OHSU Hospital, 2019.
Courtesy of Oregon Health & Science University
A new study from Oregon Health & Science University used TikTok to survey teens and young adults about their understanding of menstrual health. It found that although the vast majority of respondents would prefer to control or stop their period using hormonal medications, nearly two-thirds were unsure whether it would be safe to do so. Researchers also found that health literacy was lowest among respondents who identified with a Christian family background or who lived in the U.S. South.
Maureen Baldwin, associate professor of obstetrics and gynecology at OHSU, joins us with more details on how parents and health care providers can help fill gaps in menstrual health knowledge.
The following transcript was created by a computer and edited by a volunteer:
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. A new study from Oregon Health & Science University used TikTok to survey teens and young adults about their understanding of menstrual health. It found that although the vast majority of respondents would prefer to control or stop their periods using hormonal medications, nearly two-thirds didn’t realize that it would be safe to do so. Researchers also found that health literacy varies by region and by religion. Dr. Maureen Baldwin is one of the coauthors of the study. She is an associate professor of obstetrics and gynecology at OHSU and she joins us now. It’s great to have you on the show.
Dr. Maureen Baldwin: Hi, Dave. Thanks for having me.
Miller: Yeah. Thanks for joining us. What prompted this study?
Baldwin: This was a team research study project. It was driven by a group of premedical and medical students here at OHSU and at University of Washington. Alexandra Jones Packham, Colin Boehnlein and Sydney Jones were the students. They wanted to get a team perspective about their knowledge, about using medications for menstrual suppression.
Miller: Why was it necessary or interesting to learn what teens knew or thought about that?
Baldwin: Well, I think we were interested in understanding whether most teens would want to use a medication that would change their period. And if they did, would they want their bleeding to be totally absent or to mimic a normal period and be on a monthly schedule? And I think we know a lot about what contraception does to change periods and we have a lot of information from adults about what their preferences are. But we haven’t really ever asked teens what they want.
Miller: We’ll get to what you learned in just a second. But why use TikTok as a way to find respondents for the survey?
Baldwin: Yeah, usually surveys historically have been put out by phone call, but nobody answers their phone anymore. And sometimes using a QR code in a magazine will help get you respondents. But our students thought that we could get more teens to answer a broad national [and] get a broad national sample if we put out a recruitment on social media. And as you know, TikTok is short videos, around 30 seconds long. And there are certainly influencers who put on a lot of these videos. So we wanted to use that venue to try to find a lot of teens who would be interested in the topic.
Miller: How did you target them?
Baldwin: So it just so happens that one of my colleagues from residency here at OHSU, Dr. Jennifer Lincoln, who’s an OBGYN here in Portland, has a pretty good influencer status on TikTok right now with almost 3 million followers. And so we worked with her to use her TikTok channel, which is what she calls “the class you wish you had in high school” about reproductive health and it’s targeted toward teens. So we asked her if she would be so kind as to put a recruitment ad up on her TikTok channel and she got totally into it. And we were able to have over 3,000 completed surveys within less than a few weeks using that method.
Miller: For folks who miss it, we actually talked to Dr. Lincoln last year after her book “Let’s Talk About Down There” came out and among other things, we actually talked about her decision to try to reach out to young people on social media and on TikTok to talk about menstruation and sexual health and other body issues - folks can find that on our website.
So the survey, among other things, focused on questions about stopping or suppressing menstruation with hormonal medication. What most stood out to you in terms of what you heard from the respondents in terms of what they would want?
Baldwin: Well, I think first just to maybe ask like, why would a teen want to stop their bleeding? Why would we be talking about menstrual suppression using hormonal medications in a teen or even a child as young as nine years old? I think it’s really important to take a step back and say that periods can be extremely disruptive for a substantial number of children, can make them miss classes, make them stay home from school and can be very painful. And in addition, can be one of the first signs of somebody having a bleeding disorder. And so it’s really important that we learn how to talk about using the medications that we know are safe with these children to help them get back to their normal lives.
So you were asking me what we found. We introduced the research questions by saying we were studying preferences about the bleeding part of periods only, not like cramping or other symptoms. And we asked, if they could magically pick their period bleeding style and it would have no permanent effects on their body, like their ability to have children in the future, in a very typical sort of teen question way, we asked would you rather have bleeding when you expect it, no bleeding at all, or hardly any bleeding, but not know when to expect it? And then we also give them the choice of honestly not knowing what they would prefer because that has to always be a choice for teens.
Miller: And what were the results?
Baldwin: So from the initial sample, only 4% said that they would be OK with not knowing when they would expect to bleed. And that was not surprising to me because most teens I’ve met are really not excited at all about starting their period unexpectedly.
Miller: I mean, is anybody?
Baldwin: No, but I think adults are maybe a little bit more equipped with menstrual products in their bag to deal with it. And teens are just not quite ready for that yet. They just don’t want to have an accident because they forgot to stock their backpack. And so what they end up doing is they go home from school.
Miller: What about the options that they were most likely to choose?
Baldwin: Yeah. So in the analysis, we ended up removing those people who were OK with the unexpected bleeding and the few people who were totally unsure and we looked at the numbers of teens who would prefer either the regular scheduled period, or no bleeding at all, which is amenorrhea, is the word for that. And I’ll remind you, we told them up front it would not affect their body permanently. And from there, it was about 70-30 with preference for amenorrhea, no bleeding in 70% versus scheduled bleeding in 30%. And that was pretty much what we see in line with patients in the clinic as well.
Miller: What did you find when you tried to understand the extent to which these teens understood that hormonal therapy, hormonal birth control, is safe for this use? You called it “magical” and wouldn’t affect them, but which is a kind of fanciful way of describing what for the vast majority of patients is actually the truth. But what did you find out in terms of their knowledge of this safety?
Baldwin: Well, I mean, using FDA approved hormonal medications, most but not all of which are approved as contraceptives and so have like a giant amount of data behind them. It has just a huge amount of safety data, including in young people. And however, because they’re approved as contraceptives, I think that lends itself to a lot of fear for younger people. And especially because most of us, even many of my colleagues in medicine, will still use the term birth control even when we’re talking to an 11-year- old. And I think that just lends itself to so many myths about fertility, about changing their body, about medication building up in their body, about if the blood doesn’t come out and we stop it from coming out, where is it going?
Because we don’t talk about it very much, or hardly ever in public, I think there’s just a lot of secret fears. We found when we introduced the topic, saying that, even prefacing medications that won’t cause long term effects, that they were still very unsure about safety and particularly they were very unsure about the fertility impacts.
Miller: What do you think it would take to change that? Because, I mean, in general, my feeling is if young people don’t know things, it’s often not their fault, it’s because they weren’t taught those things. So what do you think it would take to change what you found?
Baldwin: I think that having health education that’s evidence-based in schools would be a start. And I think we’re on our way there in Oregon. It’s been a huge boon to have the Oregon Menstrual Health Dignity Act, which was passed in 2021 as House Bill 3294. That act requires all schools to provide menstrual products in bathrooms and in both gender-neutral and male and female restrooms in schools and it also provides some stipulations about what the content of some education in health education classes, often called sex-ed classes in schools, and at which grade level they should be introduced as well. And that’s a huge start. But often those lessons don’t occur until later than when they would be needed. And so I think we need to think about age appropriate education at even younger grade levels, even in second and third grade.
Miller: What did you learn in terms of the answers young people gave you based on region and religion?
Baldwin: We compared knowledge questions that we asked teens and we asked them about their family religious background and also where they were and this was a pretty widely distributed U.S. sample of, again, over 3,000 teens from age 14 to 24. We asked them to identify their family religious background and about 61% had a Christian family background and a really large percent had a non-religious background. So we just compared those two large groups and we left out the smaller numbers of a wide variety of other religious backgrounds, as we were looking for a big contrast.
What we found is that [when] comparing Christian family background to non-religious background, 31% versus 24% thought that hormonal medication suppressing periods would be unsafe. So about a third in both, but a statistically different number higher in the Christian family background. And 33% versus 20% thought that these medications would lead to infertility. So again, about a third and higher in the Christian family background. So I think this just demonstrates that there are some gaps with a differential, based on potentially a cultural family background.
Miller: What do you hope that parents or caregivers will take from this? And we have about a minute left.
Baldwin: Well, I’m a parent and I think this can be a scary topic to talk about, both with a kid, not wanting to talk about it with you, but also just not knowing what other people are telling your child and whether it’s age appropriate. And I think it’s just important to start by normalizing periods, normalizing the discussion about periods and taking it away from talking about sex and the more adult side of reproductive health, just making sure that kids stay in school and keep their iron storage levels up and not bleed too much.
Miller: Dr. Maureen Baldwin, thanks very much.
Baldwin: Thank you.
Miller: Maureen Baldwin is an associate professor of obstetrics and gynecology at OHSU.
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