Introduction

Although menstruation is a universal phenomenon experienced by almost all women, it is still not talked about openly and continues to be a little-understood aspect of a woman’s life (Kulakaç et al., 2008). The menstrual period is a unique experience for every woman. When women start menstruating, they bond with other women and feel themselves a part of the women’s group as a whole. However, in most societies, there are sociocultural norms, such as the concealment of menstruation (Brantelid et al., 2014; Garg & Anand, 2015). A study conducted by Orringer and Gahagan (2010) on various races found that the level of knowledge of women about the menstrual period differs according to social and cultural factors. In addition, it was determined that women sometimes expressed their menstrual period in negative terms. In Türkiye, menstruation period is generally referred to as “getting dirty” or “getting sick” (Marva´n et al., 2008; Ozkan et al., 2015).

Vaginal bleeding often occurs at the beginning of the menstrual period. Having sexual intercourse during this period may be uncomfortable or undesirable for some women (Van Lonkhuijzen et al., 2023). However, some women may prefer sexual activity during their menstrual period. This all depends on personal preferences and discomfort levels. Some women may experience an increase in libido during this period (Gómez-Sánchez et al., 2012; Allen & Goldberg, 2009). After menstrual bleeding ends, women often feel more comfortable and may be more willing to engage in sexual activity. In later periods, their bodies may be more ready due to hormonal changes (Rubinsky et al., 2021). Sexual activity and desire can be affected by women’s hormonal changes and the couple’s beliefs and attitudes. However, every woman’s experience is different. In addition, the emotional and physical state of the relationship and partners also affects sexuality (Rubinsky et al., 2021; Schooler et al., 2005). Therefore, it is important for each couple to manage sexual activity by respecting their own needs and preferences (Allen & Goldberg, 2009; Gómez-Sánchez et al., 2012).

While studies on the menstrual cycle around the world generally deal with women’s feelings, reactions, and attitudes about the menstrual period and hygiene, few studies have examined how menstruation affects women’s sexual life (Brantelid et al., 2014; Kumar et al., 2011; Ozel et al., 2018). Van Lonkhuijzen et al. (2023) found that both men and women have stigmatizing attitudes toward menstruation and sexual activity during menstruation. In addition to this, Allen and Goldberg (2009) reported that half of the women and men in the study had active sexual intercourse during the menstrual period, and 10% of the women reported that they tried sexual intercourse once but never wanted to repeat it. Determining women’s views and experiences regarding sexual intercourse during menstruation is important in terms of both health and safety and relational dynamics. Open communication allows partners to respect each other’s needs and maintain a healthy sexual life.

In Turkey, sexuality is an issue that is often ignored during the menstruation period, as well as throughout a woman’s life. It is a taboo subject that is not talked about because the majority of the country’s population in Turkey is Muslim, and sexual intercourse during the menstruation period is not considered appropriate in the verses of the Qur’an (Ulu, 2012). For this reason, the subject of sexual life has never before been investigated in studies on the menstrual period in the country (Bolsoy et al., 2006; Derya et al., 2017). This study was conducted to determine the views and experiences of women in their reproductive period regarding their sexual life during their menstrual period. This study may also contribute to the development of the knowledge and awareness of health professionals and society in general about the sexual activity experiences of women during their menstrual period.

Methods

The research was conducted according to COREQ (Tong et al., 2007).

Research Question

What are the views and experiences of women in the reproductive period regarding sexual life during menstruation?

Study Population

Data were collected between January and July 2020. Participants were selected using the purposive sampling method. The sample included 16 women of reproductive age, aged 18–49 years; who had an active sexual life (engaging in any form of sexual activity with someone from touching, hugging, and kissing to sexual intercourse); had menstrual cycles; had no chronic disease; volunteered to participate in the study; and came to gynecology outpatient clinic appointments at a research hospital in Istanbul, TurkeyX. Women who did not have internet access and a smartphone, did not allow voice recording, or had a psychiatric or neurological disease were excluded from the study. Data saturation was taken into consideration when determining the sample size. Five women with any gynecological problems were excluded from the study.

Data Collection

In-depth, individual qualitative interviews were conducted to collect the data (Creswell, 2020). This technique provides detailed information about the true causes and structural determinants of feelings, thoughts, beliefs, experiences, and observations. Women who came to the gynecology outpatient clinic of the research hospital in XX were informed about the content and purpose of the study. To conduct qualitative interviews with the women who were accepted for the study in the gynecology outpatient clinic, contact information was obtained from the women, and appointments were made. Due to the COVID-19 pandemic, face-to-face meetings with women could not be held. The research was conducted via WhatsApp. One of the female researchers (FA) conducted the interviews who has an MSc degree in women’s health and disease nursing working as a research assistant. FA was trained in qualitative research. Researchers and participants did not have a relationship prior to the study commencement. Participants knew the institution and profession of the researcher who conducted the interviews.

The aim and methods of the research were explained to the women who met the inclusion criteria, and video call hours were determined on WhatsApp. Semi-structured interviews lasted an average of 30 (min, 25 min; max, 40 min) minutes. Verbal consent was obtained from the women at the beginning of the interviews. Written notes and a voice recorder were used to record the data. Three participants who did not agree to be audio recorded were excluded from the study. Transcripts were emailed to participants for comments or corrections.

Measures

A semi-structured interview form consisting of open-ended questions regarding the effects of the menstrual period on sexual life and an introductory information form prepared by the researchers in line with the literature were used for the data (Allen et al., 2009; Derya et al., 2019; Kumar et al., 2011; Ozel et al., 2018). The open-ended questions used in the semi-structured questionnaire are provided in Table 1.

Table 1 Interview guide
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Analysis

After the audio recordings were transcribed, the consistency and accuracy of the transcripts were checked. The collected qualitative data were evaluated using MAXQDA 20.0 statistical software. The interviewer took handwritten notes and recorded the participants’ nonverbal responses. After the audio recordings were transcribed, the consistency and accuracy of the transcripts were checked. During the analysis period, all transcripts were read and interpreted repeatedly. The transcripts were coded by the researchers, and all researchers came together and agreed on the codes, categories, and themes. In qualitative studies, the concepts of credibility, transferability, reliability, and confirmability criteria were used for reliability. To ensure credibility, the MAXQDA 20.0 program was used, and participant approval was obtained. A clear presentation of the working process and method transferability is provided. The findings were examined by someone other than the researchers, and dependability was ensured in this way. Confirmability was achieved by coding the data independently by different researchers.

The data was analyzed according to Colaizzi’s phenomenological analysis steps (Colaizzi, 1978).

  • The formulated meanings were grouped into categories, themes, and subthemes.

  • After examining these meaningful expressions, meanings were created.

  • The results were combined with comprehensive life experiences.

  • The basic conceptual structure of the case was defined.

  • Each transcription was shared with the participant who gave the data in that file, and the participant approved the content.

Ethics Approval

Ethical approval for this study was obtained from the Istanbul University–Cerrahpasa Social and Humanities Ethics Committee (Approval no: 2019/174). The research conforms to the provisions of the Declaration of Helsinki. The interviews were held in a comfortable and friendly atmosphere for the participants. The interviewer herself was alone in her room during the interview. Participants attended the interviews from their own homes. Necessary time was allocated for participants’ questions regarding the research process. Participants were informed about the purpose and process of the research. Care was taken in the collection and storage of the data.

Results

The mean age of the women participating in the study was 31.69 ± 6.45. Of the women, 50% were working, 31.25% were primary school graduates, 25% were high school graduates, and 43.75% were university graduates or higher. The average marriage year was 7.38 ± 8.43, and 81.25% of the participants were satisfied with their marriage. Of the women, 43.75% had never been pregnant, and 37.5% had one or two children. Seventy-five percent were satisfied with their sexual life, 81.25% had regular menstruation, and the mean age of menarche was 13.12 ± 1.4.

Six themes emerged from data analysis: “symptoms of the menstrual period,” “the duration and severity of symptoms during menstruation,” “effect of the menstrual period on sexual life,” “sexual desire during the menstrual period,” “opinions about sexual life during menstruation,” and “spouses’ opinions about sexual life during menstruation (Table 2).”

Table 2 The content analysis of themes, subthemes, and codes
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Theme 1: Symptoms of the Menstruation Period

Most of the women stated that they experienced dysmenorrhea. Some of the women were affected psychologically and had difficulty performing their daily work.

During this period, I have severe cramp-like pain that interferes with my life activities. I experience nausea, back and stomach pain. Sometimes, I even have trouble walking. My life energy is very low. I do not want to do anything. I don’t want to get out of bed (Participant 1).

Five days before the menstruation period, I have abdominal pain, restlessness, tension, swelling, and an excessive desire to eat sweets. I also have the urge to urinate frequently. My abdominal pain continues for three or four days of my menstruation period (Participant 12).

Two women stated that they had no symptoms during this period:

I don’t have any pain during this period. It just bothers me that the amount of bleeding is high in the first days (Participant 5).

Theme 2: The Duration and Severity of Symptoms During Menstruation

Some of the participants stated that their menstrual symptoms lasted for 3 or 4 days:

My abdominal pain and bloating lasts up to three or four days of my period. Sometimes, it prevents me from falling asleep at night. I find it very difficult to do my daily work, especially in the first two days. The pain decreases toward the end of the period. However, I have to take painkillers, especially the day before and the first three days of my period (Participant 9).

The women especially complained of pain during the first 2 days, with the majority of the participants stating that their menstrual symptoms decreased after experiencing severe symptoms during this period.

I have severe pain in the first two days of my period. If I don’t take painkillers, menstrual pain is so uncomfortable that I can’t do my daily work. I have trouble going to work. Smells and food make me nauseated. I have a hard time walking because I have severe back pain. Sometimes, I have to go to the hospital to have injections and IVs. I have to get a report because I have a serious illness (Participant 16).

Some of the participants stated that they experienced symptoms on the first day of menstruation. It was stated that these symptoms disappeared within 2–3 h, and there were no problems in daily life afterwards.

I experience discomfort on the first day of my period. I complain about pain more than these ailments. My pain comes and goes from time to time. However, it does not prevent me from doing my housework. My menstrual pain lasts for 2–3 hours on average during the day. Apart from the pain, I experience occasional nausea (Participant 8).

Theme 3: Effect of Menstrual Period on Sexual Life

The majority of the women stated that their sexual life was negatively affected during their menstrual period. Subthemes negatively affecting their sexual life included the presence of menstrual symptoms (such as pain, bloating, and stress); sexual intercourse during menstruation not being compatible with their religious beliefs and cultural values; the smell of blood; the discomfort caused by wearing a pad; feeling dirty; and the experience of sexual intercourse during menstruation.

Our sexual life is interrupted for a week during the menstrual period. During this period, I stay away from sex because of my pain. Getting close to my husband makes me uncomfortable. I want to sleep, listen, and be alone. Because I am angry and nervous, I cannot bear to kiss or even touch. For these reasons, our sexual life is adversely affected during this period (Participant 11).

I experienced it once with my husband. I did not get pleasure or satisfaction from sexual intercourse. We had placed a towel on our bed for sexual intercourse. I was very irritated to see blood on this towel. I also felt bad and sinful after sexual intercourse. At that, after my period is over, I am with my husband (Participant 10).

During my menstrual period, my sex life is interrupted. Because I experienced it once in the first year of my marriage, as a result of my experience, I had webs during menstruation. That’s why I take a shower and have sexual intercourse after my period is over (Participant 15).

A few of the women stated that their sexual lives were not adversely affected during the menstrual period.

I don’t even think about sex the day before and the first day of my period. Except for sexual intercourse, other activities (such as touching, kissing) continue during the menstrual period. … In the early days of our marriage, even at the moment of touching and hugging, I felt bad. However, now that my husband has normalized this situation with his words, gestures, and attitudes, I now feel comfortable. Sexual intercourse starts on the third or fourth day when the bleeding decreases (Participant 14).

I have been married for two years, and I occasionally have sexual intercourse during my menstrual period. At first, my husband and I had some trepidation about doing this. However, after providing the necessary environment, we realized that sexual intercourse during the menstrual period did not disturb us. Sometimes, I even enjoy it. How is this happening? [Laughs] (Participant 13).

Theme 4: Sexual Desire During the Menstrual Period

The participants’ sexual desire status during the menstrual period was categorized as having sexual desire and no sexual desire. Half of the participants stated that they did not have sexual desire during the menstrual period.

My sexual desire decreases during the menstrual period. I don’t even think about sex because of the problems of severe pain, tension, etc. I usually avoid sex (Participant 8).

Since I have pain on the first day of my period, there is sexual reluctance. There is no change in my sexual desire on other days of my period. It begins and continues when both myself and my husband are satisfied with sexual activity. No matter who initiates sexual activity, it is jointly for it to continue (Participant 3).

On the first day of my period, there is an increase in sexual desire. But, my husband and I do not have sexual intercourse because we do not find it appropriate religiously (Participant 7).

Theme 5: Views and Experiences About Sexual Life During Menstruation

Most of the participants were of the opinion that sexual life should not continue during the menstrual period. Subthemes of the view that sexual life should not continue included the presence of menstrual symptoms (such as pain, bloating, and stress); inconsistency with religious beliefs and cultural values; bad smell; disgust; risk of infection; and fear of being alienated by the spouse.

I don’t find the sexual life right during the menstruation period. In other words, I am very disgusted because of the bleeding, the smell. … I worry that my husband will be disgusted with the bleeding. I myself feel uncomfortable with the smell of blood during the menstrual period. … Also, since the risk of infection increases, I do not find sexuality correct during this period. … Since sexuality is a sin during menstruation in our religion, I prefer to control myself. After all, it’s not a lifelong situation; it’s not the end of the world, let alone sex for a week. I can never sin (Participant 10).

I think that sexual intercourse should not be experienced during the menstrual period. However, I think that situations such as hugging and kissing are also included in sexuality. I think that these actions can make the woman happy and reduce the pain experienced, especially during this period (Participant 16).

Absolutely, it should not be entered in sexual intercourse. Menstrual blood can get on the bed or get on my clothes during sexual intercourse. I can’t deal with his stain coming out. Also, the smell of blood makes me and my husband nauseated, and my husband may turn cold from me (Participant 11).

Some of the participants expressed a positive opinion about the continuation of sexual intercourse during the menstrual period.

Sexual intercourse can occur when the necessary hygiene rules are provided and both parties are sexually willing. In fact, this may facilitate sexual activity by creating a lubricating effect (Participant 2).

Sexual activity can be engaged in, depending on the woman’s feeling of well-being. However, I don’t find it right when there is serious bleeding. Maybe if there is little or no bleeding in the last days, sexual intercourse can be experienced (Participant 4).

Theme 6: Spouses’ Opinions About Sexual Life During Menstruation

Participants were also asked about their spouses’ views on sexual intercourse during their menstrual period. Most of the women reported that their husbands also thought that sexual life should be interrupted during this period. The women participating in the study expressed their husbands’ thoughts on this issue as follows:

My husband does not want sexual intercourse during this period. He is disturbed by the bleeding. He is disgusted with blood. He is of the opinion that infection can occur, and it is a sin in our religion. Also, he doesn’t want sexual intercourse because I have a lot of pain (Participant 2).

My husband is also willing during this period, but because I do not find it hygienic, he waits for my period to end. However, during this period, my husband occasionally masturbates (Participant 7).

Participants stated that their spouses wanted their sexual life to continue in the form of sexual intercourse or touching, hugging, or kissing when they were in mensturation period. The spouse’s positive thoughts about sexual life are reported in the following statements:

Like me, my husband wants our sexual intercourse when the period ends. During this time, he touches me and kisses me. This satisfies me and reduces my menstrual problems (Participant 6).

[My spouse] thinks that sexuality should continue in its normal order during my periods (Participant 3).

Discussion

This study aimed to determine the views and experiences of women of reproductive age regarding sexuality and sexual life during their menstruation phase of the menstrual period. Women experience many symptoms during their menstrual period, and their quality of life is negatively affected by these symptoms. Of the women who participated in our study, 88% stated that they experienced dysmenorrhea during their menstrual period, 56% were affected psychologically, and 31% had difficulty performing their daily work. Schoep et al.’s (2019) study determined that 85% of women experienced dysmenorrhea, 77% had psychological complaints, and 71% had fatigue during their menstrual period. In addition, 38% of the women reported that they could not perform their daily activities during their menstrual period. Yilmaz et al. (2020) determined that 69% of women had breast tenderness during their menstrual period; 68% had increased edema; 58% had a change in eating patterns; and one out of every two experienced headache, irritability, and fatigue. As in these studies, most of the women in our study experienced at least one symptom during their menstrual period. Depending on these symptoms, the quality of life of women is adversely affected.

In this study, it was determined that the participants and their spouses did not continue their sexual life during menstruation period for reasons such as religious beliefs, incompatibility with cultural values, presence of menstrual symptoms, blood odor, discomfort of wearing pads, feeling dirty, previous experience of sexual intercourse during menstruation, and fear of the partner’s withdrawal. Having sexual intercourse during the menstrual period differs according to social and cultural factors (Allen et al., 2009). In a study by Allen and Goldberg (2009), 37 of 92 women who said they were sexually active never had intercourse during their menstrual period, eight women tried once but would never try again, seven women said they could have sexual intercourse rarely but only under certain conditions, and 40 stated that their sexual intercourse continued during the menstrual period. None of the women who continued to have sexual intercourse during their menstrual period expressed disgust. In Ozkan et al.’s (2015) study to determine the cultural behaviors and practices of midwifery students during their menstrual period, 51% of the students stated that it is forbidden to have sexual intercourse during the menstrual period, 75% stated that they did not have sexual intercourse during this period, and 12.5% only experienced it once. In Turkish society, menstruation is generally perceived as “getting dirty” or “getting sick,” and sexual intercourse during menstruation is seen as a sexual taboo. Accordingly, sexual intercourse is not experienced in this period. Fahs (2011) conducted a qualitative study with 40 women of various ages, races, and sexual orientations to examine women’s sexual experiences during menstruation. According to the results of the study, 25 women gave negative, two gave neutral, and 13 gave positive reactions about sexual experiences. Negative reactions were grouped around four themes. These themes were determined as physical labor to provide general discomfort and necessary hygiene for women, partner discomfort, negative self-perception, and emotional labor to manage partner’s disgust. Similarly, the current study determined that there were thoughts that menstrual blood would contaminate the sheets or clothes, that it would require effort to clean it, and that the spouse would move away from them depending on the sight and smell of blood. As in most societies, the fact that men are more dominant in sexuality arouses the desire of women to be liked by men. In this case, this supports the existence of gender discrimination. According to a verse in the Qur’an, the holy book of Islam, “It [menstruation] is a distressing situation; Therefore, stay away from women during menstruation and do not approach them until they are clean. When they are cleansed, come to them from where Allah has commanded you” (Baqara 222). In this verse, the worship and sexual restriction of the woman during the menstrual period is not compatible with the woman’s being disgusting, it is based on the fact that women are more emotionally sensitive and physiologically more susceptible to infections during this period (Katmer, 2020). Because the majority of the population in Turkey is Muslim, sexual intercourse during menstruation is viewed negatively.

Half of the women who participated in the current study stated that there was no change in their sexual desire during menstruation. However, women who experienced severe menstrual symptoms stated that sexual intercourse was the last thing they would want during this period. Morotti et al. (2013) conducted a study to evaluate clitoral changes, sexual behavior, and perceived body image during a menstrual cycle (follicular, periovulatory, and luteal phases). The results of the research found that, during the periovulatory phase of the menstrual cycle, there was a significant increase in clitoral body volume and a decrease in the pulsatility index of the clitoral artery. These changes were positively associated with estradiol levels. However, no significant changes were found in women’s sexual function, body image perception, and depression symptoms throughout the entire cycle (Morotti et al., 2013). The presence of estrogen, which affects anatomical and vascular changes, may support genital excitability.

A few women who participated in the study stated that having sexual intercourse during the menstrual period may cause infection. According to Turkish culture, women feel dirty during their menstrual period, and it is thought that having sexual intercourse during this period may cause reproductive system infections (Ozkan et al., 2015). In a study conducted with young Thai women to determine risk factors for bacterial vaginosis, sexual intercourse during menstruation was found to be an important risk factor for bacterial vaginosis (Rugpao et al., 2008). Another study on women living in rural Africa found that having sexual intercourse during the menstrual period did not pose a risk for bacterial vaginosis (Morison et al., 2005). Lurie (2010) stated in her study that having sexual intercourse during the menstrual period does not pose a risk of pelvic inflammatory disease. According to these studies, there is no definite conclusion that having sexual intercourse during menstruation will cause reproductive system infections.

Menstrual symptoms can begin during and before menstruation (premenstrual syndrome). In this period, receiving psychosocial and emotional support, especially from one’s spouse, can reduce the symptoms that a woman experiences. Morowatisharifabad et al. (2014) investigated the effects of education on the marital satisfaction of couples by distributing brochures and text messages (SMS) about the premenstrual period to married men. The research found that the education given about the premenstrual period increased marital satisfaction (Morowatisharifabad et al., 2014). Another study found that three sessions of premenstrual supportive behavioral training given to spouses reduced the physical and psychological–behavioral symptoms of women (Rezaee et al., 2016). Similar to the literature, the women in the current study stated that their menstrual symptoms decrease with the social support they receive from their husbands. Also, participants stated that their spouses wanted their sexual life to continue in the form of sexual intercourse or touching, hugging, or kissing when they were in mensturation period. Sexuality is not just about coitus, it is multidimensional like touching, kissing, and hugging, and it is more important for spouses to maintain their sexuality in this way. The results obtained in educational studies may depend on learning the multidimensional structure of sexuality.

Conclusion

Women experience physiological and psychological symptoms during their menstrual period. Although some of the women in this study do not have a change in sexual desire during this period, most think that they should not engage in sexual intercourse due to the symptoms they experience during their menstrual period, religious beliefs, and sociocultural values.

In Muslim countries, such as Turkey, abstaining from sexual intercourse during menstruation is among sexual myths, and it is not even considered appropriate to discuss in public. Nurses should counsel couples about the possible advantages and disadvantages of sexual intercourse during menstruation without displaying a judgmental attitude. Sexual intercourse during menstruation period may have benefits such as relaxation, stress reduction, pain relief, and strengthening emotional intimacy. Disadvantages may include discomfort, risk of infection, cleaning and hygiene difficulties, and emotional sensitivity. In addition, during this period, sexuality should not be perceived as only sexual intercourse for women and their spouses; it should be explained that displays of emotion, such as touching, hugging, and kissing, are also a part of sexual life. It is not possible to determine whether religious reasons or discomfort during menstruation are more effective in not experiencing sexuality. Therefore, it may be useful to adopt a holistic approach that focuses on the interaction of all factors. Nurses can use community service programs, online resources, health fairs or community events, non-governmental organizations and associations, workshops and seminars, home visits, educational materials, and telephone counseling to provide sexual education, counseling, and awareness to couples not involved in the health system.