using MS Excel software. For continuous variables like age, mean with standard deviation was calculated. Categorical data like menstrual material used, frequency of changing menstrual material used, and place of disposal of material at home was presented as proportion.

Study duration

Three months (From November 2024 to January 2025).

A total of 284 girls participated in the study. [Table. 1] shows distribution of participants by age and grade. The Mean age of participants was 15.05±1.20 years (range 12–18) and the mean age at first menstruation was 12.5±1.20 years (range 12–18). Most of the participants (83.8 %) were from grade eight, nine and ten. Almost 99 % girls have someone (either mother, female relative or friend) whom they would feel comfortable asking for support regarding menstruation.

As per [Table. 2], showing knowledge about menstruation among participants, significant number of girls (32%) had not received any information about menstruation before menarche, meaning roughly one-third were unprepared at first period (68% had prior knowledge). 83% understood the physiological reason for menstruation, while 17% did not. School-based education was high: 96.5% reported being taught appropriately about menstrual hygiene in school, and 95% had been taught about menstruation at home. About 10% girls believed menstruation was a curse or that menstrual blood was impure, while 90% disagreed. Only 72% correctly identified the vagina as the source of menstrual blood; 24% said “don’t know” and 4% incorrectly said “urethra.” This indicates about a quarter of girls had confusion about basic menstrual physiology.

[Table. 3] shows hygiene practices during menstruation among participants. Nearly all girls (96.1%, 273/284) used disposable sanitary pads; only 1.1% used cloths, 1.8% reusable pads, and 1.1% absorbent underwear. When asked what they would prefer if given an option, 85% chose single-use pads, 6% menstrual cups, 3.5% reusable pads, 6% absorbent underwear, and the remainder “other”. During their last period, the number of pad changes per day was mostly ≥ 3 times/day (68.3 %), meeting recommended hygiene frequency while 27.5 % reported twice and 4.2 % reported one time a day. Hygienic bathing and cleaning were common: 100% reported bathing during menstruation, with 47% washing genitals ≥3 times per day and 32% twice per day. Hand washing with soap before/after handling menstrual material was nearly universal (283/284, 99.6%). However, soap use on genitals was lacking: 40% never used soap on genital wash, 31% sometimes, and only 29% always did so. Thus, a substantial proportion did not regularly clean with soap, which could pose infection risks.

Disposal of used pads was mostly done by burning (57% of girls). Others disposed in household garbage either into a latrine toilet bin (25%) or outside bin (18%). Only 2% reported disposing pads without wrapping; 98% wrapped pads (mainly in paper (66%) or plastic (27%)). Among girls who reused cloth and absorbent underwear (n≈6), 73% soaked/wash with soap and 75% always sun-dried or ironed them for sterilization.

According to [Fig. 1], school absenteeism was reported by 11% of girls (32/284) who often missed school during menstruation; 89% never missed. Those missing school primarily cited discomfort or lack of facilities. Despite overall good school education on menstruation, any absenteeism highlights remaining barriers. About 64% reported genital itchiness during periods (mostly “sometimes”), and 3.5% reported a history of reproductive tract infection (RTI); 96.5% had never had an RTI.

This study was carried out to assess the awareness and practices related to menstrual hygiene among 284 young school-going girls aged 12-18 years in Sindhudurg district, Maharashtra. The mean age of the participants was 15.05±1.20 years (range 12-18) and the mean age at first menstruation was 12.5±1.20 years (range 12-18). In our study, 68% of participants had heard of menstruation before experiencing menarche. This finding is similar with studies carried out by Sarangi S et al. in Delhi (70%) and Kaliappan I et al. in Coimbatore (65%) [12, 13]. This proportion also parallels international data from Kenya (72.8%) and Nepal (66%)[14, 15]. The existence of prior knowledge suggests that awareness programs and peer discussion may be reaching a significant proportion of girls. However, the finding that 32% participants were unaware prior to menarche highlights the continuing gaps in early reproductive health education. Insufficient knowledge before the onset of menstruation can contribute to the feelings of anxiety, fear and confusion, often leading to negative psychological experiences during menarche. Implementing early, age-appropriate reproductive health education ideally integrated within school curricula and community based programs can help normalize menstruation as a natural physiological process rather than a source of shame or embarrassment. In this study, 83% of participants correctly recognised menstruation as a physiological and natural process. These findings are in line with previous Indian studies conducted in West Bengal (86%) and Maharashtra (71%) and comparable with study from Ethiopia (78%) [16-18]. These findings suggest that school-based education and media have played a helpful role in spreading awareness about menstruation. 

Regarding myths and misconceptions, only 10% of participants believed that menstruation to be a curse or that menstrual blood was impure comparable to sub-Saharan Africa (8-14%)[19]. While the study carried out by Lonimath A et al. found that 27.4% of girls believed menstrual blood was impure[20]. These findings suggest a gradual cultural transition towards greater menstrual awareness; however strong social stigma still makes it hard to talk openly and learn about it. About 72% girls correctly identified the vagina as the outlet of menstrual blood, similar to findings from urban Indian schools (70-75%) and Ghana (68%)[21, 122]. Despite this, confusion persisted among 28%, revealing partial understanding of reproductive anatomy. 

A remarkably high proportion (96%) of respondents reported using disposable sanitary pads, similar to rates reported from urban India (92-97%) and Ghana (96%)[12, 13, 23]. This contrasts with rural Indian data where usage remains between 60-70% and with Nigerian findings showing 88%[17, 24]. This disparity reflects the role of socioeconomic status, accessibility and awareness. About 68% of participants changed pads ≥3 times/day, meeting CDC-recommended hygiene standards[25]. These findings are consistent with findings from Delhi (65%) and Maharashtra (63.3%)[12, 26]. Frequent pad changes prevent microbial growth and infection, contributing to reproductive tract health. However the remaining 32% changing pads less frequently may face risks of infection and discomfort, emphasizing the need to reinforce hygiene practices through school health programs. Nearly half (47%) washed genitals ≥3 times/day, aligning with studies by Kadpatti MG et al. (46%) and Hussein J et al. (48%)[27, 28]. However, only 29% reported using soap consistently, which is concerning as poor genital hygiene can predispose individuals to infections. A study by Adhikari P et al. from Nepal (11%) further supports this challenge[15]. Barriers may include limited privacy, water availability and lack of awareness about proper washing techniques. Hence MHM programs must not only emphasize frequency but also quality of hygiene practices.

Burning was the most common method of sanitary pad disposal (57%) consistent with finding from rural India (61%), followed by disposal in household garbage (43%), similar to Gupta et al. (37%)[17, 29]. Although prevalent, these practices raise environmental concerns due to emissions from open burning and inadequate waste handling. None of the participants reported disposing of pads into latrine pits which is positive finding, as such practices can obstructs drainage systems and pose environmental risks. In contrast, other studies have reported latrine disposal leading to drainage blockages[18, 22, 23]. Establishing incinerators in schools and community facilities can promote safe, hygienic and environmentally sustainable menstrual waste management.

Menstrual-related school absenteeism was reported by 11% of participants, aligning with findings from various other studies[16, 23, 29]. The main causes included discomfort, poor sanitation and fear of staining and teasing. Such absenteeism hinders academic performance and reinforces gender disparities in education. Establishing menstrual-friendly schools with adequate water, sanitation and disposal facilities, along with teacher sensitization, can greatly improve girls attendance and confidence during menstruation. 

About 64% of girls reported genital itchiness and 3.5% had symptoms of RTI, consistent with study by Mathiyalagen P et al. linking poor hygiene to such issues[30]. Infections during adolescence can impact future reproductive health, highlighting the life-course approach that early hygiene practices shape long term well-being. Preventive education during adolescence is therefore crucial for sustaining reproductive health.

The majority adolescent school-going girls in our cross-sectional study demonstrated satisfactory awareness and hygienic practices regarding menstruation, still significant gaps remain in knowledge of reproductive physiology and consistent hygienic behaviours. Nearly one-third of participants were unaware of menstruation before menarche, and misconceptions such as perceiving menstruation as curse persisted among a minority. Even though almost everyone used disposable sanitary pads, it was reported that some participants didn’t change their pads often enough and didn’t clean their genital properly. School absenteeism, while comparatively low, highlights the persistent challenges presented by discomfort and insufficient facilities. These findings emphasize the importance of strengthening school-based health education, improving WASH infrastructure, installing pad disposing machines under government programs and promoting culturally sensitive awareness programs to ensure safe and dignified menstrual hygiene management for adolescent girls.

The data were self-reported, which may be affected by recall or social desirability bias, particularly for culturally sensitive topics. As the research was confined to a single district, the findings may not fully represent areas with different sociocultural settings. Moreover, the use of structured questionnaire limited the ability to explore deeper insides into attitudes, beliefs and stigma surrounding menstruation.

Funding: No funding sources.

Conflict of interest: None declared.