Failed foundations

The situation for US women

In the aftermath of the overturning of important women's rights legislation, we’re in a perfect storm. Women’s health clinics are closing, doctors are fearing prosecution, and the education system is failing to properly teach reproductive health. To understand the impact on US women, Flo Health commissioned this report.

Flo Health found that against this deeply troubling background, women are craving a deeper understanding of their health; 70% of those aged 18 to 44 would like to grow their knowledge of women’s health.¹ As credible sources of information disappear, they are searching for answers online, where they are confronted with widespread misinformation.

Flo Health research can reveal that:

• Almost one in five women (18%) go to YouTube, online forums, or social media to gather information on menstrual health. 
• 56% of women do not currently use contraception.
• More than six in 10 women aged 18 to 24 (63%) say they have learned more about women’s health from social media than they did in school.
• 33% of women are unaware that you can catch a sexually transmitted infection (STI) without having penetrative sex. 
• More than one in 10 women (13%) use the pullout method.
• 16% of women don’t understand or aren’t sure how STIs can be acquired during oral, vaginal, or anal sex.
• More than half of women (54%) don’t know how many days a month they are fertile.
• 70% of women aged 18 to 44 would like to grow their knowledge of women’s health.

Flo Health recognizes the importance of having access to medically credible and — more crucially than ever — personalized health information. We’re aligned with the World Health Organization in its assertion that every woman has the right to accurate information and education, as well as access to necessary health care.²

This empowers women to better understand their bodies, destigmatizes taboos, and vastly improves health literacy. Low health literacy is a direct contributor to the spread of misinformation³ and leads to poor health outcomes and unhealthy behaviors,⁴ especially in the areas of menstruation, sexual health, and pregnancy health.

The following findings underline where we’re going wrong and the far-reaching impacts.

We’re failing women on health foundations

Knowledge is power, but more than that, in the health space, knowledge is safety. Yet women are being failed. Flo research reveals that:

• For 30% of women, the first they knew of menstruation was when they started their period.
• 42.7 million women (54%) were not aware of premenstrual syndrome (PMS; common symptoms women can experience before their period) prior to their first period.
• 9.5 million women don’t know what any phases of the menstrual cycle are.
• 62% of women are unfamiliar with or have never heard of polycystic ovary syndrome (PCOS; one of the most common causes of female infertility).⁵ 
• Half of women (50%) are unfamiliar with or have never heard of endometriosis, rising to 62% among Asian women (it affects 10%6 of the US female population during their reproductive years).¹ 

The fragmented educational picture
 

According to the Guttmacher Institute,⁷ only 38 states and the District of Columbia mandate sex education and/or education about human immunodeficiency virus (HIV), and just 17 states require the content to be “medically accurate.”

Nineteen states⁸ simply teach abstinence, teaching that this method of birth control is the only 100%-effective way of preventing pregnancy and infection.

Diagrams of the female anatomy and recommendations for abstinence with little or no emotional or practical guidance leave girls and women lacking the skills and knowledge to manage their cycles or have healthy sex lives. 

Flo research reveals that 58% of women don’t know what a normal menstrual cycle is. According to the American College of Obstetricians and Gynecologists, “A normal menstrual cycle lasts between 21 and 35 days, and a typical period lasts two to seven days, with the heaviest bleeding in the first three days.”⁹
 

Menstruation education matters 
 

Insufficient menstrual health education can negatively impact health and well-being in far-reaching ways,10 yet many US children are taught about periods after they have begun menstruating. Research has found that just ​​21% of elementary schools currently provide puberty education.¹¹

There is a recognized trend¹² of periods starting at a younger age. Research has shown that 10% of girls start their period by the age of 10, and 26% do by age 11,¹³ so many researchers, medical professionals, and experts in public health (Flo experts included) believe girls need to learn about their changing bodies in fourth or fifth grade. 

Yet there are worrying signs of the exact opposite happening. Florida lawmakers, for example, are considering a draft law¹⁴ to ban any instruction in schools about menstrual cycles before the sixth grade. 

Research¹⁰ has shown that menstrual stigma can cause anxiety and stress and hinder girls academically and socially. Those who begin puberty earlier are more vulnerable to depression and engagement in risky behaviors such as substance use and early initiation of sexual activity. Education is crucial.
 

What’s normal?

• 54% of women feel that they have a problematic cycle.
• 58% of women don’t know what a normal menstrual cycle is.
• 12% of women (9.5 million) say they don’t know any phases of the menstrual cycle. 
• 58% of women see period pain or PMS as “normal” and just something to put up with.

Missing Diagnoses

A lack of education around menstruation can have far-reaching implications. One concern is delayed diagnoses. Research15 has shown that it can take between five and 12+ years to receive a definitive diagnosis of endometriosis. The study’s authors discuss how often the first signs of endometriosis appear just after a teen starts their period, but parents may consider that pain to be normal or misinterpret it as a way to get out of school. Similarly, research has found that women only receive a diagnosis of PCOS following months to years of consultations with multiple health professionals.¹⁶ 

Flo has found that nearly two-thirds of women (62%) have never heard of and are unfamiliar with PCOS,¹ which according to the Centers for Disease Control and Prevention (CDC)¹⁷ is one of the most common causes of female infertility, affecting at least 5 million US women of reproductive age. 

As well as impacting fertility, PCOS significantly increases a woman’s risk of gestational diabetes, is linked to depression and anxiety, and is associated with greater chances of developing Type 2 diabetes, among other negative outcomes. Often, irregular monthly periods are the first sign, yet many women will miss these signs if they don't have access to the knowledge of what a regular cycle is.

Similarly, 50% of American women are unfamiliar with endometriosis. This percentage rises among Asian American women (62%).¹ Endometriosis affects roughly one in 10 women of reproductive age¹⁸ and is associated with severe, life-impacting period pain, chronic pelvic pain, bloating, nausea, fatigue, and sometimes depression, anxiety, and infertility. While there is no known cure, treatment can help control symptoms — but only if you know that it exists. 

Nearly six in 10 women (58%) see period pain or PMS as “normal” and just something to put up with¹ which begs the question, how many women could have undiagnosed PCOS or endometriosis?

Mind the Stigma

Menstruation in 2023 also remains heavily stigmatized. 

Flo has found that 34% of girls first learned about their periods from a parental figure, but research¹¹ has shown that across multiple American demographics, many families still don’t talk about menstruation at home. This means that American adolescents are unprepared, particularly those from low-income communities and Black, Indigenous, and people of color, who, research has shown, often experience puberty and menarche (onset of their first period) earlier than their white and/or high-income peers.¹⁰ 

Even among families who discuss periods, a 2021 systematic review¹⁹ found that in high-income countries, girls are still told by their mothers to keep their periods a secret, perpetuating a sense of shame. 

Arguably, social media feeds into this stigma. Social media platforms,^{20 21} for instance, have received criticism for removing posts and ads that depict menstrual blood. On Instagram, policies remain unclear, as menstrual blood isn’t explicitly mentioned in their guidelines.²²
 

Confusion reigns: Fertility & contraception

According to the Guttmacher Institute,²³ in the first 100 days after Roe v. Wade was overturned, at least 66 health clinics in 15 states stopped providing abortion care. As of November 2022, Abortion Care Network reported that 42 independent abortion clinics had closed or were forced to stop providing abortion care — more than double the 20 closures in 2021.²⁴ When health clinics close, women lose vital local medical expertise around reproductive health, not just access to abortion.

Given what we already know about the education system and familial hesitation to discuss menstruation and reproductive and sexual health, women have fewer places to turn to for credible information. That leaves them vulnerable to misinformation.

Flo research can reveal that:

• 13% of women (4.1 million) use the pullout method.
• 54% of women don’t know how many days a month they are fertile.
• The second most popular nonhormonal birth control method is the pullout method (13%).¹
• A third of women (33%) are unaware that you can catch a STI without having penetrative sex.
• Almost one in five women (16%) don’t understand how STIs can be acquired during oral, vaginal, or anal sex.

Sketchy contraception myths

There is concern²⁵ that in America, contraception is being conflated with abortion, and some lawmakers may wish to ban certain forms of birth control as a result. President Biden has signed an executive order²⁶ that aims to safeguard access to reproductive health care services, including contraception, and to protect patients’ access to accurate information, but women are being warned²⁷ that their right to birth control may also be restricted. 

According to the CDC, approximately 45% of all pregnancies in the United States are unintended,²⁸ so access to information around contraceptive choices is crucial for women.

According to Planned Parenthood,²⁹ for every 100 people who use the pullout method perfectly, four will get pregnant. But the word “perfectly” really matters because it’s hard to practice the pullout method perfectly. In the real world, about 22 out of 100 people who use the pullout method get pregnant every year.

Flo research has found that 56% of women do not currently use any form of contraception. Among those who do, 37% use the pill, 29% use the male condom, and nearly a fifth (19%) use an intrauterine device. Perhaps surprisingly, 13% of women (4.1 million) use the pullout method.¹

Fertility blind spots

Fifty-four percent (54%) of women are unsure how many days a month they are fertile, and that figure rises to 61% among women aged 18 to 24.¹ Even those actively trying to conceive can be unaware of this vital knowledge. Research³⁰ that recruited women in Canada and the United States who had been struggling to conceive naturally for a year found that 70% were not aware which week was associated with the highest chances of conception.

The dangerous ‘information sources’ filling the gaps

Key statistics from Flo research reveal that:

• 63% of women aged 18 to 24 say they have learned more about women’s health from social media than they did in school.
• 70% of women aged 18 to 44 would like to grow their knowledge of women’s health.¹
• Almost one in five women (18%) go to YouTube, online forums, or social media to gather information on menstrual health.
• 30% of women wrongly believe that the more sex you have, the looser your vagina will be.
• More than one in three women (36%) wrongly believe that you should regularly wash the inside of your vagina.

After June 2022, much of the content spilling onto the internet around sex, pregnancy, women’s health conditions, and symptoms is misleading. Twitter, YouTube, and Facebook have the highest rates of health misinformation,³¹ with misinformation spreading 1,000 times farther and 20 times faster than the truth.³²

Family first, but then tiktok?

Flo Health found that the majority of US women first learned about their menstrual cycle from a parental figure (34%) or school-provided health classes (18%). Two-thirds of women (60%) gathered information on women’s health online through outlets including search engines, YouTube, social media, online forums, and the internet. A staggering 45% of women say they learned more about women’s health from social media than they did in school. That figure rises to 63% among women aged 18 to 24.¹

Similarly, 28.5 million women (36%) first learned about what causes pregnancy and what to do to prevent it from a parental figure, 31% learned from a health class,¹ and 18% of women went to YouTube, online forums, or social media to gather information on menstrual health, with that figure rising to nearly a third among women aged 18 to 24 (28%).¹ 

Which begs the question, just what are they “learning,” and from whom?
 

The fake news factory
 

For a long time, the suggestion was that users lacked the critical thinking skills to identify so-called “fake news,” but research³³ now shows and experts agree that social media platforms are built to amplify misinformation thanks to their built-in “rewards system.” 

This is all about keeping us on their platforms, posting and sharing, and more sensational, eye-catching, and/or shocking content is posted and reshared by the algorithm.
 

The medical wild west

As a result, credible medical experts are constantly fighting a tidal wave of disinformation. TikTok videos claim that drinking caffeine before sex can increase the likelihood that you’ll have a boy and that the color of your period blood reveals estrogen dominance.³⁴ Content creators post videos recommending stopping birth control, claiming it solves everything for women, from anxiety to weight gain, or that it even causes infertility.

The comments section under one TikTok video asking for natural birth control methods is teeming with unfounded suggestions, including everything from drinking teas to vaginal steaming.

Nearly two-thirds of women aged 18 to 24 (63%) learned more about women’s health from social media than they did in school.¹ Thus, social media is almost acting like a stand-in health education teacher. Bearing in mind what we know about the way algorithms work, that means they’re visiting apps that make more money by spreading what shocks, not what educates.  

Where were the classes on that?

Women want to be informed. Two-thirds of them (66%), rising to 70% of those aged 18 to 44, would like to grow their knowledge of women’s health, while 57% of women would like to increase their knowledge about the menstrual cycle and their bodies.¹ 

Women are also surprised by the gaps in their education; 76% of women reported that they have learned something new about women’s health as an adult that they were surprised wasn’t covered when they were younger.¹

When it comes to menstruation, four in 10 women (41%) have learned something new that wasn’t covered when they were younger, rising to 49% for women aged 18 to 34. Nearly half of women (47%) have gained knowledge they weren't equipped with about pregnancy, rising to 53% among women aged 18 to 44.¹

This isn’t trivial knowledge. It’s vital health information about living a healthy, happy, safe life in a female body.

Unmasking myths

What next? Predictions for the future of women’s health

It’s a troubling landscape, with uncertainty and fear impacting women’s health choices, so what comes next? As Flo works to build a better future for female health, it predicts that three key trends will take precedence over the next year.

Artificial intelligence (AI) is a major talking point, with ChatGPT having become the “fastest-growing consumer application in history³⁶ and with 93.9% of organizations planning to increase their investments in data in 2023.” ³⁷ While it may assist in alleviating some administrative tasks in women’s health, AI won’t be able to replace the expertise of medical professionals, especially in women’s health, just yet.

The technology has advanced rapidly, but it cannot ethically and accurately answer all questions about health, especially women’s health topics.

One key reason for this is the gender research gap. It’s well documented that within medicine and medical research, women, particularly women of color, are underrepresented.³⁸ There is therefore less information available on women’s health for AI to learn from, making it likely that it will perpetuate this male bias. 
 

Misinformation and deliberate disinformation will continue to exist across the internet and social media platforms, but Flo Health predicts that an increasing number of medical influencers will try to redress the balance, sharing medically credible information and tackling shame. 

With the pandemic having exposed how vulnerable we are to health misinformation and how dangerous that can be, efforts will be made to increase digital literacy. As such, Flo predicts that we will become increasingly aware of how to identify misinformation and disinformation and more knowledgeable about how to access trustworthy sources online.

Friend or foe: Assessing expertise online

A series of letters after someone’s name, a white lab coat, scrubs, a stethoscope around their neck … Any of these things could signal that the person speaking is trustworthy, but it’s not as simple as that. Here, Dr. Claudia Pastides, MBBS, general practitioner and director of medical accuracy at Flo Health, explains how to better spot influencers providing credible medical information:

• Check their qualifications: Is the doctor you’re following for advice about women’s health an obstetrician, gynecologist, or general practitioner? Check the qualifications they list on their social profile/website/LinkedIn profile (e.g., college degree, medical or surgical training qualifications, society membership, etc.).
• Question their claims: A good and sensible clinician is aware of the limitations of sharing health information online, so they should explain that not all the information they give is suitable for everyone to follow.
• Look for references: Check if the medical influencer shares references for any cited statistics or facts. Then check out that research to see if it is credible. For instance, is it from the World Health Organization, CDC, etc.? Don’t hesitate to question where someone got a statistic from if it isn’t clear.
• Don't buy into ‘Miracle cures’: In medicine, there are rarely quick-fix solutions, and even fewer that would apply to everyone. If an online doctor is promoting something that seems hard to believe (e.g., juice cleanses, dietary restrictions, etc.), it often isn’t credible.

In the age of technology and with traditional sources of information under increasing threat, women will supplement their menstrual and sexual health knowledge with personalized health insights. 

As explored, search engines, social media, and AI tools don’t always provide the most relevant or even medically accurate results. If you want to know why your period hasn’t arrived or how to determine if you are ovulating, you may find a long list of confusing and potentially inaccurate information that doesn’t even answer your questions. You need information that is tailored to you, your body, and your cycle.
 

The most relevant information for you
 

Through its machine-learning model, Flo Health uses the information you log in the app about your body and your cycle, such as days of menstruation and different symptoms of your experience, to provide the most relevant insights tailored to you. This means that the more you log, the more you learn.
 

About Flo
 

Flo supports women and people who menstruate during their entire reproductive lives by providing curated and predictive insights about their cycle and ovulation tracking, personalized health insights, expert tips from 120+ medical experts, and a closed community for people to share their questions and concerns.

In the past year, 53% of women have learned something about women’s health that was easy to understand but previously unknown to them. Women who use Flo and other period-tracking apps are more likely to say this than women who do not (70% versus 42%).¹

Flo’s medical expertise: Flo works with an international team of 120+ doctors, health experts, and scientific researchers to ensure that everything at Flo — from its content to app features — is medically accurate and clinically safe for its users worldwide.

Disclaimer: If you are ever concerned about your health, please get in contact with your primary care physician or a medical provider.

Disclaimer: As a note, Flo Health uses the terms “women/woman” interchangeably with “female” in this report as our research only sampled those who identify as “women.” However, Flo Health recognizes that both sex and gender can exist on a spectrum. We aim to be inclusive of all people born with female reproductive organs, regardless of gender, anyone who identifies as a woman, and all individuals who menstruate.