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DOI: clinical their into care health menstrual Keywords: incorporate needs better the health should pediatricians address effectively To patients, area. female this of in gaps knowledge exhibit and menstruation surrounding tions self- lower topics. significantly Conclusions: these had of knowledge and measured topics, and patients menstruation-related rated to evaluate menstruation- regarding in patient-education likely Gaps provide less patients. significantly and were with cycles pediatricians products Male feminine noted. discuss were last to knowledge their unlikely related of were date the majority patients The ask pre-menarchal (28.4%). or to (33.1%) period menstruation patients post-menarchal regarding with guidance menstruation anticipatory discuss provide (24.7%), patients routinely not do they reported were Many (58.2%) pediatricians the of majority all The at Caucasian. were 79.2% female, were 78.8% criteria; inclusion and correlates between Results: associations randomly. assess stateselected to mem- used each were in AAP regressions pediatricians logistic 2500 and pediatricians to t-tests, with tests, emailed U approach, Mann-Whitney was sampling geographically-stratified questionnaire a The using topics. bers menstruation-related regarding practices clinical pediatricians Methods: examines topics. study health this menstrual Additionally, surrounding products. attitudes feminine and menstruation patients evaluating about routinely by recommendations (AAP) Pediatrics Objective: 3 2 1 products feminine and menstruation surrounding practices Pediatricians Milanaik Ruth Singer R. Miriam GRUYTER DE 00Wle eGutrGb,Berlin/Boston. GmbH, Gruyter de Walter 2020 © Milanaik Ruth Abstract: eateto eitis tvnadAeadaChnChildren Cohen Alexandra and Steven Pediatrics, of Department iiino eeomna n eairlPdarc,See n lxnr oe Children Cohen Alexandra and Steven Pediatrics, Behavioral and Developmental of Division oadadBraaZce colo eiiea osr/otwl,Hmsed Y S,E-mail: USA, NY, Hempstead, Hofstra/Northwell, at Medicine of School Zucker Barbara and Donald Mlninrheleu https://orcid.org/0000-0002-2352-702X. [email protected]. ok 93Mru vne ut 3,Lk ucs,N 14,UA hn:+1-0-10 a:+1-0-11 E-mail: +516-802-6131, Fax: +516-802-6100, Phone: USA, 11042, [email protected] NY Success, Lake 130, Suite Avenue, Marcus 1983 York, al Mlninrheleu https://orcid.org/0000-0002-2352-702X. [email protected]. mail: 10.1515/ijamh-2019-0179 ” ronly or iehnrdadegte u f20 eitiin atcptd(epnert 07) 6 met 462 20.7%), = rate (response participated pediatricians 2500 of out eighteen and hundred Five uut2,2019; 21, August eiiehgee eace menstruation menarche, hygiene, feminine 3ie nieqetoniewsdvlpdt vlaepediatricians evaluate to developed was questionnaire online 53-item A stecrepnigauthor. corresponding the is hssuyivsiae hte rmr aepdarcasahr oteAeia cdm of Academy American the to adhere pediatricians care primary whether investigates study This ’ ocrignme fpdarcasi ainlsml ontaieb A recommenda- AAP by abide not do sample national a in pediatricians of number concerning A nweg,attdsadpractices. and attitudes knowledge, “ 1,2,3 slightly 1 iiaSood Nikita / ” aiirwt h A udlnso niiaoygiac urudn menarche. surrounding guidance anticipatory on guidelines AAP the with familiar Accepted: ’ nweg,attdsand attitudes knowledge, 1 l Rapoport Eli / oebr1,2019 17, November 1 aln Gim Haelynn / nentoa ora fAoecn eiieadHat.22;20190179 2020; Health. and Medicine Adolescent of Journal International ’ eia etro e ok aeSces Y S,E- USA, NY, Success, Lake York, New of Center Medical s 1.Ti ulcto,rafre n21,includes in 2015, reaffirmed publication, This [1]. 1 nrwAdesman Andrew / ’ esra ylsadeuaigpatients educating and cycles menstrual ’ eia etro New of Center Medical s ’ nweg,attdsand attitudes knowledge, 1,2 / ’ nweg and knowledge esrainin Menstruation ’ menstrual “ not 1 Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd hi ouaiyadbcuete r h he rdcsmnindo ACOG on mentioned products three early the in are patients they with because product and each popularity discussing their of likelihood their (12 and adolescence cups) menstrual pads, developed menstrual were pons, section this be in should females ucts Items young that products. recommendation AAP/ACOG these the on surrounding based practices patient-education and differentiate products to patient ability girl adolescent the the girls, evaluate to adolescent how know of to skill [2]. patterns flow the [1], menstrual menstrual and normal menstruation, the abnormal considered of and is normal understanding between what an on have and to products clinicians feminine of use the on tient period menstrual the first regarding a in- attitudes of recommendations, and AAP/ACOG knowledge specific self-rated on based their developed as cluding: were well items as These cycle, menstruation. of menstrual discussion the of discussion final and The ation feedback. incorporate to Appendix. the revised in subsequently anadoles- found and be content, can including and questionnaire pediatricians 53-item clarity care for primary specialist) five was medicine residents, questionnaire pediatric cent initial (two The physicians aged19 menstruation. seven with on seven females experiences pilot-tested of early group their focus regarding by a conversations structured in raised concerns specific and mendations 5 anonymous The Instrument Board Review no Institutional and the anonymous by were approved was responses Health]. study All [Northwell hygiene. This of feminine obtained. resource( in was online interest information clinical strong identifying a personally have toanadditional not may who emails pediatricians access follow-up Two offering questionnaire. email the recom- final in Guide AAP/ACOG questions the relevant factual with all summarized sent, to researchers, were answers the correct provided by and developed mendations providers, healthcare for informed resource were a pediatricians receive participate, would to incentive they an that As USA). UT, Provo, LLC, (Qualtrics software Qualtrics care. primary ineachstate providing Sections pediatricians Committees, target AAP to specifically Pediatricians belong to toparticipate. not Councils did invited or who state AAP pediatricians to per the recruitment limiting randomly, from 50pediatricians selected were selected were with approach, pediatricians sampling US stratified 2500 of total A Subjects Methods topics. these to related knowledge/practices surrounding measured knowledge self-rated between trends and topics to andexplore aims menstruation-related and study measures the Additionally, these products products. across feminine differences feminine gender and regarding assess menstruation patient-education of knowledge surrounding measured and attitudes self-rated and (3) investigate practices to pediatricians is (2) study explored cycle, this has of menstrual date purpose pediatricians the to care Thus, study area. primary no clinical US important health, this menstrual in practices to or related attitudes knowledge, topics about patients educating and Adolescents [3]. AAP and providers the Children, pediatric Infants, in of emphasized Supervision Health further for are Guidelines recommendations These [2]. [1], 2 eto ehd 1 tm,5pitLkr cls vlae pediatricians evaluated scales) Likert 5-point items, (15 Methods Section pediatricians assessed scales) Likert 5-point items, (11 Introduction Section through created questionnaire online an to link a and study the of explanation an emailed were Pediatricians pediatricians highlighted have ACOG and AAP the While ” ’ is a fhrls esra eidadteptenofmenses pattern and the period menstrual her last of day first s 1,[] h is ieiesakdpdarcast aeterkoldeo he eiieproducts (tam- feminine of three their knowledge rate to pediatricians asked items nine first The [2]. [1], ” igre al. et Singer opdarcaswocmltdteqetonie[] hsscn netv a neddt motivate to intended was incentive second This [4]. questionnaire the completed who pediatricians to ) “ lncassol dct il n hi aeaes(..prnso urin)aotwa oexpect to what about guardians) or parents (e.g. caretakers their and girls educate should Clinicians – 3yas n i-dlsec (16 mid-adolescence and years) 13 – i nieqetoniewsdvlpdb h eerhr ae nAPAO recom- AAP/ACOG on based researchers the by developed was questionnaire online min 7 “ ” eiieHgeeFc Sheet Fact Hygiene Feminine ; “ negrsbgnmntuto,ciiin hudaka every at ask should clinicians menstruation, begin girls Once ’ 1 rcie n tiue urudn h vlainaddsuso fthe of discussion and evaluation the surrounding attitudes and practices (1) : – 17 years). These specific products were selected based on selected were products specific These years). 17 ” pncmlto fteqetonie hsclinical This questionnaire. the of completion upon ’ ’ seta oei vlaigtemntulcycle menstrual the evaluating in role essential s “ hc rvdseiec-ae udneto guidance evidence-based provides which , ebrDirectory Member ” ’ eet(07 dto of edition (2017) recent s ; “ on females Young “ ntutdo s ffmnn prod- feminine of use on instructed ’ efrtdkoldeo feminine of knowledge self-rated ’ ’ fiilmenstrual-education official s rcie eae oteevalu- the to related practices – ” 3yaswoparticipated who years 23 ” and ; sn geographically a using … “ hudb instructed be should DDMedication ADHD “ … ti motn for important is It ii o h pa- the for visit rgtFutures: Bright EGRUYTER DE ” ’ Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd 88 n=34 ftesml a eaead7.%( 6)ietfe sCuain ute apecharac- sample Further 1: as Caucasian. Table identified 366) = (n 79.2% US); 1. and the Table female in in was practicing shown sample currently are and the pediatrician; teristics 20.7%) of care = 364) primary rate = (self-reported (response (n criteria questionnaire 78.8% inclusion the the completed met pediatricians (89.2%) 518 462 emailed, pediatricians 2500 the Of Results (R 3.5.2 version R, significant. software statistically statistical considered were the 0.05 using than less performed p-Values 7.3 regres- version were MASS, odds logistic analyses package and All Foundation), gender. proportional for using controlling identified sions, were menstruation/tampons concerning edge/practices using thetwo-sided gender. and wereidentified items individual to scales responses these of for genders results between were Welch as Differences scales, composite items. create tampon-related to summed for were error items were I menstruation-related Type for responses Results be of correctness. to [7]. for Distributions items found Likert items. been 5-point has Likert for which 5-point 0.05 test, of as U alpha scored Mann-Whitney an were two-sided at robust 2 the using and gender 1 across sections compared in items to Responses analysis Statistical setting the reported their also of Pediatricians rural) practice. suburban, (urban, in density years population of surrounding practice. number and hospital-based) and clinic, residence practice, of (private region and state nicity, use focus tampon the hymen; by the identified and tampons areas between on relationship [6]. based use; swimming) inserted; tampon were when left for three be age and can (minimum tampon important sleeping) as time when (maximum group use tampons and tampon Drug Administration use Food safely absorbency; the to tampon know by tam- safest to regarding consumers for know identified cycle as important information on should menstrual as sources, (FDA) pediatricians based alternative the were information using questions evaluate developed what three properly Specifically, were specify pons. to items) not physicians (six do tampons for in- recommendations about AAP/ACOG on necessary questions directly deemed Knowledge-based based ACOG [2]. were and [1], items) (eight AAP menstruation the about formation questions Knowledge-based usage. tampon werealsoincluded. safe group focus the by asimportant identified topics tampon-related specific discussing of hood page, GRUYTER DE Gender pediatrician of Characteristics Region Race soitosbtenmaue nweg ocrigmntuto/apn n efrtdknowl- self-rated and menstruation/tampons concerning knowledge measured between Associations system binary a on scored were 3 section in items tampon-related and menstruation-related to Responses pediatricians solicited (13 items) section final The pediatricians assessed multiple-choice) items, (14 Results Section Northeast West South Other Islander Hawaiian/Pacific Native American Black/African Hispanic/Latino American Asian/Asian White/Caucasian Male Female Other a “ ’ w-apetts.Mliait oitcrgeso a sdt xlr soitosbtencorrectness between associations explore to used was regression logistic Multivariate t-test. two-sample s orFrtPro Epcal o Teens) for (Especially Period First Your apecaatrsiso rmr aepdarcas( 462). = (n pediatricians care primary of characteristics Sample – ” 12RCr em ina uti;MS,Srne,NwYork). New Springer, MASS, Austria; Vienna, Team, Core 51.2(R 5.A diinlsxqetosrgrigpediatricians regarding questions six additional An [5]. ’ eorpi nomto,icuiggne,race/eth- gender, including information, demographic ’ nweg eadn esrainand menstruation regarding knowledge igre al. et Singer 2 (26.6) 123 (31.0) 143 (79.2) 366 (78.8) 364 8(21.2) 98 (21.0) 97 o (%) No. 9(4.1) 19 (3.2) 15 (4.1) 19 (9.5) 44 ’ (0.2) 1 (0.9) 4 likeli- 3 Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd tuto.Wt epc ops-eaca ains 69 n=39 fpdarcasrpre htte discuss they that reported pediatricians of 309) = (n 66.9% with patients, menstruation post-menarchal to respect With struation. was guidance anticipatory this were felt men- 327) surrounding = guidance (n anticipatory provide they of that caregivers reported pediatricians of to 348) struation = (n 75.3% total, In knowledge self-rated and attitudes practices, clinical cycle: menstrual The a 4 of date the felt and they menstru- indicating 0.001) about knowledgeable 32.0% < only less evaluate p felt with to pediatricians 0.001), 4.76, likely < male vs. Finally, less p 3). (4.30 also 3.85, (Table were menses vs. 0.001) = They (3.29 < of p 0.001). ation p pattern < 4.22, 3.97, their vs. p vs. about (3.61 4.13, LMP (3.55 patients vs. their (3.78 asking patients Similarly, p important by post-menarchal 0.001). less cycle 3.76, < was with menstrual vs. p so the menstruation 3.98, (3.35 doing vs. discuss caregivers that (3.65 felt to their important and likely less and 0.005) as less 0.001) guidance were < anticipatory pediatricians of p provision male 4.10, the vs. rated and (3.65 0.002), patients = pre-menarchal 331). to = menstruation n about (71.6%, LMP their of date the and as 436) themselves = rated 2). 279) n = (94.4%, (n menses 60.4% of Overall, pattern their about patients menarchal or esraincmae o6.%o eaepdarcas(al n al 3). Table and 2 (Table pediatricians female of 68.1% to compared menstruation ujcscudslc utpeoptions. multiple select could Subjects

experience/training Clinical

practice in years of Number practice of density Geographic rciesetting Practice “ M rga npdarcgynecology pediatric in program CME gynecology pediatric in Rotation medicine adolescent in Fellowship medicine adolescent in program CME medicine adolescent in Rotation years 25 Over 21 16 11 6 1 Rural Urban Suburban Other Hospital Clinic rvt practice Private Midwest oprdt eaepdarcas aepdarcaswr eslkl opoieatcptr guidance anticipatory provide to likely less were pediatricians male pediatricians, female to Compared extremely – – – – – Years 10 Years 5 “ igre al. et Singer 5Years 25 Years 20 Years 15 o tall at not “ “ most ” most a ” motn od o h aoiyrpre htthey that reported majority The so. do to important ronly or ” “ ” most or or “ “ lotall almost “ ” lotall almost slightly a or a “ lotall almost ” ” aiirwt A udlnssronigatcptr udnefrmen- for guidance anticipatory surrounding guidelines AAP with familiar ” r-eaca ains n 21 n=27 eotdta hyeducate they that reported 287) = (n 62.1% and patients, pre-menarchal r-eaca ainsaotwa oepc fmnrh.Wie70.8% While menarche. of expect to what about patients pre-menarchal ” otmnrhlptet n 86 n=33 eivdi was it believed 363) = (n 78.6% and patients post-menarchal “ “ very very ” ” or or “ extremely “ extremely “ ” very ” nwegal bu esrain(Table menstruation about knowledgeable “ eyoften very motn,temjrt 5.% 269) = n (58.2%, majority the important, ” or “ extremely ” or “ lotalways almost ” nwegal about knowledgeable EGRUYTER DE ” 2 (26.0) 120 (67.1) 310 2 (27.5) 127 (54.3) 251 (39.2) 181 6 (56.9) 263 s post- ask 3(18.0) 83 (18.2) 84 0(15.2) 70 (15.4) 71 (15.2) 70 4(18.2) 84 6(20.8) 96 8(21.2) 98 3(9.3) 43 (4.8) 22 6(3.5) 16 (6.5) 30 (0.9) 4 “ very ” Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd EGRUYTER DE

Table 2: Pediatricians’ practices, self-rated knowledge, and attitudes surrounding the discussion and evaluation of the menstrual cycle. Response (Likert score) Overall no. Female no. Male no. (%) Overall no. Female no. Male no. (%) Overall no. Female no. Male no. (%) (%) (n = 462) (%) (n = 364) (n = 97) (%) (n = 462) (%) (n = 364) (n = 97) (%) (n = 462) (%) (n = 364) (n = 97) “Almost none” (1) or “Few” (2) “Some” (3) “Most” (4) or “Almost all” (5)

“To how many of your 46 (10.0) 30 (8.2) 16 (16.5) 68 (14.7) 51 (14.0) 17 (17.5) 348 (75.3) 283 (77.7) 64 (66.0) pre-menarchal female patients do you provide anticipatory guidance about menstruation during annual well-child visits?” “With how many post-menarchal 65 (14.1) 41 (11.3) 24 (24.7) 88 (19.0) 71 (19.5) 17 (17.5) 309 (66.9) 252 (69.2) 56 (57.7) female patients do you discuss menstruation, including menstrual hygiene products such as pads and tampons, during annual well-child visits?” “How many caretakers of 71 (15.4) 48 (13.2) 23 (23.7) 104 (22.5) 78 (21.4) 26 (26.8) 287 (62.1) 238 (65.4) 48 (49.5) pre-menarchal female patients do you educate about what to expect of a first menstrual period?”

“Not at all” (1) or “Slightly” (2) “Moderately” (3) “Very” (4) or “Extremely” (5)

“Please rate your familiarity with 269 (58.2) 212 (58.2) 56 (57.7) 138 (29.9) 105 (28.8) 33 (34.0) 55 (11.9) 47 (12.9) 8 (8.2) the AAP guidelines surrounding anticipatory guidance for menstruation.” “Please rate your knowledge of 16 (3.5) 6 (1.6) 10 (10.3) 167 (36.1) 110 (30.2) 56 (57.7) 279 (60.4) 248 (68.1) 31 (32.0) menstruation from a clinical standpoint.” “How important do you think it 22 (4.8) 15 (4.1) 7 (7.2) 113 (24.5) 77 (21.2) 35 (36.1) 327 (70.8) 272 (74.7) 55 (56.7) igre al. et Singer is for pediatricians to provide anticipatory guidance surrounding menstruation to pre-menarchal female patients during annual well-child visits?” 5 Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd 6 “How important do you think it 25 (5.4) 18 (4.9) 7 (7.2) 74 (16.0) 47 (12.9) 26 (26.8) 363 (78.6) 299 (82.1) 64 (66.0) is for pediatricians to discuss menstruation (including al. et Singer menstrual products) with post-menarchal female patients during annual well-child visits?”

“Almost Never” (1) or “Rarely” (2) “Sometimes” (3) “Very Often” (4) or “Almost Always” (5)

“How often do you ask 55 (11.9) 33 (9.1) 22 (22.7) 76 (16.5) 57 (15.7) 19 (19.6) 331 (71.6) 274 (75.3) 56 (57.7) post-menarchal female patients for the first day of their last period during annual well-child visits?” “How often do you ask 11 (2.4) 5 (1.4) 6 (6.2) 15 (3.2) 6 (1.6) 9 (9.3) 436 (94.4) 353 (97.0) 82 (84.5) post-menarchal female patients about their pattern of menses (i.e. period frequency/flow) during annual well-child visits?” EGRUYTER DE Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd lorpre htthey that reported also 16 12 with cups menstrual or a was there that reported pediatricians Many knowledge self-rated and practices clinical products: Feminine b a products. feminine 3: Table GRUYTER DE aig agdfo o5. to 1 from ranged Ratings niae infcne( <0.05). (p significance Indicates esrain efrpre rcie,kolde n attitudes and knowledge, practices, self-reported Menstruation: n h hymen the and use 16 patients patients 12 patients patients practices discussion and knowledge self-rated products: Feminine menses of pattern period last their of day patients post-menarchal with products) patients pre-menarchal to guidance anticipatory menstruation for guidance anticipatory menarche of expect to what about patients patients post-menarchal with products) patients pre-menarchal to menstruation – 7ya-l ains(epciey 44,n=19 98,n=14 92,n=42.Asbtnilpercentage substantial A 412). = n 89.2%, 184; = n 39.8%, 159; = n 34.4%, (respectively, patients 17-year-old (1.23) 2.33 tampons (1.31) between 3.09 relationship discussing swimming of Frequency when use tampon discussing sleeping of (1.32) Frequency when 2.93 use tampon discussing of Frequency tampon with associated risks tampon discussing a change of Frequency to often how discussing tampon of a Frequency insert to how discussing of Frequency with – cups menstrual discussing of Likelihood 16 with pads discussing of Likelihood 16 with tampons discussing of Likelihood with – cups menstrual discussing of Likelihood 12 with pads discussing of Likelihood 12 with tampons discussing of Likelihood cups menstrual of knowledge Self-rated pads of knowledge Self-rated tampons of knowledge Self-rated their about patients post-menarchal asking of Frequency first the for patients post-menarchal asking of Frequency (including menstruation discussing of importance Rated menstruation providing of importance Rated menstruation of knowledge Self-rated surrounding guidelines AAP with familiarity Self-rated pre-menarchal of caretakers educating of Frequency (including menstruation discussing of Frequency about guidance anticipatory providing of Frequency 7ya-l patients 17-year-old patients 13-year-old Gender differences in pediatricians differences Gender “ lotnever almost – 3ya-l ains(epciey 19,n=20 35,n=15 18,n=44 or 424) = n 91.8%, 155; = n 33.5%, 240; = n 51.9%, (respectively, patients 13-year-old – – ” 17-year-old 13-year-old ’ rcie,sl-ae nweg,adattdssronigmntuto and menstruation surrounding attitudes and knowledge, self-rated practices, or – – 17-year-old 13-year-old “ rarely “ eylow very ” ics apnisrin(19,n=26,hwotnto often how 286), = n (61.9%, insertion tampon discuss ” or vrl (n Overall “ .1(.1 .6(.2 .3(0.95) 1.63 (1.03) 1.86 (1.02) (1.05) 1.86 1.71 (1.21) 2.62 (1.01) (1.28) 1.81 (1.21) 2.38 2.58 (1.22) 2.46 (1.27) (1.27) 2.24 (0.84) 2.94 1.53 (1.27) (1.07) 2.86 (0.83) 2.23 1.47 (1.06) (0.88) 2.08 (1.01) 1.49 2.55 (0.87) (1.12) 1.49 (1.06) 2.85 2.52 (1.10) (1.11) 2.79 (0.85) 3.09 1.44 (1.12) (0.78) 2.97 (1.05) 1.39 2.57 (0.80) (1.12) 1.40 (0.95) 3.09 2.25 (0.82) 1.54 (1.11) (1.09) 2.98 (0.96) 2.63 2.63 (1.08) (0.94) 1.95 2.53 (1.07) (0.93) 2.55 3.62 (1.04) (0.96) 1.86 3.52 (1.02) 3.41 (0.91) 4.30 (1.04) 3.31 (0.56) (1.38) 4.76 3.61 (0.69) (1.12) 4.66 (0.84) 4.22 3.78 (1.21) (0.83) 4.09 (0.83) 4.13 3.65 (0.79) 3.29 (0.84) (0.83) 4.06 3.98 (0.73) (0.93) 3.85 2.26 (0.84) 3.91 (0.78) (1.09) 3.73 (1.18) 2.23 3.35 (1.06) (1.09) 2.24 (1.30) 3.76 3.55 (1.12) (1.10) 3.67 (1.17) 3.97 3.65 (1.15) (1.00) 3.88 4.10 (1.05) 4.00 low 462) = ” ieiodte ol ics apn,pads tampons, discuss would they likelihood enLkr tmsoe(SD) score item Likert Mean eae(n Female 364) = ae( = (n Male 97) a igre al. et Singer etp-value test hte U Whitney <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 Mann- 0.002 0.005 0.02 0.01 0.03 0.96 0.64 0.61 b b b b b b b b b b b b b b b b b b b b b 7 Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd apn 25 s .2 .0) as(.3v.36,p<001 n esra us(.4v.19,p<0.001) < p 1.95, vs. (1.54 cups menstrual and 0.001) to < p respect 3.62, with vs. noted (2.63 were pads differences to discuss 0.001), for gender < 3). scores likely No knowledge (Table p 16 safety. less self-rated 3.52, lower significantly with and had vs. also and pediatricians usage (2.53 were male tampon 0.001) tampons Overall, They cups. to < 0.03). menstrual = related p discussing p of areas 3.09, likelihood 2.85, six vs. vs. the 2.57 2.55 of 0.001; 0.001; < each < 4). p (Table p 3.09, 39) 2.63, vs. = n 2.52 vs. (respectively, (8.4%, 2.25 cups (respectively, menstrual patients or 211) old = n the (45.7%, possessed and pads they tampons 199), sleeping between felt = relationship pediatricians when n of the use (43.1%, and minority tampon tampons 235), a 168), about Only = = 354). n n = (50.9%, swimming n (36.4%, when (76.6%, tampons hymen use with tampon associated 286), risks = n 164), (61.9%, = n (35.5%, tampons change 8 aepdarcaswr eslkl hnfml eitiin odsustmosadpd ih12 with pads and tampons discuss to pediatricians female than likely less were pediatricians Male igre al. et Singer “ high ” or “ eyhigh very – 7ya-l patients 17-year-old ” knowledge EGRUYTER DE – 13-year- Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd EGRUYTER DE

Table 4: Pediatricians’ self-rated knowledge and patient-education practices regarding feminine products. Response (Likert score) Overall no. Female no. Male no. (%) Overall no. Female no. Male no. (%) Overall no. Female no. Male no. (%) (%) (n = 462) (%) (n = 364) (n = 97) (%) (n = 462) (%) (n = 364) (n = 97) (%) (n = 462) (%) (n = 364) (n = 97) “Very low” (1) or “Low” (2) “Moderate” (3) “High” (4) or “Very high” (5)

Self-rated knowledge of specific feminine product Tampons 90 (19.5) 44 (12.1) 46 (47.4) 173 (37.4) 133 (36.5) 39 (40.2) 199 (43.1) 187 (51.4) 12 (12.4) Pads 74 (16.0) 32 (8.8) 41 (42.3) 177 (38.3) 137 (37.6) 40 (41.2) 211 (45.7) 195 (53.6) 16 (16.5) Menstrual cups 352 (76.2) 268 (73.6) 83 (85.6) 71 (15.4) 60 (16.5) 11 (11.3) 39 (8.4) 36 (9.9) 3 (3.1) Likelihood of discussing product with 12–13-year-old patients Tampons 240 (51.9) 175 (48.1) 64 (66.0) 141 (30.5) 119 (32.7) 22 (22.7) 81 (17.5) 70 (19.2) 11 (11.3) Pads 155 (33.5) 109 (29.9) 45 (46.4) 162 (35.1) 126 (34.6) 36 (37.1) 145 (31.4) 129 (35.4) 16 (16.5) Menstrual cups 424 (91.8) 335 (92.0) 88 (90.7) 21 (4.5) 16 (4.4) 5 (5.2) 17 (3.7) 13 (3.6) 4 (4.1) Likelihood of discussing product with 16–17-year-old patients Tampons 159 (34.4) 109 (29.9) 49 (50.5) 152 (32.9) 123 (33.8) 29 (29.9) 151 (32.7) 132 (36.3) 19 (19.6) Pads 184 (39.8) 139 (38.2) 44 (45.4) 170 (36.8) 131 (36.0) 39 (40.2) 108 (23.4) 94 (25.8) 14 (14.4) Menstrual cups 412 (89.2) 324 (89.0) 87 (89.7) 27 (5.8) 21 (5.8) 6 (6.2) 23 (5.0) 19 (5.2) 4 (4.1)

“Almost never” (1) or “Rarely” (2) “Sometimes” (3) “Very often” (4) or “Almost always” (5)

Likelihood of addressing specific tampon-related topics How to insert a tampon 286 (61.9) 205 (56.3) 81 (83.5) 134 (29.0) 120 (33.0) 13 (13.4) 42 (9.1) 39 (10.7) 3 (3.1) How often to change a tampon 164 (35.5) 110 (30.2) 54 (55.7) 135 (29.2) 109 (29.9) 25 (25.8) 163 (35.3) 145 (39.8) 18 (18.6) Risks associated with tampon 168 (36.4) 125 (34.3) 43 (44.3) 149 (32.3) 115 (31.6) 33 (34.0) 145 (31.4) 124 (34.1) 21 (21.6) use Tampon use when sleeping 286 (61.9) 208 (57.1) 78 (80.4) 98 (21.2) 87 (23.9) 10 (10.3) 78 (16.9) 69 (19.0) 9 (9.3) Tampon use when swimming 235 (50.9) 161 (44.2) 73 (75.3) 131 (28.4) 116 (31.9) 15 (15.5) 96 (20.8) 87 (23.9) 9 (9.3) Relationship between tampons 354 (76.6) 273 (75.0) 80 (82.5) 76 (16.5) 65 (17.9) 11 (11.3) 32 (6.9) 26 (7.1) 6 (6.2) and the hymen igre al. et Singer 9 Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd tuto 6.%v.6.% .2 n apn 5.%v.7.% .0)(al 5). (Table 0.001) < p 70.7%, vs. (51.7% tampons and 0.02) = p 67.8%, vs. (63.7% struation 16 with tampons discussing of likelihood tampons(aOR, higher about and 1.43), knowledge self-rated 1.14 for higher CI, 95% predictor 1.29; significant a was questions knowledge related 16 0.94 12 (CI), interval with confidence about menstruation ation 95% 1.08; knowledge in self-rated (aOR), ratio menstruation-related anincrease on odds for score [adjusted composite predictor in significant tam- increase a time An not 5). maximum was than (Table questions the correct) more knowledge (47.2% about occur knowledgeable inserted occasionally least left were be periods safely pediatricians if can tampons, pons of necessary to length is respect average evaluation With occurs, apart. medical menarche days a 90 which whether at than and stage less menarche, Tanner menstruation, of the to bleeding about respect knowledgeable menstrua- With were tampons. about pediatricians about of questions questions half knowledge-based knowledge-based of of (4.00/6) (5.35/8) 66.7% and 66.9% tion answered correctly pediatricians average, On knowledge measured products: feminine and Menstruation 10 – aepdarcasahee oe vrg opst cr nkoldebsdqetosrgrigmen- regarding questions knowledge-based on score composite average lower a achieved pediatricians Male 0.91 CI, 95% 1.04; (aOR, olds year 17 igre al. et Singer – 3ya ls(O,10;9%C,0.95 CI, 95% 1.09; (aOR, olds year 13 – .6,hge ieiodo icsigtmoswt 12 with tampons discussing of likelihood higher 1.46), – .9.Hwvr -on nraei opst cr ntampon- on score composite in increase 1-point a However, 1.19). – .5,o h ieiodo icsigmntuto with menstruation discussing of likelihood the or 1.25), – 7ya ls(O,11;9%C,1.01 CI, 95% 1.14; (aOR, olds year 17 – .4,telklho fdsusn menstru- discussing of likelihood the 1.24], – 3ya ls(O,12;9%C,1.25 CI, 95% 1.27; (aOR, olds year 13 – 1.28). EGRUYTER DE – Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd EGRUYTER DE

Table 5: Pediatricians’ measured knowledge of menstruation and tampons and comparisons across gender. No. (%) correct Logistic regression Overall (n Female (n Male (n Odds ratio (95% p-Value = 462) = 364) = 97) CI) Menstruation-related questionsa “What is the median age of menarche?” [12–13 years old] 326 (70.7) 260 (71.4) 66 (68.0) 1.17 (0.72, 1.89) 0.52 “At what Tanner stage breast development does menarche typically occur?” [Stage IV] 169 (36.7) 145 (39.8) 24 (24.7) 2.01 (1.23, 3.40) 0.007d “What is the typical length of bleeding for first menses?” [2–7 days] 186 (40.3) 154 (42.3) 32 (33.0) 1.49 (0.94, 2.41) 0.10 “How long after onset of breast development does menstruation typically begin?” [2–3 years] 438 (95.0) 352 (96.7) 86 (88.7) 3.75 (1.58, 8.84) 0.002d “Please indicate whether a medical evaluation may be necessary in the following scenario for an otherwise normally developing female patient” “Menstrual periods have not started by 15 years of age” [Yes, medical evaluation may be necessary] 331 (71.8) 251 (69.0) 80 (82.5) 0.47 (0.26, 0.82) 0.01d “Menstrual periods have not started within 3 years of thelarche” [Yes, medical evaluation may be 368 (79.8) 294 (80.8) 74 (76.3) 1.31 (0.75, 2.21) 0.33 necessary] “Menstrual periods are irregular within the first year of menarche” [No, medical evaluation is not 455 (98.7) 360 (98.9) 95 (97.9) 1.89 (0.25, 9.86) 0.46 necessary] “Menstrual periods occasionally occur more than 90 days apart” [Yes, medical evaluation may be 194 (42.1) 157 (43.1) 37 (38.1) 1.23 (0.78, 1.96) 0.38 necessary] Tampon-related questions “What is the maximum time a tampon can remain in the body before it should be removed?” [8 h]b 218 (47.2) 178 (48.9) 39 (40.2) 1.42 (0.91, 2.26) 0.13 “True or False: Patients should use the lowest effective absorbency tampon in order to minimize risk 288 (62.3) 250 (68.7) 38 (39.2) 3.40 (2.15, 5.45) <0.001d of TSS?” [True]b “Can girls/women sleep with a tampon in?” [Yes, but tampon should be removed within 8 h]b 287 (62.1) 243 (66.8) 43 (44.3) 2.52 (1.60, 4.00) <0.001d “Is there a recommended age at which patients can start using tampons, given they have started 365 (79.0) 319 (87.6) 45 (46.4) 8.19 (4.96, 13.69) <0.001d menstruation?” [No, it is up to patient preference]c “Can girls/women swim in the ocean with a tampon inserted?” [Yes]c 376 (81.4) 311 (85.4) 64 (66.0) 3.03 (1.81, 5.04) <0.001d “If a girl with an intact hymen uses a tampon, can the tampon tear her hymen?” [Yes, it could tear the 317 (68.6) 244 (67.0) 72 (74.2) 0.71 (0.42, 1.16) 0.18 hymen but it is unlikely]c

Composite score Average no. correct (%) t-Test p-value

Menstruation-related questions (scored from 0 to 8) 5.35 (66.9) 5.42 (67.8) 5.09 0.02d

(63.7) al. et Singer Tampon-related questions (scored from 0 to 6) 4.00 (66.7) 4.24 (70.7) 3.10 <0.001d (51.7) 11 Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd 12 aInformation included based on American Academy of Pediatrics (AAP)/ American College of Obstetricians and Gynecologists (ACOG) recommendations.

bInformation included based on Food and Drug Administration (FDA) consumer information (FDA 2018). al. et Singer cInformation included based on female focus group. dIndicates significance (p < 0.05). EGRUYTER DE Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd xadn t ain dcto aeil[] ial,bodrefrst euescea tgasurrounding stigma societal reduce to efforts broader Finally, [5]. material education patient resources a its patient-education be expanding would some ACOG resources Though as these education. visits, such patient well-child exist, of supplement currently constraints to time pediatricians the for Given web- way role. and convenient important pamphlets cycle an as play menstrual should such also the materials resources can of patient-education evaluation these sites Third, Fu- Additionally, the topics. regarding Bright [3]. menstruation-related physicians of [2], AAP for discussion guidance [1], the and detailed disseminated and more widely provide Opinion to more expanded Committee be information, be AAP/ACOG also Existing medical the [25]. should for including pediatricians Guidelines, Internet study, for tures the this specifically these include on developed in be rely should referenced should frequently resources menstruation physicians practices, to that physician related show influence resources studies web-based effectively as to Second, shown [24]. education been topics medical have continuing interactive which First, programs, topics. menstruation-related (CME) of discussion accurate Given and provide cycle [23]. pediatricians menstrual menstruation that topics. with school important these associated particularly regarding in stigma caregivers is education their the it menstrual and and education, adolescents school, constraints to health in their information time menstrual topics inform to to properly these due to barriers about absent ability these learn or their may minimal inhibiting girls often area, While is this [22]. in [21], knowledgeable moth- not [17], many that are daughters indicates females research Moreover, adolescent [20]. of of topic this components ers discussing important uncomfortable feel addresses mothers many that that care medical seenby receive to andadolescents likely girls less health. even young female that be suggest may findings pediatricians scores These knowledge male andself-rated assessed. topics measured menstruation-related lower femi- all significantly discuss obtained for and also cycle pediatricians menstrual and Male the patients products. evaluate pre-menarchal nine patients, to post-menarchal guidance with anticipatory menstruation provide discuss to caregivers, likely less were pediatricians male diatricians, not ofpediatricians do gaps knowledge predictor pediatricians patients. by significant why with explained a unclear usage/safety partially was tampon is knowledge be tampon-related it may as While trend previous area, this [19]. given this products, [17], in concerning improperly feminine are about used serious patients results if pose educate syndrome These can routinely shock which [18]. toxic products, [17], feminine as use about such knowledge tampon risks lack about generally adolescents them that to showing talked research ever 11 doctor most no while that that found This study [16]. [15], one alternative example, popular pediatricians For percentage increasingly examining higher studies an even previous cups, an with menstrual is consistent with discuss tampons), finding routinely and not (pads do products they common that most reporting the discuss routinely not abnormal do of identify they to lack ability a their demonstrated health. impede patient also further evaluate comprehensively may Respondents and which health. patterns menstruation, patient menstrual of abnormal assess areas routinely rate, fully certain patients to heart about to failing the knowledge by or needed regarding Thus, pressure information information [14]. key blood important [13], for [12], abnormal miss [2], ask to [1], or similar conditions menstruation that, health discuss shows serious indicate Research patients may LMP. post-menarchal ask patterns their routinely menstrual not of do discuss date four routinely in the one not for over do and surveyed patients, pediatricians post-menarchal with three menstruation in one Approximately recommendations. AAP/ACOG unprepared are [11]. and [10], menstruation [9], anticipa- surrounding concerns on anxiety menstrual whohave guidelines greater identify girls experience that to AAP given menarche the about be concerning with educated may particularly unfamiliar been are This not were findings caregivers. These pediatricians educate menstruation. most surrounding routinely that guidance to to tory fact menstruation failing the surrounding proportion by key guidance higher explained How- follow even anticipatory partially [8]. not provide an one [2], routinely do with approximately not pediatricians patients, example, [1], do For pre-menarchal care health surveyed adolescents. primary female pediatricians and many girls four of that in in component demonstrate menstruation study critical surrounding national a recomm hr r eea ast mrv pediatricians improve to ways several are There show studies health, menstrual about females young educate may mothers, especially parents, Although to femalepe- Compared area evaluated. every in almost differences gender significant were there Notably, that reported pediatricians of majority the products, feminine regarding patient-education to respect With with line in care receiving be not also may menarche experienced already have who Adolescents ’ webpage, s “ orFrtPro Epcal o Teens) for (Especially Period First Your – 8ya-l eae aeue apn,temjrt report majority the tampons, used have females 18-year-old ’ nweg n rcie urudn h vlaino the of evaluation the surrounding practices and knowledge ’ ieiodo icsigfmnn products. feminine discussing of likelihood ’ esra yls eitiin may pediatricians cycles, menstrual ” h A hudconsider should AAP the , ’ ieiodo discussing of likelihood igre al. et Singer 13 Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd iaca disclosure: Financial source: Funding of interest: conflicts Potential development the to essential were that conversations structured Fruit- questionnaire. thank Kate in the Schecter, to of participating Rachel like Kiely, for also Bridget Sidhu) would Gao, We Sharnendra Ruiyi clarity. Rigsby, man, Devyn and Kuznetsova, content and (Anna for MD, members Waters, questionnaire group Joseph the MD, focus Sklar, reviewing Jamie for MD, Hambrook, MD, Megan Papaioannou, MD, Helen Chung, Richard thank to like would We Acknowledgments menstruation. surrounding pediatricians adolescent recommendations increase improve AAP to to to adherence Efforts initiatives topediatricians and products. respect include feminine with should and noted health menstruation were female regarding practices differences clinical ac- gender and Significant in have knowledge attitudes cycle area. pediatricians menstrual clinical many educate that this the routinely reveal evaluate in not findings gaps or do the Moreover, pediatricians topics recommendations. of menstruation-related AAP number about with concerning caregivers cordance a their that and suggest patients study female national this of results The Conclusion pediatricians into insights health. menstrual unexplored surrounding reflect previously fully and not may important questions vides these on scores group), pediatricians by focus highly relevant reviewed FDA, from was Opinion, questionnaire were developed Committee the (AAP/ACOG While questions sources the knowledge-based validated. and formally not pediatricians was study non-affiliated multiple this menstruation-related of in knowledge used measure instrument to instrument findings the may existing topics, the an of that absence the to indicate due Finally, factors knowledge. these Together, desirability. social pediatricians by overestimate affected been have may nation- responses pediatricians been care have primary may pediatricians of Moreover, pediatricians, 66.9% [31]. male to compared ally than female, average were on respondents of scores 78.8% higher as overrepresented, had who to pediatricians, topic female the Also, in interest. interested pediatricians encouraged the have though may questionnaire participate, the a completed care offering Additionally, who memberdirec- study. primary AAP respondents this the to US of from generalizability of the ofpediatricians representative limited have fully sampling may stratified be tory example, not For [30]. may [29], sample [28], the [27], pediatricians methods, their online using from pediatricians health surveyed menstrual about information out seek actively [26]. to providers patients encourage would menstruation 14 female on sheet fact time! your a given for be advance will in you you survey, Thank the guidelines. completing Your health to After women. right adolescent time. and the any have girls You at questions. of participation the health all from the answer withdraw improving Please towards anonymous. are step responses important Your voluntary. an is is participation study This health! menstrual and Appendix Introduction hssuyhssvrllmttos lhuhtersos ae(07)i oprbet te tde which studies other to comparable is (20.7%) rate response the Although limitations. several has study This hn o o geigt opeeti -i R-prvdsre eadn dlsetfmnn hygiene feminine adolescent regarding survey IRB-approved 5-min this complete to agreeing for you Thank igre al. et Singer ’ vrl nweg.Dsieteelmttos hssuy elcigalrentoa ape pro- sample, national alarge reflecting study, this limitations, these Despite knowledge. overall ofnigwsscrdfrti study. this for secured was funding No h uhr aen iaca eainhp eeatt hsatcetodisclose. this article to relevant relationships financial no have authors The “ DDMdcto Guide Medication ADHD ’ vrl deec oAPAO eomnain n efrtdadmeasured and self-rated and recommendations AAP/ACOG to adherence overall h uhr aen ofit fitrs eeatt hsatcetodisclose. article this to relevant of interest conflicts no have authors The ’ rcie eesl-eotd n huhteqetoniewsanonymous, was questionnaire the though and self-reported, were practices ” a sdt netvz atcpto needn fthis of independent participation incentivize to used was ’ nweg fmntuto-eae topics menstruation-related of knowledge ’ nweg,attds n practices and attitudes, knowledge, “ eiieHgeeFc Sheet Fact Hygiene Feminine ’ knowledge, EGRUYTER DE ” Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd 1. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. 3. 2. 1. GRUYTER DE eto .AttdsadPatcsSronigteEauto n icsino Menstruation of Discussion and Evaluation the Surrounding Practices and Attitudes 1. Section eto .PtetEuainPatcsadSl-ae nweg urudn eiieHgeeProducts Hygiene Feminine Surrounding Knowledge Self-Rated and Practices Patient-Education 2. Section o aycrtkr fpemnrhlfml ainsd o dct bu htt xeto is men- first a of expect to what about educate you do patients female pre-menarchal of caretakers many How menstru- about guidance anticipatory provide you do patients female pre-menarchal your of many how To (elaborate)] [Yes/No/Other pediatrician? care primary a yourself consider you Do you that information The minutes. few a take only will It participate? to want not do you sure you Are participate. to like would I and study, voluntary a is this that understand I statements, above the reading After hndsusn apn ihyu ains o fe oyudsustefloigtopics? following the discuss you do often how patients, your with tampons discussing When knowledgeable/Slightly all at standpoint.[Not clinical a from menstruation of knowledge your rate menstruation. Please for guidance anticipatory surrounding guidelines AAP the with familiarity your rate Please length? cycle menstrual normal of range the about educate you frequen- do period girls adolescent (i.e. of menses caretakers many of How pattern their about annual patients female during post-menarchal period ask last you their of do often day How first the for patients female post-menarchal ask you do often How hygiene menstrual including menstruation, discuss you do patients female post-menarchal many how With old/7 years 7 [Under patients?* female with menstruation discussing start generally you do age what At aeaeso otptet/aeaeso lotalpatients] patients/- all some almost of of patients/Caretakers few patients/Caretakers of most patients/Caretakers of no Caretakers almost of [Caretakers period? strual patients/Al- patients/Most patients/Some patients] patients/Few all no most [Almost visits? well-child annual during ation selects respondent if survey of End survey/No, this taking “ continue will selects I respondent [Yes, if survey] survey! survey this End this in complete participate to to choose like you not if would sheet I fact women around a practices get improve also help can will and important is with us provide selects respondent If [Yes/No] c. b. a. important/Slightly all at [Not visits? well-child annual important] during important/Extremely important/Very patients important/Moderately female post-menarchal with ucts) important/Slightly all at [Not visits? well-child important] annual important/Extremely during important/Very important/Moderately patients female pre-menarchal to struation knowledgeable] knowledgeable/Extremely knowledgeable/Very knowledgeable/Moderately familiar] familiar/Extremely familiar/Very familiar/Moderately familiar/Slightly all at [Not of patients/Caretakers some of patients] patients/Caretakers all almost few of of patients/Caretakers patients/Caretakers most no almost of [Caretakers always] often/Almost never/Rarely/Sometimes/Very [Almost visits? well-child annual during cy/flow) always] often/Almost never/Rarely/Sometimes/Very [Almost visits? well-child patients/- patients/Few no [Almost visits? well-child patients] annual all patients/Almost during patients/Most tampons, Some and pads as such products old/8 years 8 old/14 o motn oyutiki sfrpdarcast ics esrain(nldn esra prod- menstrual (including menstruation discuss to pediatricians for is it think you do men- important surrounding How guidance anticipatory provide to pediatricians for is it think you do important How Yes ik soitdwt apnue[lotnvrRrl/oeie/eyotnAms always] often/Almost never/Rarely/Sometimes/Very [Almost use tampon with associated Risks o oisr apn[lotnvrRrl/oeie/eyotnAms always] often/Almost never/Rarely/Sometimes/Very [Almost tampon a insert to How o fe ocag apn[lotnvrRrl/oeie/eyotnAms always] often/Almost never/Rarely/Sometimes/Very [Almost tampon a change to often How ” oqeto or 1 question to – 5yasold/15 years 15 – er old/9 years 9 “ “ No, – e,Iwl otnetkn hssurvey this taking continue will I Yes, 6yasold/16 years 16 ” diinlquestion: additional – 0yasold/10 years 10 “ o ol o iet atcpt nti survey. this in participate to like not would I No, “ No. – 7yasold/17 years 17 ” frsodn selects respondent If – 1yasold/11 years 11 – 8yasodOe 8yasold] years 18 old/Over years 18 – ” 2yasold/12 years 12 oqeto ,adtoa questions: additional 2, question to “ Yes ” or “ ’ Other, elh laermme you remember Please health! s – 3yasold/13 years 13 ” ” diinlquestions: additional frsodn selects respondent If igre al. et Singer – 4years 14 15 – Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd 9. 8. 7. 6. 5. 4. 3. 2. 1. 4. 3. 2. 16 10. eto .KoldeBsdQetos apn Qetos19 (Questions Tampons Questions: Knowledge-Based 3. 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Medication ADHD Elk The ed. A. 4th Adesman Adolescents, [4] and Children, Infants, of Supervision Health for Guidelines Futures: Bright eds. PM, Duncan JS, Shaw JF, Hagan Men- [3] 651: No. Opinion. Committee ACOG Care. Health Adolescent on Committee Gynecologists and Obstetricians of College American [2] Adoles- on Committee Gynecologists and Obstetricians of College American Adolescence, on Committee Pediatrics of Academy American [1] References 9. 8. 7. 6. 5. 4. 3. 2. 1. 11. GRUYTER DE 5 mrcnCleeo bttiin n yeooit.Yu is eid(seilyfrTes.https://www.acog.org/Patients/FAQs/Your- Teens). for (Especially Period First Your Gynecologists. and Obstetricians of College American [5] eto .DmgahcInformation Demographic 4. Section o o ayyashv o enpatcn?[1 practicing? been you have years many how For [ apply. that all check Please identify? you do How [Male/Female/Other] gender? your is What o ayduhesd o aei h olwn g ranges? age following the in have you do in daughters [Rotation many apply. 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Breech MR, Laufer A, Diaz Care, Health cent 45/46 lander American is-eidEpcal-o-en.Acse ac ,2019. 2, First-Period-Especially-for-Teens. 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Northwell Center Medical s – 15/16 ” / “ – White/Caucasian 20/21 ” / – “ 25/26 aieHwia/aii Is- Hawaiian/Pacific Native – – 6. 30/31 ” / “ igre al. et Singer – Black/African 35/36 ” itdas listed – 40/41 17 – Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd 3]Tee S ikB ua ,RcesnJ,Pri M eea eitiin n au-ae amns eitis 2018;142(4):e2018050. Pediatrics. payments. value-based and pediatricians General JM. Perrin JE, Richerson M, Hudak B, Sisk JS, Tieder [31] Pediatricians DR. Durbin BD, Hoffman practices EK, Sauber-Schatz clinical MR, and Zonfrillo knowledge, attitudes, [30] of examination An DL. Bogen WC, Barnhart K, Colborn ED, Davies DR, Moss CA, ill- Lucero pediatric [29] inpatient common of management in CP. Variations Landrigan MC, Ottolini V, Chiang E, Stucky S, Edwards PH, Conway [28] 2013;68(1):9 Pediatricians Roles. SB. Sex Kinsella stigma. RL, social Carl as [27] menstruation mark: menstrual The JC. Chrisler I, Johnston-Robledo [26] Physicians S. Strasser R, Kristofco L, Casebeer N, Bennett education [25] continuing traditional other or rounds workshops, conferences, do education: medical continuing formal of Impact D. Davis [24] women western Young AG. Razor Pædi- CC, Acta Beausang menarche. [23] at girls in womanhood and menstruation towards feelings and Attitudes RK. Gunnarsson M, daugh- Möller and GI, mothers Rembeck of [22] attitudes and knowledge cycle: menstrual the and Menstruation 2010;31:831 S. Int. Women Abraham D, Care Llewellyn-Jones Health C, study. exploratory Knight multiethnic C, Lei a [21] menstruation: define girls men- Adolescent a S. of Gahagan use K, the Orringer with [20] associated syndrome shock toxic of case confirmed A SM. 1988;11(3):143 Hosseini-Moghaddam Gynecol. S, Adolesc Arntfield Pediatr S, J Bisch women. MA, young Mitchell in [19] use Tampon KC. Perkins S, Aggarwal HA, Gynecol. Omar Adolesc [18] Pediatr J use. tampon regarding mothers their and girls adolescent among Perceptions J. Varughese AB, Middleman [17] at: Available cup. the about know not might you things tampons: vs. cups Menstrual System. Health Clinic Mayo [16] J Women bleeding. Young menstrual for heavy Center with [15] females young in abnormalities Hemostatic LV. Srivaths DL, Yee D, Jr Mahoney JE, uterine Dietrich abnormal R, with Díaz adolescents [14] in disorders hemostatic of Prevalence V. Bruni E, Paladino M, Dei E, Peruzzi S, Linari V, Seravalli Gynecol. [13] Obstet women. in disease Willebrand von 580: No. Opinion Committee Gynecologists. and Obstetricians of College American [12] 2013;34(1):6 Rev. Pediatr disorders. Menstrual Nurs. SH. Sch Gray J [11] girls. post-menarcheal and pre- seventh-grade and sixth-, fifth-, among menstruation about Attitudes T. Williams Psychiatry. D, Adolesc Frank Child [10] Acad Am J menarche. of significance interpersonal and Sci. personal Acad The S. Y Jacobson N J, Ann Rierdan adolescents. E, in Koff health [9] general of marker biological a cycle: menstrual The LM. 2010;15(11):1 Nelson Eval. KA, Res Calis Assess T, Mann-Whitney-Wilcoxon. Pract Prodanov versus VB, test Popat t [8] Items: Likert Five-Point D. Dodou JC, Winter de [7] Tampons on Facts The Administration. Drug and Food U.S. [6] 18 asne aey eit.2014;165(5):1040 Pediatr. J safety. passenger 2009;4(2):83 Med. Breastfeeding smoking. and breastfeeding regarding pediatricians Pennsylvania among 2006;118(2):441 Pediatrics. pediatricians. community and hospitalists nesses: 2014;53(7):689 Pediatr. Clin study. cross-sectional a management: sion 2004;24(1):31 1999;289:867 Assoc. Med Am J outcomes? care health or behavior physician change activities 28. 2006;95:707 atrica. 1987;8(1):33 Fam. Marriage Sex J Aust ters. 2015;26(4):218 Microbiol. Med Dis Infect J Can cup. strual 2012;25(4):267 2019. 28, January Accessed 2016. Updated about-the-cup. https://mayoclinichealthsystem.org/hometown-health/speaking-of-health/menstrual-cups-vs-tampons-things-you-might-not-know- 2019. 28, January Accessed 2016. Updated https://youngwomenshealth.org/2013/03/28/period-products/. 2014;27:324 Gynecol. Adolesc Pediatr 2013;26:285 Gynecol. Adolesc Pediatr J bleeding. 2013;122:1368 1999;15:25 1981;20(1):148 2008;1135:43 2019. 28, January Accessed 2018. https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm612029.htm. Updated igre al. et Singer – 31. – – – – 51. – 8. 73. 58. 9. – 14. ’ elh eidPout:IfrainaotTmos as n oe vial at: Available More. and Pads, Tampons, about Information Products: Period Health. s ’ nweg fcretsot ocsinlgsainadgieie n ofr ihsot concus- sports with comfort and guidelines and legislation concussion sports current of knowledge – 9. – 42. – 5.e52. ’ xeine fmnrh n esrain elhCr oe n.2010;21(6):517 Int. 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