Menstruation is the natural process in which normal uterine bleeding occurs once every month [1]. Normal menstruation often disrupts women’s physical, mental, social, and cultural well-being [2]. On the other hand, abnormal uterine bleeding (AUB) refers to continuous bleeding and its pattern, volume, and duration are longer and sometimes overlap the menstrual periods for long periods of time [3,4]. AUB affects the women’s health-related quality of life, sexuality, intimate relationships, social life, and participation, mental health (including anxiety, stress, and depression), access to education and employment opportunities, stigma and shame, and economic burden [5-7].

Prevalence of AUB is significantly higher in adolescents, women of reproductive age, and premenopausal age than prepubertal and post-menopausal age [8]. A study showed that the prevalence of AUB was found to be 8.9% of total women visiting the gynecology department in tertiary care hospital [9]. A study conducted in Brazil found that 31.4% of women faced AUB [10] which is aligned with another study from Ethiopia [11] but another study from India reported 18.3% of women in premenstrual age faced the problems [12]. The incidence of AUB worldwide is estimated to be 3-30% and the majority of cases occurs at menarche or near menopause [13]. Findings from a systematic review revealed that the prevalence of AUB in developing countries was found to be 5-15% [14]. Vaginal bleeding is a shared characteristic of both menstruation and abnormal uterine bleeding. This similarity might lead patients to overlook the need for diagnosis, treatment, management, and other social and cultural consequences. Given the lack of nationwide data concerning AUB, its prevalence within the community can be linked to an iceberg -predominantly concealed from view. So, this mini review tries to appraise the social and cultural issues of menstruation and AUB in Nepal.

AUB is a significant clinical entity. AUB and heavy menstrual bleeding (HMB), a subgroup of AUB, are frequent conditions that affect 14–25% of women of reproductive age. They may have a major negative impact on the physical, social, emotional, and material quality of life of these women. Every year, more than 800,000 women in the UK seek treatment for AUB. There are huge costs to the economy and health services in addition to the direct effects on the lady and her family. According to a US study, home administration expenses and missed work expenditures result in financial losses of more than $2,000 per patient annually [15].

Menstruation is the physiological process where vaginal bleeding occurs due to the shedding of the uterine mucosa. The length of the menstrual cycle varies among women, but the average duration is about 28 days from the start of the menstrual period to the next. Menstruation consists of four phases i) Menstrual phase (0-4 days) ii. Proliferative phase (0-14 days) iii. Ovulatory phase (14^th day) iv. Secretory phase (14-28 days). The menstrual cycle occurs due to a decrease in estrogen and progesterone which is followed by the proliferative phase that coincides with the follicular phase of the ovarian cycle where the endometrium regrows under the influence of estrogen from developing follicles. The ovulatory phase occurs on the 14^th day which coincides with ovulation from mature follicles in an ovarian cycle that occurs under the influence of the Luteinizing hormone. The secretory phase follows the ovulatory phase where the endometrium becomes highly vascularized and edematous due to estrogen and progesterone from the corpus luteum. Menstrual blood consists of arterial blood mainly with 25% venous blood. A normal woman's menstrual cycles typically last 3-5 days, although they can be as short as 1 day or as long as 8 days. Normal blood loss might range from a little spotting to 80 mL; the typical loss is 30 mL. An abnormal loss is one that exceeds 80 mL [16].

Irregularities in the menstrual cycle that involve frequency, regularity, duration, and volume of flow are together referred to as "abnormal uterine bleeding". The International Federation of Obstetrics and Gynecology (FIGO) has developed the helpful acronym PALM-COEIN to categorize the underlying causes of irregular uterine bleeding. Structural problems are described in the first section, PALM. Non-structural problems are described in the second section, COEI.

One or more listed below causes AUB [17] and they are-

• P: Polyp
• A: Adenomyosis
• L: Leiomyoma
• M: Malignancy and hyperplasia
• C: Coagulopathy
• O: Ovulatory dysfunction
• E: Endometrial disorders
• I: Iatrogenic
• N: Not otherwise classified

Most world religions typically have negative views and impose prohibitions on menstruation and women experiencing it except Sikhism [18]. The woman with menstruation is untouchable and ritually unclean and may not have intercourse with her according to the book of Leviticus Hebrew Bible [19]. Menstrual-related hygiene and sanitation are important components of good menstrual practices. Globally 500 million women and girls lack facilities for menstrual hygiene [20]. Since there is no direct connection between menstrual hygiene and abnormal bleeding prolonged use of more than 6 hours of tampon may cause menstrual toxic shock syndrome [21].

The studies from various countries revealed different societal attributes. A study from France found that almost 81% of women and girls preferred disposable sanitary pads [22]. Another study found that 27.2% of women had experienced heavy uterine bleeding [23]. The study from India found that menstruating girls and women were treated as taboo and discriminated against in social as well as religious activities. Hindu, Muslim, and Orthodox Jews still abide by these taboos [24]. A similar study from Bangladesh found that, menstruating women and girls are impure and restricted in socio-cultural and religious activities. Almost 91% used old, unhygienic cloths as menstrual pads [25]. However, another study from Sri Lanka found that menstruation is treated as a physiological process and related problems to hormone levels and pathological conditions of the uterus [26]. This difference may be due to the high literacy rate in Sri Lanka.

Menstruation is a natural physiological function of the female reproductive system, but it is enveloped by different myths, superstitions, religious and cultural traditions. Ancient cultural myths describe menstruation as sacred and magical, attributing it to divine gifts or punishments in the legends and prehistory of various societies.

The cultural issues surrounding menstruation are complex and deeply ingrained in Nepal. They are influenced by cultural beliefs, religious practices, and societal norms. Menstruation and childbirth involve vaginal bleeding, which has been historically deemed ritually unclean, leading to be adaptation of restrictions in various religious, social, and cultural contexts [18,27,28]. AUB creates confusion for the duration of restriction (usually 4-5 day) for menstruation and sometimes would be longer in this case. Regular bleeding creates problems of hygiene and restrictions on several activities. Most Nepali believe Hindu religion and believe that women and girls with vaginal bleeding are impure and are restricted and excluded from participation in daily, community, and religious activities. Those women and girls are prohibited from entering the prayer room/temple, kitchen, and touching male family members, sleeping on their own beds separately, and cannot even touch the beds of male members, and sometimes going to school. Menstruation is perceived as a stigma and taboo in the western hilly region of Nepal. Menstruating girls and women were unclean, and untouchable, and kept outside of their homes in a hut made from stone and mud without a lock, window and very small in height or in a cowshed called Chhaupadi [29]. At the time of menstruation, they are not only isolated from home and family but also restricted from drinking milk and dairy products and cannot touch men, water sources, plants in kitchen gardens, or visit public places [30]. A recent study revealed that most of 84% of adolescent girls were practicing these practices [31]. Cultural and sociodemographic factors contribute to inadequate personal hygiene, lack of information regarding normal and abnormal bleeding, safe water, and use of safe, clean toilets and protective absorbents [32]. The legal provision in Nepal prohibits exploitation in the name of customs, traditions, and behavior. The Supreme Court of Nepal directed the Nepal government to formulate a law to control such bad practices in May 2005 [30] but the implementation of the legal provision has not reached to affected community.

There are several social issues of menstruation and abnormal bleeding.

1. Affect on quality of life: Heavy menstrual or uterine bleeding significantly affects the quality of life more than normal bleeding among women [33]. Several other studies also support these findings [6,34]. Excessive blood loss may interfere with the physical, emotional, social, and material quality of life of women [35].
2. Social isolation: women with heavy uterine bleeding might feel socially isolated due to the fear of experiencing unexpected heavy bleeding in a public setting. A qualitative study revealed that a person with menstruating or heavy bleeding might be attributed to the perception that not adhering to the tradition of seclusion during menstruation could lead to potential religious consequences or curses [36].
3. Loss in work productivity: Some study findings revealed that work productivity has been diminished due to AUB. 20% of women with menorrhagia reported they had missed work because of their disease [37]. Other studies suggested that 40% of women with bleeding due to fibroid took leave from their work for several days a month from their works [38]. Women who needed surgical treatment took more leave than women with medical conditions [39].
4. Intimate relationship: AUB can affect intimate relationships due to physical discomfort, blood stains during coitus, unpredictable bleeding, and unclean vaginal canal, and also may lead to decreased sexual activities and communication challenges and strain on partnerships.
5. Social stigma and shame: Menstruation and AUB are subjected to various kinds of social stigma and shame. Because of social taboos, women, in rural areas of Nepal are unable to use disposable sanitary pads leads to staining, leaking, and being the source of infection of the reproductive tract [40].

The hygienic menstrual pad has an important role in maintaining menstrual hygiene. A study conducted among school girls reported only one-third use disposable sanitary pads [41]. A similar study conducted in the rural population of the mid-western region found that only 40.4% used sanitary pads [42]. The study results from the far-western province are more treacherous than other parts of Nepal, which showed that more than 70% of girls did not use disposable sanitary pads because of more expensive prices and only 44% used new clothes for their last menstruation [43]. Different factors such as education, family size, living with relatives [44], and other several sociocultural and religious factors are the major drivers behind it including illiteracy, superstitions, stigma, existing gender-based discrimination, cultural, traditional, and religious beliefs, and poor implementation of laws are major drivers behind it [30]. Nevertheless, ongoing interventions by various organizations, including education programs, income generation initiatives, local government efforts, and law enforcement, are underway, aiming to enhance and promote better practices, fostering anticipated improvements in menstrual hygiene.

All religions except Sikhism have negative views of good practice during menstruation. Nepali women from some parts of the country still follow unacceptable and unhealthy practices regarding menstruation and AUB. Restriction and prohibition of touching some food items, sleeping in the same house, and inadequate personal hygiene during menstruation are reported by many researchers as cultural issues. Health-related quality of life, sexuality and intimate relationships, social life and participation, mental health (including anxiety, stress, and depression), access to education and employment opportunities, stigma and shame, and economic burden were reported social issues in Nepal. About one-third of menstruating woman used disposable sanitary pads. To address those issues, it is essential to implement awareness initiatives, educational intervention programs, menstrual health education, thorough investigation of AUB causes, and enforcement of legal measures.