Heavy menstrual bleeding (HMB) is a common but under-researched public health challenge that significantly affects women’s physical, emotional and social wellbeing [1]. Clinically, HMB is defined as excessive menstrual blood loss that interferes with a woman’s quality of life [2, 3]. While biomedical literature often uses an objective threshold of ≥80ml of blood loss per cycle, this measurement rarely reflects many women’s lived experience. Many women report significant pain, fatigue, or disruption to their daily activities even when their bleeding does not meet the clinical cutoff. For this reason, a woman’s own perception of heaviness and functional impact of her bleeding are now recognised as equally important indicators for diagnosis and care. Heavy menstrual bleeding affects nearly one in three women worldwide, yet only a small minority are ever diagnosed or treated. Approximately 30% of women are affected globally [2, 4, 5], and only around 20% are ever diagnosed or treated [6], reflecting a substantial gap between lived experience and clinical recognition. The gravity of this issue demands that heavy menstrual bleeding be treated as the serious health crisis it is – it leads to widespread anemia, lost productivity, and a diminished quality of life for millions of women [7].
One reason for this care gap is that many women are unaware that HMB is a recognised medical condition with various treatment options [6]. Women are often given ‘band-aid’ solutions that lack comprehensive discussions with their healthcare providers about treatment options. Intrauterine devices (IUDs), particularly the levonorgestrel-releasing IUD, are the most recommended and effective treatment options for HMB [12] and while this is effective in thinning the uterine lining to reduce blood flow, hormonal IUD uptake remains low in sub-Saharan Africa [8] This is because treatment options are often based on availability, cost, healthcare provider preference as opposed to the patient’s informed choice [9] and lack of trained capacity to insert hormonal IUDs. Another is the persistent stigma surrounding menstruation: painful or heavy periods are often normalised in society and even dismissed in healthcare. As a result, women forgo care, enduring fatigue, anaemia, and disrupted daily functioning as part of what they believe it means to be a woman. Studies have shown that many women associate heavy bleeding with shame, fear of social embarrassment and often experience decreased productivity due to the physical exhaustion, physical discomfort and cognitive disruption that can lead to absenteeism. [10] These factors increase both psychological and physical distress as a result of the condition.
In sub-Saharan Africa, where menstrual health discourse remains limited and often uncomfortable, these behavioural and social barriers to accessing care are even more pronounced. Menstrual health sits at the intersection of gender, culture, and access and despite this, heavy bleeding rarely features in public health agendas or clinic protocols. Instead, it is reduced to private suffering – a topic too shameful to discuss, too “ordinary” to diagnose, and too easily dismissed.
When silence becomes the default response
From the first period, girls are socialised to hide menstrual products, avoid discussing pain, and manage their periods discreetly. The behavioural costs of this silence and shame are profound. When menstruation is treated as a private matter, women internalise the idea that it should be endured rather than addressed. This is a pattern that is shaped by social norm theory, where people adjust their behaviour to fit what they believe others expect.
This silence has behavioural consequences. Normalisation bias leads women to interpret even debilitating symptoms as typical because there are so few visible or openly shared reference points. Stigma, reinforced by social norms, discourages open discussion and help-seeking, activating pluralistic ignorance where each woman assumes others are coping without difficulty. Over time, this creates a feedback loop grounded in behavioural mechanisms: concealment reduces the availability of information (availability heuristic), silence reinforces social norms, and these norms sustain inaction.
Even when women overcome these internal barriers, their experiences are often invalidated in clinical spaces. Providers may attribute menstrual concerns to stress, contraception, or hormonal fluctuations, without deeper investigation. Clinical guidance is clear: assessment of heavy menstrual bleeding should include a structured history, screening for anaemia, and where indicated, pelvic examination or ultrasound to rule out underlying causes [7]. Despite clear clinical guidance, a study found that a large proportion of healthcare providers (HCPs) under-utilise screening tools and fail to carry out the full gynaecologic work-up required to diagnose HMB [13]. As a result, many women and girls remain undiagnosed and untreated. Such dismissal, whether intentional or not, perpetuates the belief that menstrual pain and heavy bleeding are inevitable rather than treatable.
Silence shapes perception and behaviour: it makes women less likely to see HMB as a health condition, and healthcare systems less likely to identify or prioritise it.
A behavioural lens for change
Behavioural science offers practical tools to challenge this cycle of silence by shifting perceptions, norms, and cues in the environments where women live and seek care.
- Reframing what’s “normal”: Behavioural change begins with redefining existing social norms. Public health messaging that explicitly states, “One in three women experience heavy bleeding but it can be treated,” can help reposition HMB as a medical condition rather than a private burden. Reframing menstruation as a signal of health and not shame, encourages recognition and dialogue.
- Making symptoms salient: Many women underestimate their bleeding because there are no visible cues for comparison. Visual tools such as posters in clinics or digital trackers can help women identify when their bleeding is excessive. Prompts like “Do you change pads hourly?” or “Does bleeding limit your daily activities?” make the condition tangible and actionable.
- Trusted messengers: Peer educators, nurses, and community health workers can use everyday interactions to initiate non-judgmental conversations about menstrual health. When information comes from familiar and trusted figures, particularly at a younger age, it carries more weight and can help dismantle stigma, prompting earlier diagnosis and treatment.
- Embedding prompts in care pathways: A simple question like “How are your periods?” added to routine health assessments can normalise menstrual discussions and increase diagnosis. Behavioural research shows that small, well-timed prompts and provider responses can shift patterns of care-seeking behaviour dramatically.
- Creating supportive spaces: Beyond clinics, workplaces and universities can become sites for change. Sexual and reproductive health-focused centres, awareness campaigns, peer-support groups and student-led initiatives can foster open conversation and peer support.
Reframing the discourse around menstruation does not ignore the pain or the barriers; it recognises that acknowledging menstrual experiences publicly is itself a form of advocacy. Behavioural interventions that affirm this through inclusive messaging, peer storytelling, and visible institutional support, transform how women engage with their own health.
Call to action
In sub-Saharan Africa, HMB can no longer remain hidden behind cultural silence and clinical neglect. The region’s diagnosis and treatment rates for this condition remain significantly low, reflecting the immense barriers women face in seeking care [11]. Breaking this silence and inaction requires empathy, open dialogue, and a fundamental shift in how we view women’s health. When a woman says, “my bleeding is heavy,” it must be recognized as a legitimate health concern and an urgent call for care, not dismissed as something “normal.” By leveraging behavioural insights and community engagement, we can reframe social norms, reshape harmful cues, and amplify women’s voices so that experiences of heavy bleeding are no longer silenced but addressed head-on.
Overcoming these barriers means educating communities to eliminate the myth that heavy bleeding is “normal,” promoting menstrual literacy from adolescence onward and ensuring that women have the language and confidence to describe their symptoms. This also requires training healthcare providers to take menstrual complaints seriously, and ensuring clinics have the resources to treat HMB effectively. Heavy menstrual bleeding affects up to one in three women in parts of Africa [7], and despite this immense burden, most of those women never receive proper care due to stigma and scarce resources while research as well as healthcare initiatives to address HMB remain insufficient.
Behavioural science offers opportunities to embed simple, scalable solutions that ensure that HMB is not just seen, but acted upon. From low-cost screening prompts in primary healthcare, to the co-creation of behaviourally informed campaigns that dismantle menstrual stigma and IUD misinformation. Behavioural insights can also offer the design of user-centred screening tools, clear decision checklists for HCPs, and accessible training materials. We call on health authorities, policymakers, and global partners to invest in the research and interventions needed to break this cycle of silence and neglect. Heavy periods should never be accepted as normal or inevitable; they must be noticed, named, and treated. Addressing HMB is not just a clinical imperative; it is a matter of justice, and health equity.
References
- Oderkerk, T.J., et al., Patients’ motives and considerations on treatment decision-making for heavy menstrual bleeding: a qualitative study. BMC Women’s Health, 2024. 24(1): p. 439.
- Sinharoy, S.S., et al., Prevalence of heavy menstrual bleeding and associations with physical health and wellbeing in low-income and middle-income countries: a multinational cross-sectional study. The Lancet Global Health, 2023. 11(11): p. e1775-e1784.
- Vannuccini, S., et al., From menarche to menopause, heavy menstrual bleeding is the underrated compass in reproductive health. Fertility and Sterility, 2022. 118(4): p. 625-636.
- Dutton, B. and J. Kai, Women’s experiences of heavy menstrual bleeding and medical treatment: a qualitative study in primary care. British Journal of General Practice, 2023.
- Ibrahim, P.M. and E.L. Samwel, Prevalence of heavy menstrual bleeding and its associated factors among women attending Kilimanjaro Christian medical centre in northern Eastern, Tanzania: a cross-sectional study. East African Health Research Journal, 2023. 7(1): p. 1-6.
- da Silva Filho, A.L., et al., The difficult journey to treatment for women suffering from heavy menstrual bleeding: a multi-national survey. The European Journal of Contraception & Reproductive Health Care, 2021. 26(5): p. 390-398.
- Australian Commission on Safety & Quality in Health Care (2024). Heavy Menstrual Bleeding Clinical Care Standard – updated clinical standard emphasizing diagnosis, informed choice, and least invasive effective treatment.
- Maphiri, A.M. and T. Bongongo, Profile of women requesting intrauterine contraceptive device at a public health facility in Pretoria, South Africa. The Open Public Health Journal, 2023. 16.
- Ramsay, J., et al. Navigating treatment options: a qualitative study exploring Australian women’s decision-making experiences and satisfaction with treatment of heavy menstrual bleeding. BMC Women’s Health, 2025. 25 (327): p. 1-14.
- Cooper, N.A.M., et al., Qualitative study exploring which research outcomes best reflect women’s experiences of heavy menstrual bleeding: stakeholder involvement in development of a core outcome set. BMJ open, 2023. 13(7). p. 1-10.
- Obeagu, E.I., Prevalence and risk factors of heavy menstrual bleeding in Africa: a narrative review. Annals of Medicine and Surgery, 2025. 87(7).
- Mokgethi, N.E. and M. Mofokeng, Health care providers’ experiences in expanding access to contraceptive implants in South Africa. South African Journal of Public Health, 2024. 7(3): p. 112–117
