12th Report – Menstrual health of girls and young women

We welcome the changes to the statutory guidance on relationships and sex education and health education (RSHE). They are the crucial first step towards ensuring all girls have an adequate understanding of their menstrual cycle and know when and how to seek help for period problems. The challenge now is to prepare schools and teachers to deliver that education effectively. We are not entirely reassured that the Government is taking all the necessary steps to meet that challenge. (Conclusion, Paragraph 29)

The Government should encourage schools to use part of the RSHE grant funding to train teachers on the menstrual and gynaecological health elements of the curriculum. The Department for Education should work with the Department of Health and Social Care and stakeholders such as Wellbeing of Women and the Royal Colleges to ensure that effective training and resources are made available to schools. There are educators and campaigners willing to provide training and resources for limited cost. Adequate training need not be time-consuming. (Recommendation, Paragraph 30)

The new RSHE guidance on menstrual and gynaecological health needs to recognise the diversity of experiences of menstruation and menstrual health. Many, including Deaf BSL signers and children with learning disabilities, will also face communication barriers to effective menstrual education. Girls from different racial and ethnic groups and disabled and Deaf girls can face a broad range of different cultural, social, linguistic and cognitive barriers to understanding their periods and menstrual health and seeking help when necessary. (Conclusion, Paragraph 31)

The Department for Education and the Department of Health and Social Care should work with expert stakeholders to ensure the range of guidance being produced to support the introduction of the new RSHE curricula in September 2026 reflects the diversity of experiences of menstrual wellbeing and needs of students. Schools will need guidance on teaching menstrual and gynaecological health to pupils from different racial and ethnic 69 backgrounds and to those with disabilities. Teaching materials should reflect a broad range of lived experiences so that students from a diverse range of backgrounds can feel represented and teaching can be tailored to their needs. (Recommendation, Paragraph 32)

As part of the rollout of the updated RSHE curriculum, the Department for Education should develop resources and guidance for teachers and other school staff to embed menstrual health awareness and support at a whole school level. That guidance should include advice on best practice on access to period products and in a way that does not perpetuate stigma. (Recommendation, Paragraph 37)

While take up of the period product scheme is high there are still some institutions that have not engaged. The Government should seek to understand why some schools and colleges have not participated in the scheme and encourage them to do so. The scheme should be extended indefinitely. The Government should also explore extending access points beyond schools and colleges to other settings. (Recommendation, Paragraph 38)

Reports that access to school toilets is being restricted are troubling. The Government should investigate the extent to which this is happening and request that school leaders take alternative approaches to tackling issues regarding discipline. (Recommendation, Paragraph 39)

School nurses can play a crucial role in helping girls recognise menstrual problems and provide a necessary, early pathway to appropriate care. However, the school nurse system has seen a substantial overall reduction in funding over many years and is now severely under-resourced. Many pupils have no access at all to a school nurse. (Conclusion, Paragraph 44)

The renewed Women’s Health Strategy should include an aim to improve the provision of school nurses, particularly in more deprived areas, where need is often greatest. Improving early access to care reduces the risk of symptoms worsening and the increased health and economic costs that accompany delayed treatment. Investment in school nursing would likely lead to savings over the longer term and aligns with the prevention and community-based care goals in the Government’s 10-year Health Plan for England. (Recommendation, Paragraph 45) NHS website, social media and “FemTech”

We congratulate Wellbeing of Women on developing and rolling out its period symptom checker. It is an excellent tool, which has the potential to be a major breakthrough in improving awareness and understanding of menstrual health problems and speeding up girls’ and women’s access to 70 care and treatments. We welcome the Minister’s commitment to include a link to the checker on the women’s health area of the NHS website. The Government must ensure this happens as soon as possible. It is vital that girls and women can access a symptom checker that they can trust. Primary Care Networks must encourage its use. (Recommendation, Paragraph 54)

Wellbeing of Women’s period symptom checker should be added to the NHS app. The Government should work with Wellbeing of Women to determine whether conditions in addition to heavy bleeding and pain, such as irregular bleeding, depression and anxiety, might also be captured by the checker. (Recommendation, Paragraph 55)

The Government’s use of social media to disseminate engaging and accurate information and advice for girls and younger women on menstrual health has been poor. The 2022 Women’s Health Strategy talked ambitiously about raising awareness and understanding through social media. Two YouTube videos and ad hoc information posted on Instagram fall far short of achieving that ambition. Girls and women now increasingly access health advice from social media. Much of it is inaccurate and some is potentially harmful. Tangible progress in this area is not a “nice to have” addition. It is essential. (Conclusion, Paragraph 61)

Countering women’s health misinformation through increased official and accurate social media content is vital and should be a key part of the renewed Women’s Health Strategy. The renewed Strategy must include a clear plan with measurable actions and targets to demonstrate that this is a top priority. (Recommendation, Paragraph 62)

The Government must improve NHS England’s processes for approving and publishing third-party health content. There is a growing number of expert healthcare professionals putting out accurate, engaging and helpful information on social media that merits wider publication and promotion via official channels. The Government should expand the channels via which the NHS communicates, including TikTok and other platforms popular with girls and younger women. (Recommendation, Paragraph 63)

The suppression of vital online information about women’s health is a pressing issue, which requires immediate action. The assurances provided to us by the Minister were inadequate. We do not share the Government’s confidence that the Online Safety Act 2023’s transparency and accountability provisions will solve the problem, and, in any case, the media regulator Ofcom is unlikely to be able to monitor compliance until at least

The Government must hold social media platforms to account for inappropriate censorship of important women’s health content. “Shadow banning” is unacceptable and must cease. Social media companies must 71 recognise the significant role they play in girls’ and women’s access to important health-related content. The Government must ensure that strategies are in place to tackle this problem. This must be a key objective of the renewed Women’s Health Strategy. (Recommendation, Paragraph 69)

FemTech apps such as period trackers have the potential to transform girls’ and women’s understanding of, and ability to advocate for, their menstrual health and wellbeing. The 2022 Women’s Health Strategy, however, was not sufficiently alert to the risks. These apps are now very popular with girls and younger women, who are at acute risk from inaccurate information and advice and inappropriate monetisation of their personal health data. Apps that do not draw on sufficiently diverse data risk entrenching health inequalities for girls and women from minority racial and ethnic and other groups. We previously identified a need for urgent steps to ensure the NHS starts keeping pace with the private sector in this area. We were deeply disappointed by the Government’s response and are not reassured by its evidence to this follow up inquiry. Vague commitments to collaborate with the sector and a few ad hoc projects are insufficient. (Conclusion, Paragraph 77)

The Government should set out in the renewed Women’s Health Strategy a rigorous approach to tackling the risks from ineffective, unsafe and exploitative for-profit FemTech apps. To combat demand for these apps the Government must increase resourcing of the NHS’s Innovation, Research and Life Sciences team, to drive forward NHS provision of digital tools. The strategy should set out clear priorities for the development of women’s digital health functionality, which we believe should include accurate and effective period trackers, grounded in diverse data, and accessible to girls and women via the NHS app. The strategy should set out a timeline to implementation of this functionality. (Recommendation, Paragraph 78) Workforce training; empathy; pain management

Dismissal of women’s period problems and the normalisation of period-related pain in primary care is now recognised as a concern by the healthcare sector. However, there is little evidence of systemic improvement. Young women and girls are still reporting their concerns being ignored, being told they are too young get a menstrual health condition such as endometriosis and being prescribed hormonal medication to manage pain without discussion or investigation of underlying causes. We recognise the efforts of the Royal College of General Practitioners and others to improve training for GPs on menstrual health and provide better, more empathetic care for girls and women, but they are severely hampered 72 by pressures in the system. Many GPs simply do not have the time to take up “specialist” training in women’s health or the time in appointments to make a satisfactory judgement on the symptoms presented. However, the concerns raised above are not complicated to communicate across primary care. (Conclusion, Paragraph 98)

The renewal of the Women’s Health Strategy must include an objective accompanied by clear actions to improve the level of awareness among all primary care practitioners of menstrual health conditions, including that symptoms can begin at puberty. This will require targeted funding and ring- fenced time for GP training. (Recommendation, Paragraph 99)

We were dismayed to learn that training modules in menstrual and gynaecological health for nurses are very limited and typically undertaken only by those who choose to “specialise” in women’s health. Nurses are at the frontline of sexual and reproductive healthcare, and they should all have a solid grounding in menstrual and gynaecological care as standard. (Conclusion, Paragraph 100)

The Government must work with the Royal College of Nursing to ensure that menstrual health is included in the standard training offer for all nurses. The renewed Women’s Health Strategy must include this as an objective together with a clear plan and timeline for implementation. (Recommendation, Paragraph 101)

Discriminatory attitudes and assumptions about the pain tolerances of women from some racial and ethnic minority groups, particularly Black women, persist. This is wholly unacceptable. Racial discrimination by healthcare professionals must be vigorously rooted out. It is deeply disappointing that robust action to tackle this pernicious problem has not yet been taken. Steps to address racial discrimination must be included in the renewed Women’s Health Strategy. Compulsory training on avoiding racial biases in women’s health must be core components of training programmes for nurses and doctors. (Recommendation, Paragraph 102)

Girls and young women with disabilities and sensory impairments face additional barriers to menstrual wellbeing. Taboos around periods are compounded by those around disability. Disabled and Deaf girls’ period- related needs are routinely ignored or dismissed. We were shocked to hear that girls in specialist spinal cord injury centres receive no advice or support on menstrual wellbeing or managing periods and period products after paralysis. (Conclusion, Paragraph 103)

The Government must work with the health and care sectors’ professional bodies to improve health and social care practitioners’ understanding of the menstrual wellbeing needs of young disabled and Deaf women. The needs of this group were underrepresented in, and underserved by, the Women’s 73 Health Strategy published in 2022. Spinal injuries units should be required to provide support and guidance to girls and women on managing menstrual health after paralysis. (Recommendation, Paragraph 104)

The renewed Women’s Health Strategy should include a specific objective on improving the menstrual wellbeing of disabled and Deaf girls and young women. This should include provision of information and advice in suitable formats, including in Easy Read for girls with learning disabilities and in British Sign Language for Deaf girls. (Recommendation, Paragraph 105)

There has been long-overdue progress towards tackling the problem of painful gynaecological procedures such as hysteroscopies and some intrauterine device contraceptive coil fittings. The relevant guidelines from the Royal College of Obstetricians and Gynaecologists and the College of Sexual and Reproductive Healthcare on avoiding unnecessary pain are now good and comprehensive. We welcome evidence that many sexual health services are now adopting improved practice in relation to coil fittings. However, concern remains that improved pain management is still not being applied consistently, and women are still enduring unnecessary pain. (Conclusion, Paragraph 116)

We are partly reassured by the evidence of NHS England’s National Clinical Director for Women’s Health that the renewed Women’s Health Strategy for England will include measures on ensuring women have sufficient information in advance of procedures to make informed choices; improving training for healthcare professionals; and new pain relief options. We expect these to be set out in full, with a clear timeline for implementation, when the strategy is published. (Conclusion, Paragraph 117)

We urge the NHS to record the pain history of women undergoing procedures so that their needs can be prepared for. The NHS should be able to anticipate that someone who has previously struggled, for example with a smear test, may require additional support, such as sedation or anaesthesia, for other gynaecological procedures. (Recommendation, Paragraph 118)

Additional support for women undergoing painful procedures comes at a cost but is a price that must be paid. The Government should recognise this increase in costs in its allocation of funding to providers such as sexual health services. Women should not be put through harrowing, painful procedures due to lack of funding. (Recommendation, Paragraph 119) 74 A renewed Women’s Health Strategy within wider NHS reforms

We have expedited this Report because we were not convinced by the Government’s evidence that its forthcoming renewal of the Women’s Health Strategy for England will be adequate to address the fundamental issues in girls’ and young women’s menstrual healthcare, or that women’s health will be appropriately prioritised in its wider reforms. There are individuals and groups across the health system, including the Women’s Health Ambassador, NHS England’s Clinical Director for Women’s Health, teams in women’s health hubs and sexual health services, and others who are working extremely hard to improve girls’ and women’s care. We are not convinced, however, that they have the support from Government that they, and their patients, deserve. Until menstrual and gynaecological healthcare are embedded as priorities within broader reforms, we lack confidence that improvements in girls’ and women’s care will be achieved. (Conclusion, Paragraph 131)

As much as we want to see progress, the Government must not rush out an inadequate strategy, which does not properly set out how it aligns and interacts with wider health sector reforms. A renewed Women’s Health Strategy must be carefully thought out and include clear and deliverable actions, accompanied by a comprehensive timetable for implementation and the necessary workforce and funding commitments. (Conclusion, Paragraph 132)

Implementation of the 10-year Health Plan for England alongside a renewed Women’s Health Strategy could be a turning point in how women and girls experience menstrual healthcare in this country, but the strategies must be clearly aligned and include clear commitments on women’s health. The Women’s Health Strategy should set out what it seeks to achieve in the first two years, over five years and in the longer term. We reiterate our previous recommendation of an objective to reduce diagnosis times for reproductive health conditions such as endometriosis, to give clearer focus to the strategy. We also call for the inclusion of a dedicated focus on adolescent menstrual healthcare, with clear care pathways. This would align with the Government’s ambition to move from treating sickness to prevention. Addressing racial inequality must also be at the heart of any renewal of the Women’s Health Strategy, with clear targets to close the persistent gaps in outcomes and experiences for girls and young women from minority racial and ethnic groups. (Recommendation, Paragraph 133)

We are concerned that the ongoing merger of NHS England into the Department of Health and Social Care poses risks to delivery of a renewed Women’s Health Strategy for England. The Government must ensure that 75 it retains the capacity and expertise to deliver on women’s health reforms. The renewed Women’s Health Strategy must be transparent about the workforce considerations required to achieve its aims, including how key barriers in time and capacity for training and improved service delivery will be achieved. The Government must face the reality that a workforce that is burned out and struggling to retain numbers will not be able to address the problems identified in this Report. Alongside the renewal of the strategy, we recommend the Government conduct and publish a workforce review, to ensure that it has the capacity and expertise to deliver it. It should not publish a renewed strategy until it can be certain it has the human resources required to deliver each element of it effectively. (Recommendation, Paragraph 134)

85% or more of women on elective gynaecology hospital waiting lists do not need to be there because there are effective treatments for their symptoms, which could be administered in primary or community-based care, if only they could access them. That is approaching half a million women in England with debilitating menstrual symptoms including severe pain and heavy bleeding, waiting needlessly and at risk of a deterioration in their symptoms. We agree with the Women’s Health Ambassador that this is a ludicrous situation. Women are suffering unnecessarily and it is wasting a vast amount of money. It is a national scandal, and the Government should be acting with urgency and vigour to solve the problem. (Conclusion, Paragraph 141)

The fragmented commissioning system for long-acting reversible contraception (LARC) is preventing many women from accessing LARC, which can be an effective treatment for menstrual problems. The current system results in many women being added unnecessarily to huge elective gynaecology waiting lists for hospital treatment. It also discriminates against women in lesbian couples. That so many women are unnecessarily being denied treatment is a disgrace and a result of significant, long- recognised failings across the healthcare system. This problem must be addressed urgently. (Conclusion, Paragraph 142)

The renewed Women’s Health Strategy must include increasing access to long-acting reversible contraception (LARC) as a top priority. There must be a shift across the healthcare system to view LARC as a tool for menstrual health management, not only for contraception. The current commissioning rules prevent far too many girls and women from accessing LARC for menstrual health management, including younger and older women, and women who do not have sex with men. A shift from viewing LARC only as contraception to viewing it as a tool for menstrual health management would also help reduce stigma as a barrier to access. All women whose 76 menstrual health management could benefit from LARC should be able to access it. Measures to produce this shift must be set out in the renewed Women’s Health Strategy. (Recommendation, Paragraph 143)

A key success of women’s health hubs is that they have facilitated co- commissioning of long-acting reversible contraception (LARC) by public authority sexual health services and NHS services. This can be an effective workaround for a dysfunctional LARC commissioning system that has been unfit for purpose since the Health and Social Care Act 2012 was introduced. Women’s health hubs have shown that by pooling resources as efficiently as possible, they can better meet local women’s needs for LARC for all purposes. This approach must be replicated all over the country until the necessary legislative steps can be taken to fix the dysfunctional system created by the 2012 Act. (Recommendation, Paragraph 144)

We strongly disagree with the Minister’s argument that further ringfenced funding to support NHS Integrated Care Boards to maintain and develop women’s health hubs is unnecessary. The implementation of women’s health hubs is not complete. There are inconsistencies in provision, they do not cover all areas of the country and not all of those that have been established meet the core specification. Establishing hubs in some places, including more remote areas, has been more challenging because of their rural geography. Yet, where they have been successfully established, they have delivered a substantial improvement in women’s healthcare, providing local treatment, reducing the number of appointments women need to attend, reducing referrals to secondary care and increasing access to long- acting reversible contraception. (Conclusion, Paragraph 157)

We are concerned that women’s health hubs have not been specified in the 2025/6 operational planning guidance. There is a high risk that without a central requirement to deliver women’s health hubs, and with Integrated Care Boards (ICBs) required to find substantial efficiency savings, they will be scaled back or discontinued. We believe this would be a disaster for girls’ and women’s menstrual health, when it is in dire need of more support. Given that key aims of the Government’s 10-year Health Plan for England, including prevention and community-based care, have been shown to be well supported by women’s health hubs, it would be self-defeating of the Government to deny ICBs the funding they need to maintain and develop them. The Government should protect the hubs that have been created, ensure no rollback of services and explore how best practice can be disseminated as widely as possible. (Conclusion, Paragraph 158)

The renewed Women’s Health Strategy should include a refreshed national commitment to women’s health hubs across England. We recommend the Government invest at least the same amount as in 2023–25 (£25 million) in ringfenced Integrated Care Board funding for women’s health hubs. 77 This should come with increased accountability, including assurance that all hubs meet the core specification. There must be a focus on extending the benefits of women’s health hubs to girls and women across the country, including in rural areas. The new Women’s Health Strategy must set out a plan to achieve this, with a timeline to full implementation. (Recommendation, Paragraph 159)

The renewed Women’s Heath Strategy should set out ambitions for increased research into menstrual health conditions, with specific targets and actions that will incentivise funders, industry and clinical academia to prioritise this area. Such research should focus on the root causes of conditions as well as improving diagnosis and treatment. The strategy should also consider the potential merits of dedicated research focused on adolescent girls. The Government should consider the merits of ring- fencing funding for women’s health research as part of the strategy. (Recommendation, Paragraph 164)

A substantial increase in research into menstrual health conditions is long overdue and would represent a huge stride forwards in recognising the impacts these conditions have on the lives of women and girls. However, as this inquiry has shown, better diagnostic tools and treatments coming on stream will not solve all of the problems in delays to care. Wider barriers to diagnosis and treatment, particularly those faced by disabled, Deaf and racialised women, must also be tackled. (Recommendation, Paragraph 165) 78