Menstruation is a definitive experience of a woman’s life, and an indicator of her health.
So why has period blood or menstrual fluid been largely under-researched?
Today, On Point: How periods unlock health secrets beyond the female reproductive system.
Guests
Dr. Bethany Samuelson Bannow, doctor and researcher at Oregon Health and Science University. She specifically researches the anti-coagulant properties of menstrual fluid.
Also Featured
Kate Clancy, biological anthropologist and professor at the University of Illinois at Champaign-Urbana. Author of Period “The Real Story of Menstruation.”
Emily Hoppes, technical adviser and researcher at FHI 360, specializing in the development of innovative contraception.
Dr. Sara Naseri, founder of Qvin, which makes the QPad, a diagnostic menstrual pad that has FDA approval.
Transcript
Part I
MEGHNA CHAKRABARTI: Emily Hoppes is a researcher for FHI 360, an international NGO. Her work focuses on family planning and menstrual health. It’s a field she’s professionally committed to and personally connected with.
EMILY HOPPES: I have had severe menstrual pain ever since I started my period when I was 13 years old. And that was a really hard thing to experience as an adolescent, and it only progressed and got worse as I got older and I had a really fraught relationship with the health care system.
When you’re 13, you’re still going to a pediatrician. They don’t have expertise in menstrual health. I wasn’t taken seriously. Even though I told doctors that I passed out from the pain, that I was throwing up because I was in so much pain. A lot of people just said, that’s what menstruation is, your period is hard.
You get pain, you have symptoms, and you just have to deal with it. And that’s ‘part of being a woman,’ in quotes. And that sort of progressed for a long time. I went to college, and I tried to manage my symptoms there and it was really hard, and I eventually had a health care provider who told me that contraceptives would help manage my symptoms, and that did help for a while.
When I was 30, I finally went into a doctor who took my pain and my symptoms really seriously and went and did laparoscopic surgery to try and diagnose to see if I had endometriosis. They didn’t actually find much. They found like some adhesions, which means your colon is stuck together, and they removed those.
But she said that I probably have something that’s called adenomyosis, which you can’t diagnose unless you get a hysterectomy, and they examine your uterus. There are no tools to diagnose it. And I suffer through this, and I bandage my symptoms and I found a lot of good health care providers on my way, but it took years, it took decades to put together a plan to manage my symptoms.
And I’m still in limbo. I still don’t have a diagnosis. Because we don’t have the tools to give me a diagnosis and to really get at the heart and the core of my symptoms and my issues.
CHAKRABARTI: Emily Hoppes. We’ll hear more from her later in the hour, because her situation still remains a little bit up in the air. One important reason for that is that when it comes to menstrual health, the field still has a long way to go in developing tools to make better, more accurate diagnoses. Like other aspects of women’s health, menstrual health has suffered from a paucity of research and funding for that research.
But that could be changing, because recently it’s been discovered that menstrual fluid, mostly considered a waste product of menstruation, if it’s ever really considered at all, that fluid can contain significant amounts of information about a woman’s health. In fact, new research into menstrual fluid could unlock some medical mysteries, such as why Emily Hoppes has experienced so much pain for so long. Let’s start with Dr. Bethany Samuelson Bannow. She’s a specialist in adult hematology for menstruating and pregnant women and a professor at Oregon Health and Science University.
Dr. Bannow, welcome to On Point.
DR. BETHANY SAMUELSON BANNOW: Thank you. Very happy to be here.
CHAKRABARTI: Okay, so first of all, can you describe to me if you have seen a change in interest around research regarding menstrual fluid, say, in the past five years or so?
BANNOW: Yes, that’s a great question. I think I have. I see the interest really coming almost more from the public sector. It was really quite fascinating. We published an article a year or 2 ago now looking at the absorbency of different menstrual products for menstrual blood, so we can better quantify how much folks are bleeding.
And it went viral on the internet, which was just fascinating to me. I didn’t really expect that to happen at all. But it does show that the public, I think, is really interested in menstrual health and understanding more about that. Certainly, the increased funding for women’s health in general, through the Biden administration, is very exciting to those of us in menstrual science. None of that has been earmarked for menstrual health yet. But I’m also seeing some interesting things in the tech sector. People looking at using menstrual blood and pads and things like that to make diagnoses, for example, measuring blood sugar.
So I do think that there is some progress being made. It hasn’t made it necessarily all the way into grant funds yet, but I’m hoping it’ll get there.
CHAKRABARTI: That’s interesting. Because in fact, it was the increased funding for, like you said, Silicon Valley tech startups that are trying to come up with new, let’s say, diagnostic tools that would look at menstrual fluid.
That’s one of the things that caught our attention, right? Because usually where money goes that means there’s some interest there. We want to understand why. So before we get to that, and understand a little bit more about this change in even how menstrual blood is, or menstrual fluid is seen, in terms of its importance as not just a diagnostic tool, but as a product of a woman’s natural health cycle. Let’s do a little bit of 101, doctor, if we could. Because, look, as I said, at the beginning of the show, for women who menstruate, most often, it’s just like the waste product of your period and you just want to get rid of it.
But it’s actually quite, menstrual fluid is quite complex. So it’s more than just blood, right?
BANNOW: That’s absolutely correct. Yes.
CHAKRABARTI: So tell me more. What constitutes menstrual fluid?
BANNOW: Yeah. If I could go back a little bit to basics, just about the menstrual process, I think that helps a little bit.
The idea behind menstruation is that the shedding of the lining of the uterus, and that develops on a monthly basis, about every 28 days it builds up over the course of that 28-day cycle. And then what we see is actually this very b3lood rich tissue all of a sudden has its blood supply cut off.
The hormone progesterone drops in the body. The special blood vessels in the uterus really constrict down. And that causes the death of all of those cells, all of that tissue lining the uterus. This is of course, if a fertilized egg is not implanted, it’s very different if a fertilized egg is implanted.
But assuming that it’s not implanted, then all of that lining, including cells, including some blood, is shed. But it also passes through the cervix. And the cervix has some mucus around it, which is important for conception actually, whether sperm can penetrate it or not. And then it passes through the vagina, which also has its own secretions.
So there’s a combination of a little bit of blood, the endometrial tissue and then all of those other secretions as it passes into or out of the body.
CHAKRABARTI: Okay. So let’s take a look at each one of these in a little bit more detail. Because the endometrial tissue itself, during a woman’s monthly cycle, as you said, the purpose of it is to prepare the uterus for implantation of an embryo, if that indeed happens, meaning those endometrial cells themselves are changing individually, right? They take on more, what, sugars, fats, et cetera?
BANNOW: They change differently actually throughout the lining of the uterus.
CHAKRABARTI: Okay.
BANNOW: They’re going to change a bit differently at the location of the implanted embryo, which ultimately, of course, will turn into the placenta and the baby.
The placenta develops over the first trimester. Before that happens, then the embryo is getting more of its nutrition and resources just from that kind of localized area where it’s implanting. So it changes a lot over the course of pregnancy.
CHAKRABARTI: Okay. The reason why I wanted to clarify on that is because anytime anything changes, right?
In the body, that means that it’s changing due to certain signals. And I wonder if in measuring what those changes are, in menstrual fluid, if that’s one avenue of trying to understand more of the condition of the woman’s body or the signals that are perhaps leading to, as we heard earlier, in Emily’s story, this just like years of pain around her period.
BANNOW: Yes. Yes. And so actually you hit on what I think is an excellent point, because it’s actually my area of research. So I don’t do research so much in menstrual pain, but more in excessive menstrual bleeding, because I’m a hematologist, that’s my area. And what we’re doing in our research currently is collecting menstrual blood, just in menstrual cups.
It’s actually quite easy to do, over each day of the menstrual cycle. And then we’re looking at concentrations of blood clotting factors over those subsequent days. And that certainly changes with time. And ours is really the first research that sort of looked at that trajectory over the course of each subsequent day of menses.
So I don’t think that we have a ton of data around that. But it’s certainly an exciting area and it’s certainly something that we can look at. I think right now, people are looking at menstrual blood more for diagnostic purposes. Endometriosis is a very hot topic. And certainly, people, they’ve noted differences in the stem cells in the menstrual blood of folks with and without endometriosis.
And they’re also doing, I believe, there’s some look into infertility, potentially maybe some clues in menstrual blood. So yes, I think that there’s a lot of potential there. And I’m really excited to see what data start coming out of all that work.
CHAKRABARTI: So then take a minute to tell us about, again, what kinds of things might be revealed by whatever’s in cervical mucus or vaginal.
BANNOW: I don’t think we’re really looking at those so much. We’re looking more for the endometrial cells. That’s really where the cells are coming from. And most of the research, like the endometriosis type research, they’re really trying to look at the cells. And in our lab, we actually treat menstrual blood a bit like we do venous blood.
If you go to the doctor, you get your blood drawn, they draw it into a tube and then they put it in this thing called a centrifuge, which folks may or may not remember if their high school science classes had one, but basically it spins down blood at a very high rate and then the cells and the blood and other things can layer out in it.
So you can get what you’re most interested in that way. And so what we have done is separating what we call the cell pellets from the remainder of the fluid. And thus far, we’ve been treating that remainder of the fluid venous blood. Whether or not that’s exactly the right thing to do, I think, remains to be seen, but we are applying the principles that we currently have.
And there’s not really a super convenient or practical way, I think, to separate out the mucus. I think certainly, vaginal secretions, are easy to get at off menstruation just through swabs and we do that all the time.
Part II
CHAKRABARTI: I just want to be sure that I’m stating clearly what the hope is in doing more research on menstrual fluid.
Because as you described, sort of the journey that fluid takes from the uterus then out of the body. Can we make the case that because of that, it does contain information, enzymes, proteins, et cetera, that could potentially tell us more about the health of the organs by which it has passed.
BANNOW: Yes, I think that certainly is the hope. My area is specifically again, looking at these different coagulation or clotting factors, but there’s plenty of other things that we could be looking at. There’s a lot that we don’t yet understand about menstruation. And so I think first we need to figure out what normal menstrual blood looks like, and then start applying it to disease. And seeing, does it look different in diseases? I think preliminary data suggests that it does.
CHAKRABARTI: Okay. So tell me a little bit more about just in your experience, or even more broadly in medicine, why you think this kind of research hasn’t been championed before?
Is it just as simple as menstrual fluid has just been considered a gross waste product, so why bother studying it?
BANNOW: (LAUGHS) I think that’s certainly a part of it. When I first started doing research in this area and applying for funding, I was told, Oh, you’re not going to be able to get women to sign up for that.
People aren’t going to come in every day and drop off their menstrual blood. And they absolutely do. We’ve had great success getting folks willing to do that, to participate in our studies, because I think women really want this information. They want to know more and have science advance, but I do think that it has been really disregarded as a waste product.
And I think there’s, certainly, unfortunately, a degree of sexism in the taboo around menstruation. For example, we’ve certainly done plenty of studies on fecal matter over time. That hasn’t, nobody’s stopped that because it’s taboo. So I think we clearly treat menstrual fluid different than we do other bodily fluids.
And I think it’s for societal reasons more than it is for scientific reasons.
CHAKRABARTI: You just brought up an excellent counter example, one that I hadn’t thought of, right? Because you’re exactly right. Fecal matter is now used to help diagnose or track all sorts of things in the body.
BANNOW: Oh, yeah.
CHAKRABARTI: I think … there’s now quite common at home, what is it? A colon cancer test, right? That you could, or screening, right? That you use this fecal matter. And that’s been a great advance forward. If science or medical science doesn’t have this kind of like taboo grossness about that, is it just that, I don’t know.
I don’t, I hate to be reductive in certain things, but when it comes to research on women’s health, it does seem that there’s a pattern that emerges over and over again. That maybe it’s because the people funding or until relatively recently doing the research weren’t necessary, labs weren’t run by women themselves.
Is that one of the reasons why people didn’t look to menstrual fluid as a similarly potentially revealing source of information about the body?
BANNOW: Yes, I think that’s certainly part of it. I think, certainly the folks in charge of funding also until the more recent time have been predominantly men. Who perhaps aren’t thinking about this in the same way that women are. And I agree, I try to avoid being reductive, but there is a different way that we approach menstruation, even in medical school.
So for example, I learned about periods in medical school and then I went through an internal medicine residency and a hematology fellowship. It never came up again. I had to self-teach a lot of this. So it’s really not treated as something that’s important from the very beginning of our training, clear through the end.
CHAKRABARTI: Dr. Bannow, so how long was your residency in hematology and internal medicine?
BANNOW: My internal medicine residency was three years and my fellowship was three years. And in defense of my program, I did do my residency at a veterans administration hospital. So there weren’t many menstruating folks there.
But I don’t think that my experience was that different from a more general population.
CHAKRABARTI: Yeah. And it’s not as if the military doesn’t have a lot of women serving in it either.
BANNOW: Correct.
CHAKRABARTI: But this is so revealing, right? I think it’s incredibly revealing that this experience, which most women do go through for at least some period, extensive period of their lives doesn’t even get discussed outside of medical school.
So with that in mind, I want to actually just play a little bit of tape from Kate Clancy, who is the author of a book called Period: The Real Story of Menstruation. And Kate says that, honestly, the cultural framework around how we as a culture or society and also as science looks at menstrual fluid is starting to change.
KATE CLANCY: There’s this massive stigma around menstruation and menstrual blood that we perceive that has a lot to do with Western and European histories. That when we take a more expansive and global view of human cultures existing all over the planet, we recognize that it’s not a universal. Not everyone in the world thinks menstruation is actually all that gross.
So if we realize that like our cultural frame is what is producing that stigma. That allows us to release that pressure valve a little bit and say, okay, if we actually look in a different lens and understand menstruation as sacred, as important, as a sign of health, as all of these other things, does it allow us to think differently when it means to approaching the science?
I think in a lot of ways, stigma is at the lowest it’s been in a very long time, which offers us some exciting opportunities to do this work. I think the fact that so many people, thanks to the women’s health movement through the ’70s and ’80s, up through today, we’ve reduced so much stigma around having more familiarity awareness of your body and people are confronting their menstrual fluid in a way they never have before.
And I think that allows us to see that it’s just another fluid. It’s just another thing that happens in our body, which then again creates a whole different capability for how we might try to learn from that fluid in the future.
CHAKRABARTI: That’s Kate Clancy, author of Period: The Real Story of Menstruation.
And Dr. Bannow, I was wondering how you respond to that.
BANNOW: Yeah, I think she’s really right on point there. I think, we’re, again, we’re seeing more interest from the people, from the general public, from society, about menstruation, and I’m hoping that it’s going to start having almost a trickle up into the realm of research. I’m feeling more optimistic than I have in a long time, and seeing the response to some of the new research out there, looking at periods, menstrual health, things like that has been deeply encouraging to me.
CHAKRABARTI: So tell me then a little bit more. I want to learn more about some of the specific questions that could be answered by menstrual fluid. And let’s dig into what your research is on. And it’s about coagulation or anti coagulation. So give me the background on, first of all, why that’s an important issue when it comes to menstruation.
BANNOW: Yeah. My research, we call it hemostasis. Basically, that’s the process of going from bleeding to not bleeding. So for example, you get a cut on your arm, right? There’s a process your body goes through to create a clot there, that stops the bleeding and then the healing can happen.
The same thing has to happen in the uterus. Every time that lining is shed, there has to be some healing. And there has to be hemostasis achieved. And so my research is really looking at the differences in concentrations of these various proteins that are either pro clotting or anti-clotting in the menstrual blood over time to see if that differs in folks with heavy periods versus without. And our early data suggests that they do differ, that the process by which a quote unquote normal endometrium gets back to hemostasis looks different than the process by which somebody with heavy periods gets back there.
And our next steps are really, we’re trying to look at the power of RNA, which of course is related to DNA and to see how that differs in cells in the endometrium, compared to other places in the body. ‘Cause it’s really a very unique substance, for lack of a better term, the endometrium, no other organ in our body bleeds and heals without scar tissue every 28 days. It’s quite miraculous. And I think it has a lot of potential, if we can understand that better, I think it has potential to help us improve health in a variety of different ways.
CHAKRABARTI: Now you just hit it on the head, Dr. Bannow, because until you said no other body, no other organ in the body bleeds and heals without scar tissue every 28 days.
I had never thought of it in that way. So miraculous is the word, is it too far to reach to say if we figure out how the endometrium does that, perhaps we could then, this might be sci fi right now, use that understanding to help other parts of the body heal without scar tissue?
BANNOW: Yeah, I don’t think that’s too far. I think that is the hope, as folks are starting to do more and more of this research. That learning from stem cells or whatever else we’re finding in the endometrium, how can we replicate that, and potentially other locations, I think is very much an exciting idea.
CHAKRABARTI: Superpower. That’s gonna say, ladies, you got a superpower in there.
BANNOW: Yes.
CHAKRABARTI: But okay. So let me ask you also about RNA because you said that specifically that the RNA is quite different than it is in the rest of the body. I didn’t quite understand why or why that’s important.
BANNOW: We don’t know yet if it’s different.
We’re just, we’re trying to get funding for it. But RNA, basically, DNA codes everything in our bodies and the process by which our body turns DNA into something else, mostly proteins, it’s done through RNA. And so the body makes copies of the DNA called RNA that it can then turn into proteins.
And so it’s a way to measure how the body is regulating production of these proteins, perhaps these clotting factors, things like that. And it’s really an opportunity to look broadly at pretty much everything that the tissue is, or the cells are trying to make, by looking at the RNA.
And so we obviously think that’s very exciting. We have to try to convince the funding bodies that it’s very exciting. It has been done in, for example, endometriosis before. In my area, we’re looking at heavy menstrual bleeding. But I think it has a lot of potential to tell us different things about what the uterus is doing when it’s healing or when it’s building an endometrium, or when it’s making that little nest for a fertilized embryo, as my daughter’s book likes to call it.
CHAKRABARTI: Okay, so you Dr. Bannow, you can’t see this, but in front of me I have a page of notes and I’ve been putting a tick mark down for every time you’ve said the word funding.
And I’ve got like a half a dozen little marks on this page. So let’s talk about funding. You’re discussing it as if it’s still a challenge. Because I think the phrase you use is we have to try to get the funding bodies excited about the possibility of this research, even.
BANNOW: Yes. That is the goal of everybody who’s seeking funding. That’s one of the arts of writing grant applications is to try to convince the reviewers that it is exciting, that it is important, that it’s innovative. And I seek my funding through the NIH.
There’s a variety of other ways to go about it. But there’s different houses in the NIH, if you will, for different types of research. As a hematologist, I go through the heart, lung, and blood group most of the time. But my menstrual research, we’re looking at a different part of the NIH.
And there’s only so much money to go around, and they have to decide whether to spend it on, do we research my menstrual health research, or do we put it into heart attacks, or lung diseases or cancer, or there’s more good ideas than there are funds. And it’s a game to try to convince the reviewers that your research has the most potential.
CHAKRABARTI: Point well taken, right? There is only a limited amount of funds. It might be a lot of money, but it’s a limited amount. And when you’re thinking about comparing it in terms of against things like the need for funding for a cancer, et cetera. I understand. But on the other hand, look, from what I can see, there aren’t exactly tens of thousands of papers that have been written on research regarding menstrual fluid.
And on top of that, we’re talking about something that has an impact or could potentially have an impact on 50% of the planet’s human residents. I don’t know, maybe I’m just thinking of this in too simplistic of a term, Dr. Bannow, but that seems pretty innovative to me, that there’s a lot of room for very rapid advances in this research, and that may, and you’re still trying to have to work a little hard to convince NIH of that.
BANNOW: What you just said sounds very much like actually the application in the process of writing about how menstruation affects so many people and how it affects half the population for 40 years, right? And heavy periods affect one in three people who menstruate. So it is a very common problem.
I think another challenge with menstrual research, and this is something I’ve encountered in sort of other space where I’m looking at menstrual periods and folks who have to take blood thinners, is people just view menstruation as, Oh, it’s a natural process. It’s a normal process.
It’s normal to bleed, what’s the big deal about it. When actually it is a much bigger deal to the people who are experiencing it. But I have patients come in all the time. They’re 40 years old. They’ve had horrible period since they were 13. And they just, they never sought care for it, cause they thought that it was normal or they were embarrassed or maybe they said something to a doctor and the doctor brushed them off.
So I think the importance of that experience is something that people don’t necessarily feel as much.
