Menstruation & puberty

How to have a Period-Free Hajj

July 24, 2018 by The Heart Team 1 Comment

by Dr. Sameena Rahman

Woman sitting on dock near lighthouse — Photo by Ifrah Akhter on Unsplash

“As-Salaam-alaikum Doctor, I’m wondering if I can get your advice. I’m planning to go for Hajj (Muslim pilgrimage to Mecca), and I want to make sure I don’t get my period while I’m there. What are my options?”

For the last few weeks, I’ve been bombarded with patients making appointments to seek my guidance as they prepare to embark on this journey of a lifetime. I have a private gynecology practice in downtown Chicago, where a number of Muslim patients seek my care as an unapologetically Muslim woman. Usually, patients visit my office for routine care, contraception, or gynecologic issues. However, immediately following Eid-al-Fitr, my office fills with patients who have decided to perform Hajj, fulfilling one of the five pillars of Islam, and wondering whether or not they’ll be on their period at that time. I decided to write this article in order to provide additional guidance to my audience as they venture out to their own gynecologist or other health care provider to seek menses suppression.

However, this article is not meant for the utilization of a universal treatment paradigm for all readers, as each patient should be considered within the context of their medical and family history. Additionally, this is not meant to provide religious guidance or reflect any fatwas or decrees from religious authorities about whether or not it is permissible to take medication, modify menses, or enter sacred areas when menstruating.

That being said, for a woman with normal monthly menstruation to obtain optimal results, I recommend seeking medical advice from a gynecologist 2-3 months prior to the trip. For premenopausal women, attempting to eliminate menses can be successfully achieved with a combination oral contraceptive pill containing both estrogen and progestin components. Please speak with your health care provider if you have any contraindications to estrogen administration, including previous thromboembolic events or strokes, a history of estrogen-dependent tumors, active liver disease, undiagnosed abnormal uterine bleeding, or any comorbidities, such as simultaneously being over 35 years old, a cigarette smoker, and obese.

For my patients, I usually recommend a monophasic combined oral contraceptive pill, meaning that there is a consistent amount of progestin and estrogen delivered everyday throughout the cycle. This monophasic option comes in a pack of 28 pills per cycle, with the last 7 pills being the placebo, or “sugar pill.” In order to prevent getting their period while on Hajj, I advise my patients to skip the placebo pills and start the next pack of contraceptive pills immediately. I also advise my patients to take an extra pack of pills with them on the trip. For some, the mental and physical stress that comes from traveling and performing the rites of Hajj can cause intermittent bleeding. Because of this, I usually avoid low-dose monophasic pills. My preferred prescriptions include ethinyl estradiol doses of at least 30-micrograms and a variety of progestins, such as Ocella, Zarah, Yasmine, Ortho-cept, Ortho-cyclen, Apri, Microgestin. The pills should be taken around the same time daily, as missing one or two doses can lead to breakthrough bleeding and irregular spotting, often causing some panic and distress for female hajj participants. Another viable option is Seasonique, a pack of 84 active hormone tablets, which is specifically utilized for extended elimination of menstrual flow. However, unscheduled bleeding often occurs during the first few months of use, and therefore it might not be ideal for women preparing just a few months prior to Hajj.

Other options include the transdermal contraceptive patch, Xulane, which is applied every week for 3 weeks, and the vaginal contraceptive ring, NuvaRing, which is inserted vaginally once every 3 weeks. Both of these are combination estrogen and progestin methods and can be utilized continuously to prevent menstrual flow, rather than skipping a week of placebo pills to achieve the same effect. However, the transdermal patch is known to produce higher levels of estrogen in blood circulation, so it is generally avoided for the potential risk of blood clotting in the extremities or lungs. The data on the effectiveness of using the vaginal ring continuously is conflicting; however, I have had many patients utilize the ring continuously with great success and no unexpected bleeding on their trips! Some of my patients are uncomfortable inserting or leaving a contraceptive ring in their vagina, and so It is not always my “go-to” treatment option.

For those who are unable to take estrogen pills, taking a continuous dose of the progestin-only pill can reduce their flow, but limited success is seen in eliminating breakthrough bleeding. This can be discussed with your physician on a case-by-case basis. There are also progestin-only intrauterine devices, like the Mirena. In high enough doses, or if inserted early enough, approximately 6 month prior to Hajj, these can be helpful in eliminating menstrual cycles. While careful guidance regarding the risks and benefits of the device and its long-term use should be discussed with your physician at length, it is a great contraceptive method and menstrual suppressant when inserted in advance. Many women have uterine pathology such as fibroids or polyps, or medical conditions, such as Polycystic Ovarian Syndrome (PCOS), or other diagnoses that lead to heavy or irregular menstrual flow. This should be evaluated and discussed before attempting menstrual suppression with standard methods. In these situations, menstrual suppression can still be obtained, but other methods or a combination of medications or procedures may be needed in order to achieve a bleeding free interval during your pilgrimage!

I believe that if you convey to your gynecologist or health care provider that you are embarking on a special, once in a lifetime experience and ensure a full evaluation of any abnormal bleeding problems, one of the options above could be the right choice for you.

Dr. Sameena Rahman is a gynecologist-obstetrician in Chicago.

Getting into the Flow of Ramadan: Taking the Shame out of Menstruation

June 24, 2016 by The Heart Team Leave a Comment

A calendar with daisy stickers used to track menstruation

originally published on patheos.com

By Sameera Qureshi

“Raise your hand if you’ve ever faked fasting when you’re on your period.”

I posed the question and then looked around the room of 25 seventh grade girls and saw that 80 percent of them had their hands raised. Some were looking directly at me, perhaps hoping that I’d understand why, while others had their gazes directed down towards the floor.

I was not shocked by the results of this particular group or the many others I’ve run on sexual health education with Muslim girls and women. There is a great amount of shame and stigma around many topics related to sexual health, especially that of menstruation. For something that has been endowed to girls and women as a blessing — the ability to create and sustain life within our own bodies — it’s shocking how often this topic is shunned from discussion circles within our communities and not to mention in our homes.

Speaking from my own experiences, growing up as an only female sibling with two brothers, I too have been guilty of acting shamefully during menstruation. To use the term shamefully is to mean that someone looks down upon themselves as lesser than, unworthy, and even dirty for menstruating. For many years during my menstrual cycle, I would wake up for suhoor (the pre-dawn meal) and fajr prayer, pretend to pray and breakfast with my family — despite the fact that I was absolved from fasting due to my period.

There were times when my mom would vouch for me not being at the suhoor table by saying that I was sick or had a headache. I’d go to the basement to eat food during the day. As an adult, I’d head out of the house to eat while running errands or at work. While some of these practices may be seen as maintaining modesty during menstruation, they were all done under the auspices of shame rather than empowered decision making.

Had I known that menstruation is empowering, indicative of a new spiritual layer as an adult from an Islamic perspective, and that there were many ways to still connect with God — my experiences would have been quite different. I could have chosen to act differently than in the shameful fake-fasting way.
During the girls group, we dove into the religious perspectives of menstruation — namely, the rights that have been given to women during their monthly cycle. Girls and women who are menstruating are absolved of the obligation to pray and fast. What many girls especially don’t understand is that they can and should continue to worship in other ways during their menstrual cycle.

Generally speaking, when girls are taught about menstruation (typically from family members or friends), the “do’s and don’ts” are emphasized more so than “here are your other options.” Having spoken with and taught many teenage girls, it would be safe to say that a vast majority of them feel uncomfortable approaching their mothers and families members about menstruation.

If this topic is not spoken about or broached by parents, it is unfair to expect that girls will initiate the conversation themselves. Parents not talking about a subject often implies that it’s not to be spoken about. And thus, many of these girls learn by osmosis through their peers, the Internet or trial and error about physical, emotional and spiritual self-care during their menstrual cycle.

However, this information is not always accurate nor complete, to say the least. Nor does it afford them the opportunity to ask questions after they have digested the information.

Menstruation is not only physical in nature, despite this aspect being focused upon the most — it has a spiritual and emotional dimension as well. Girls and women need to learn self-care strategies around all three aspects of menstruation, especially during Ramadan, the holiest month of the year.

Body image, self-worth and having a healthy sexual identity are impacted by how a girl understands menstruation. Understanding one’s monthly cycle is empowering and leads girls and women to feel as though they are in control. This can trickle over to additional areas of sexual health self-care — understanding the importance of regular gynecological check-ups, seeking information about safe and healthy intimacy, exploring the concept of healthy relationships and so forth.

If young girls do not feel empowered or confident enough to seek information about a normal biological cycle in their body, it will be challenging for them to reach out in other realms of sexual health.

Not to mention, many Muslim women suffer silently from menstrual and/or sexual dysfunction and aren’t quite sure who to turn to for support. If we empower girls from a young age and arm them with a plethora of information and resources, we are creating pathways that makes it more than permissible to discuss any sexual health related matter with trusted adults.

The shame that girls and women feel around menstruation is not solely limited to this segment of sexual health. Speaking of sexual health, our communities are in a dire state on this topic. Apart from menstruation, we also don’t speak about sexual violence, creating safe and inclusive spaces for LGBTQ community members, what healthy relationships consist of, consent-based education and ensuring that our institutions and mosques have policies and protocols in place to protect survivors and hold perpetrators accountable.

While it is not incumbent on us to all be doing this work at the community level, it is our responsibility to become educated on these topics and at least practice creating safe spaces within our own family and friends circle. This includes men as well as women.

It’s time that both men and women place aside any shame related to menstruation and sexual health topics. Our faith tradition is rich in stories about honest and detailed questions that Muslims would ask of the Prophet (peace and blessings be upon him). We’ve definitely lost this within our own communities, and our faith tradition has been overshadowed by cultural stigma and shame.

So let’s use this Ramadan to become empowered to seek sexual health information as a means to enhance our spiritual, physical and emotional well being. Let’s not fake fasting anymore.

Sameera Qureshi is the Director of Education, Canada for HEART Women & Girls. For the last several years she led sexual health and sexual assault awareness programming for the Muslim community in Calgary and other Canadian communities. Most recently, she has moved to Washington, DC, where she hopes to continue similar programming.

Moving Beyond Shame: Working to Nurture a Healthy Sexuality

October 27, 2015 by The Heart Team Leave a Comment

originally published on http://www.patheos.com/blogs/heartfelt/

by Nadiah Mohajir

When thinking about Islamic values around sex and sexuality, two that are often emphasized are modesty and privacy. We are encouraged in Islam to embody modesty – both with respect to external appearance as well as our thoughts, behavior and interactions with others – and we are encouraged to be private about our bodies and our sexuality. Intimacy and sex are seen as enjoyable, but sacred experiences between two people, most often in the context of marriage.

While modesty and privacy are excellent values to honor and uphold, historically, faith communities haven’t done a very good job. More often than not, in efforts to uphold privacy and modesty, communities actually instill shame and promote silence around these issues. Specifically, speaking openly about these issues – especially but not only if – you are not married, is deemed immodest and no longer private. Yet, associating these feelings of shame with sexual health is actually more damaging than beneficial -whether you are a young adolescent girl or boy navigating the many physical and emotional changes of puberty or an adult navigating relationships and sex.

The best example to demonstrate this distinction is to compare menstruation – a natural, monthly, bodily process that most women and girls experience after they reach puberty – to urination and defecation, a natural, daily, bodily process that ALL people experience. We have guidelines in using the bathroom – we close the door, we practice a certain level of privacy and modesty with respect to using the bathroom. For example, we don’t speak about using the bathroom graphically, or at the dinner table.

There is a stigma and shame associated with menstruation that is not comparable to the other bodily functions. Specifically in the Muslim community, this shame and stigma leads many young girls to hide the fact that they are menstruating from the men in their lives, sometimes even being encouraged (or expected) to “fake” pray and “fake” fast, despite being lawfully excused from observing those rituals. For example, a 12 year old who may have her period in Ramadan may be asked by her mother to continue waking up for the pre-dawn meal to eat and to pretend to join in morning prayer as to avoid her father and brothers from knowing she’s on her period. Similarly, a young mother on her period may lie to her son about why she didn’t pray, rather than just being honest. The result of this approach is two-fold. First, we are more likely to lie than just be straightforward by saying, “I’m excused from praying and fasting today,” out of fear that our male relatives will feel uncomfortable. Second, we are teaching our daughters a sense of shame and our sons ignorance towards something that should be approached as a natural part of life for females.

Yet, this same shame does not exist with other bodily processes such as urination and defecation. So why the shame with menstruation, which also, is just as natural a bodily process as having to use the bathroom?

Before we can talk about how to begin working toward eliminating shame and normalizing conversations on our bodies, reproductive processes, and sex, let’s first understand why using a shame-based approach to speak about puberty and sex is so problematic.

Shame is different than guilt. Guilt can be a healthy emotion, as it makes one feel bad about something they did, whereas shame is unhealthy: shame means you feel bad about who you are, that you are blameworthy for what is happening. The definition of shame is “a painful feeling of humiliation or distress caused by the consciousness of wrong or foolish behavior.” The very definition of shame involves being aware of “wrong or foolish” behavior, when in reality, puberty, menstruation, and sex are all natural, bodily processes and desires, and not something anyone should be blamed for experiencing.

Shame leads to silence, and not reaching out when you need help or have questions. Often times, when girls or women reach out to me about a reproductive health issue they have been struggling with for a while, I’ve asked them why they hesitated initially from reaching out to a trusted adult or professional for help. Their response, almost always, is that they felt ashamed to be struggling with the issue and therefore decided to keep it to themselves.

Shame makes you feel paralyzed and not move forward. Shame is the very emotion that impedes one from dealing with the issue at hand. For example, many survivors of sexual assault are paralyzed by the shame they feel and unable to seek help from professionals trained to serve them. A woman struggling to consummate her marriage due to a easily treatable condition called vaginismus may hesitate to seek professional help because of the shame she feels when talking about sex.

Shame leads to feeling unworthy, less than another. Those who experience shame typically embody lower self-esteem and are less confident, and feel that they are less worthy than others. Moreover, they are more likely to tie that self-worth to certain milestones, like being successful professionally or getting married.

So how can we begin eliminating shame from the discussion while still honoring our faith values of modesty and privacy?

1) Use correct anatomical terms when talking to children about their bodies. There are many who come from faith-based or cultural communities that do not have a tradition of using correct anatomical terms for private parts. Rather, families refer to the general area or use code words to refer to those body parts. This is problematic because it inherently instills shame: the message that children are getting is that it is immodest or shameful to use correct anatomical terms. Using correct terminology in conversation not only normalizes these terms, but also equips your child with the correct language and tools they may need to communicate with you or their doctor should they be experiencing a problem.

2) Commit to having ongoing conversations about puberty and sex with children. Using a developmental approach to talking about sex can be beneficial in building a foundation for an important life skill. When children attend school, they learn academic subjects like Math, Science, and English, and as they grow older, the concepts build off each other and get more complicated, which ultimately provides them with a comprehensive understanding of the subject. In the same way, repeated, age-appropriate conversations about puberty and sex are crucial to give them the information and skills they need to fully process the big picture and figure out how they fit into it.

3) Create safe spaces and an open door policy. Children should feel safe to ask any question they may have about their bodies and sex, without being shamed or reprimanded for thinking about such things. If you create a loving, open and safe space for them early on, they will continue to come to you as they get older and begin navigating more complicated and nuanced situations.

4) Validate and affirm what your child may be feeling. Simple statements such as “it is normal and not surprising that you have this question” or “you’re doing the responsible thing by speaking with someone, and know you are not alone. Most kids your age have similar questions” can seem like insignificant gestures on your part, but are incredibly important for a teen trying to make sense of the many social emotional and physical changes they are experiencing.

5) Encourage father-daughter and mother-son conversations. Historically, conversations about puberty and sex are gender segregated: mothers speak to their daughters, and fathers speak to their sons. While sex may be an uncomfortable topic for dads to broach with their daughters, or mothers to broach with their sons, it is crucial now more than ever for dads and moms to engage in candid, two-way conversations about sex with all their children as a way of modeling healthy communication about sensitive topics as well as encouraging safe, and healthy relationships. Perhaps a father may not feel comfortable starting a face-to-face conversation, but would be open to journal writing with his daughter, as a way to open up the lines of communication.

As the world continues to become increasingly hypersexualized, it is crucial that we work with our children to avoid mixed messaging so that we can ultimately instill positive attitudes toward reproductive and sexual health issues. Puberty and sex are natural, healthy aspects of everyone’s lives and historically, Islamic tradition has approached them as just that. Yet, our cultural expectations and mixed messaging have led to lacing these issues with much shame and stigma. It is time we reclaim our values for what they were always meant to be: tools of empowerment to facilitate healthy sexual lives and families.

Share with us: What have you found helpful in speaking to your kids about puberty and sex? How do you work to instill a healthy attitude toward sex and our bodies?

Menstrupedia: A culturally-sensitive resource on Menstruation

February 11, 2014 by The Heart Team 1 Comment

by Nadiah Mohajir

I recently came across Menstrupedia.com, a virtual resource developed by some individuals in India who wanted to create a guide for women and girls on staying healthy during their periods. The website offers information through different media, and aims to dispel many of the myths and misinformation that have been prevalent in India for hundreds of years, such as the common misunderstanding that women should not bathe or leave the home during their periods and that they should keep their periods a secret from men.

Sites like Menstrupedia.com are pioneering in their effort to shatter the stigma and shame around an issue that should be seen as a natural part of life. Their approach should be used as a model as we as a community start thinking about how to present these topics in a way that is both medically accurate as well as respectful of our faith’s tradition of modesty. Here are some ways the founder of this resource has brilliantly managed to do both:

The site uses accurate, medical information from reputable sources, along with animated non-offensive graphics and cartoon people as visuals to explain the menstrual process, hygiene and care, and puberty.
The site uses a FAQ system to dispel common myths prevalent in India.
The site has a blog that uses storytelling, factual articles, short video clips and poetry using imagery, references, and media that are relevant to India to raise awareness about topics concerning menstruation.

This is a great website for mothers and daughters to look through together to start a dialogue about menstruation and puberty. The hush-hush nature and embarrassment that is associated with menstruation in the Muslim, particularly the South Asian, communities creates many unhealthy attitudes towards menstruation, perpetuates misinformation and myths, and serves as an obstacle for many young girls to learn about their bodies and be comfortable with them. Through HEART’s fieldwork, we have met numerous young Muslim girls and even adult women, as well as males, who did not demonstrate having adequate knowledge about menstruation. We met:

a fifth grader who missed three weeks of school, feigning illness because she thought she was dying when she started her period, not knowing what it was, too afraid to ask her mother or another adult.
adolescent girls who were not permitted to attend sex education classes, and therefore did not understand the biology of menstruation.
adolescent girls and adult women who did not know the fiqh of menstruation and ghusl (the Islamic process of ritual purity after menstruation is over).
adolescent girls and adult women who did not know how to use a tampon.
adult women – both married and unmarried – who did not know their basic anatomy.
women and girls who carried with them many myths surrounding menstruation and other reproductive health topics, such as you can’t swim when you have your period, and you are not a virgin if you wear a tampon.
boys and men who had limited accurate knowledge about the biology and anatomy of menstruation, as well as many many myths surrounding menstruation.

The stories of the women (and men) above are just a few reasons we need to change the status quo and start having conversations with both males and females about menstruation and other reproductive health topics. We will not be able to facilitate systemic change or influence cultural attitudes toward menstruation if we do not actively engage in dialogue. The founders of Menstrupedia.com saw a timely opportunity and took steps to challenge the status quo. I was really pleased to see this effort and look forward to seeing many more like this.

Menstruation & puberty

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