The first time Sabita Poudel took hormonal pills to delay her menstruation was when she was 28. There was a puja at her home and her mother-in-law suggested what she called “mahinawari pachhadi saarne aushadhi”, something that would delay the period.

“All I knew–and still know–about the medicines is that they would delay my period, allowing me to perform the rituals,” she said. The Post is identifying her with a changed name to protect her privacy.

She is 47 now. She stopped taking the pills about a couple of years ago. She is menopausal now. She does not remember the name of the pills, their composition, and possible side effects.

The deeply ingrained belief of ‘impurity’ around menstruation forces women to ostracise themselves from various social functions. Their participation is contingent upon them remaining ‘pure’ for which, many women delay their natural menstrual cycles by popping hormonal pills, mostly bought over-the-counter (OTC), and without consulting a gynecologist.

Consumption of such pills, however, poses a great health hazard to menstruating individuals, of which many are unaware.

This notion of impurity forced Ankita Ranabhat, 20, to take hormonal pills so she could attend a religious function at her home. Ranabhat was advised by her grandmother to take those pills and delay her period.

“My period was close and we were at our ancestral home in Chitwan to observe kul puja [clan rituals]. My grandmother asked me to take the pill so that I can participate in the puja, and to make sure that nothing would be impure for such an auspicious ritual,” says Ankita, who is pursuing a BHM (Bachelors in Hotel Management) at Lumbini ICT Campus.

Just like Sabita, Ankita too was completely unaware of the medicines.

“I had no idea that pills as such existed, let alone anything about the pill. My mother gave me the pills and told me that it was normal to consume them during such occasions. Apparently, she has been doing the same for long,” said Ankita.

These pills are available as OTC drugs at pharmacies, and to buy them, one does not need a prescription.

“We provide hormonal pills to delay menstruation depending on how long women want to push their periods further. A prescription isn’t required,” says Roshan Khanal, a pharmacist at Thapathali.

Asked if the buyers are told about the side effects, Khanal said: “We don’t generally explain the side effects unless the customers ask. If they do ask, we tell them that they might experience dizziness or their regular cycles might be delayed much longer than expected.”

The practice of both pharmacists and clients in disseminating and receiving information on medications is lax in Nepal.

“When I ask women what pills they have taken, many women—including educated ones—don’t know the names of the pills they are taking,” said Dr Anjana Karki, a gynaecologist at B&B Hospital. “Nor do they have any clue about the dosage. On many occasions, their husbands or older women get the pills for them.”

Ankita feels that she wasn’t able to make an informed choice about the pills, despite being a well-educated, tech-savvy girl in her 20s.

“The puja was just around the corner, and so was my menstrual cycle, I was told to take the pills. I couldn’t say no. And that is why I say that I was forced to take the pills. I don’t even know the name of the pill I took,” she said.

Though there has been a lot of change in the attitude towards menstruation in recent years, the idea that ‘chhuna hunna’, which translates to ‘women shouldn’t touch or be touched’ during menstruation is still pervasive.

“When I look around my friends, family, everyone has kept a distance from religious activities during their menses. It’s so ingrained in our societies. And especially when women do a majority of the cooking and cleaning during religious festivals, it becomes impossible for them to be exempt from it,” said Karki. “That has led to this culture of consuming pills to postpone periods.”

A woman menstruates for an average of 2,535 days–that’s almost seven years. Despite campaigns and awareness drives on celebrating menstruation–from menarche to menopause–the deep-rooted belief system in Nepal continues to bar girls and women from performing some essential chores. Many girls in rural areas miss out on school because of their periods.

While for some women, delaying their periods per their will could be liberating, others when forced upon pills to delay their monthly cycles just to ensure that they can participate in religious activities is yet another manifestation of societal control over women.

Doctors say those women who want to suppress their periods must consult experts and be informed about the possible side effects and health consequences.

Dr Bhola Rijal, a senior consultant of obstetrics and gynaecology at HAMS Hospital, says it is crucial to understand one’s hormonal cycles during menstruation prior to taking these pills.

“In the last few days of the menstrual cycle, the levels of progesterone hormone in the body decrease, causing the uterus to shed its lining, thereby causing menstruation,” said Rijal.

Hormonal pills contain hormones–estrogen and progesterone–that the female body naturally produces.

“That is why,” said Rijal, “consuming these pills to postpone periods isn’t a misuse. The only danger that it poses is when consumed without proper knowledge, in high doses, at irregular times, and for a longer period of time, or by women whose reproductive systems aren’t healthy.”

According to gynaecologist Karki, these pills simply manipulate the hormonal balance in the body.

“There are two kinds of hormonal pills that can be consumed to regulate periods, oral contraceptive pills—that contain both estrogen and progesterone hormones —and progesterone-only pills,” said Karki.

Oral contraceptive pills have been subsidised by the government and are available as Nilocon White, Gulab Chakki—that cost around Rs35-50 for a months’ dose. Progesterone-only pills are comparatively a little expensive and aren’t subsidised.

Hormonal pills, albeit safe to consume, can cause side effects on women’s bodies.

Some common side effects include irregular periods, nausea, vomiting, bloating, and breast tenderness, according to Karki.

“Once women stop taking the pills, their periods take place in the next 2-5 days, and many complain of severe cramps. But there are usually no long-term consequences,” said Karki.

Doctors say individuals need to understand their monthly cycles well and decide after consulting experts whether they should go for hormonal pills to suppress their periods.

Ankita may have been able to delay her period by taking the pills but her experience has not been very good.

The pills immensely affected her natural flow of menstrual blood, and she had no clue what she signed up for, she said.

“Even after I stopped taking the pills, I didn’t have my period for another week. And when I did, I had terrible cramps. The flow was irregular and heavy,” she said. “I was bed-ridden for almost a week.”

Karki says there are possibilities of contraindications—a situation when an individual should not use a certain drug because it might complicate the situation, as opposed to making it better—that may lead to unwarranted complications.

“For example, you shouldn’t give pills containing estrogen to obese women, women with high blood pressure, hypertension, migraine, or liver diseases. These women already have higher estrogen levels and consuming such pills might make things much worse,” said Karki.

In addition, hormonal pills should not be taken regularly or frequently.

“Manipulating your natural period cycles isn’t something that should be done regularly,” said Rijal.

Most of the time, the pills cause irregular bleeding, which isn’t necessarily a problem though, according to Karki.

But regular consumption of pills may “hide or mask the symptoms of various other diseases, such as infections in the uterus, or even cervical cancer. This leads to a delay in diagnosis and might cause complications,” she added. “That is why, it is very crucial to know about one’s own body, what the pill is, and what it does.”

The focus should be on educating the public that menstruation is a natural phenomenon if they are to tackle and overcome these social attitudes. Additionally, knowledge of the medicines one is consuming is crucial to help menstruating individuals make informed decisions.

Ankita says she has vowed never to take the pills without consulting doctors.

“To be honest, this feels totally unfair. It doesn’t make sense that God would make us impure all the while preaching that God is inside all of us,” she said. “And for me to interact with God, I would have to disrupt my entire bodily functions and fluids.”