Monitoring Menses: Design-Based Investigations of Menstrual Tracking Applications


Fox and Epstein interrogate and reimagine menstrual tracking technology, focusing on mobile applications designed to document and quantify menstrual cycle data. While such technology promises to provide users with new insights and predictions, the authors highlight how these apps are inscribed with particular visions of menstruation and encourage users to extract intimate information about their bodies. Apps regularly assume, for instance, that all possible users are women, heterosexual, and monogamous, have a “normal” cycle, and use tracking techniques exclusively to gauge fertility. Fox and Epstein present two case studies: (1) examining core issues of usability and inclusion in the design of existing applications; and (2) using participatory approaches to highlight the lived experiences of menstruators and introduce alternatives to dominant menstrual app protocols. In offering this two-part analysis, they point to important openings for exploring how these technologies might support the needs of a multiplicity of menstruating bodies.

daily collection of basal body measurements and automatic storage of such data [Magee 2015]). The start-ups tout precise data analytics to inform users about their cycles (Magee 2015;Lomas 2015), while they garner millions of dollars in venture capital. Yet, there remain questions about ways the data being collected constructs a narrow and sometimes instrumentalized view of menstrual experiences-questions we puzzle over the course of this chapter.
In examining menstrual tracking technology, we take up a designerly lens (Rosner 2018;Zimmerman, Forlizzi, and Evenson 2007), highlighting the ways in which apps inscribe particular visions of what the body is capable of and how to make sense of menstruation. In doing so, we identify openings to explore how these technologies could exist differently, to encourage self-knowledge and affirm and support the needs of different kinds of menstruating bodies (that is, beyond a fertility or contraceptive focus that occupies many apps on the market). Toward the aim of examining and reimagining, we identify expanded forms of monitoring menses-ones that emphasize modules, which work to align with people's goals and identities rather than the models that come with algorithmic ways of knowing, and dimensionality, rather than a user's relation to averages or norms.
In what follows we describe two case studies: one examines the design of existing applications and how they are interpreted by users, and the other uses participatory approaches that draw on the experiences of menstruators to introduce alternatives to dominant menstrual app protocols. With the first, we uncover core issues of usability and inclusion in existing processes of menstrual tracking-for instance, apps assume users have a regular cycle, are interested in tracking for fertility, identify as female, and have one male partner. Here, the focus is on how current apps support people's needs and what designers of personal tracking tools might learn from people who record and make use of their menstrual cycle data. The other study examines tracking as an under-interrogated form of recordkeeping about the body and traces how it has evolved to serve people differently. It further takes up collaborative techniques of design to invite members of the menstruating public to reimagine these technologies to better serve their own goals of menstrual sensemaking.

Background
Before describing these cases in detail, we first turn to a backdrop of design activity within and just outside the space of menstrual tracking that both animates and motivates our discussion.

The Personal (Informatics) is Political
Health is a big information problem waiting for data analytics and wearable sensors. I wanted to start somewhere to make a difference [. . .]  Within the realm of technology design, the past decade has seen a turn toward big data. Though not a wholly new phenomenon, innovation in terms of cloud storage and machine learning has introduced an era where "value comes from the patterns that can be derived by making connections between pieces of data, about an individual, about individuals in relation to others, about groups of people, or simply about the structure of information itself" (boyd and Crawford 2012). Practitioners and "tech evangelists" alike preach the almost limitless potential of data to tell us things about the world-with enough of it, we can cast away uncertainty and focus the fuzziness associated with forms of risk. From forecasts on market performance to understanding food inequity (De Choudhury, Sharma, and Kiciman 2016), data is seen as the answer to some of the world's most elusive concerns.
There is hardly a more apt embodiment of this utopian view of technology than the above statement from Max Levchin, Co-Founder of the menstrual tracking app Glow (Goode 2013). Prior to Glow, Levchin's interests largely focused on building finance companies, including a startup that enables people to send money to others (Paypal) and another to predict the risk associated with lending (Affirm). As he explained during Glow's debut at the technology conference D: All Things Digital, concerns for menstrual tracking and financial transaction are not so distinct-predictive models could guide both this modern form of fertility awareness and market decision-making (Goode 2013). In a world where infertility is largely left uncovered by health insurance, Levchin insists, menstrual tracking fills a gap, offering a form of technologically aided assurance in place of medical attention. If one carefully collects data, such as cervical mucus texture and menstrual cycle dates, and follows the guidance of the predictive model, then medical or health advice (through a doctor or doula) is no longer necessary to achieve pregnancy-all one needs is a smartphone, an internet connection, $47.99 (for a premium account), and a willingness to track.
In applying a design-oriented lens to menstrual tracking, we sought to understand the ways these contemporary technological infrastructures are not formed de novo (Star 1999;Ribes and Jackson 2013), but are instead inscribed with particular histories. For instance, many of the measurements and predictive models upon which popular menstrual apps rely are drawn from fertility awareness-based methods, or recording techniques designed to encourage "natural family planning." Promoted by Catholic physicians, endorsed by the Pope, and taken up by parishioners over most of the last century, these birth control methods aimed at allowing Catholic couples to have more control over the size of their families (Ashley 2006). Here, then, menstrual tracking apps not only inherit modes of counting but also moral orientations.

Beyond 'Fertile Windows'
A contemporary political climate particularly unfriendly to forms of reproductive healthcare and education has placed new weight and sense of importance on data-rich menstrual tracking technologies. A leaked White House memo, for instance, described a US Department of Health and Human Services proposal to remove all forms of family planning programming for teens aside from the promotion of fertility awareness-based methods (Beutler 2017). In Europe, Natural Cycles was the first menstrual tracking application to be certified by the European Union as a method of contraception (a designation later also conferred by the United States Food and Drug Administration). This move has since garnered renewed attention and scrutiny, as a Swedish clinic raised flags after 37 of their patients reported unwanted pregnancies despite using the app (Pardes 2018;England 2017). These cases begin to expose the limits to a singular vision on the role of technology in menstrual tracking and the ways in which these apps-of both political and personal consequence-are ripe for critical, empirical investigation.
Toward developing techniques for conducting such critical investigation, we draw on recent approaches within the field of Human-Computer Interaction that argue for a feminist practice of technology design. For example, civic media scholar Catherine D'Ignazio and colleagues use the format of the large-scale hackathon to focus engineering attention on the task of redesigning the breast pump, a technology the researchers identify as long overlooked by industry (D'Ignazio et al. 2016). Similarly, Almeida et al. (2016) use familiar smartphone technology to promote pelvic floor fitness and everyday engagement with reproductive health concepts. Together these projects have helped scaffold a growing literature concerned with offering direct ways for researchers and practitioners alike to critically and productively explore alternatives to current design situations. In the cases described below, we take up methods common in processes of technology development and evaluation (for example, surveys, heuristic evaluation, interviews, app review analysis, participatory design) to investigate and conceptualize alternatives to available apps that reinforce particular visions of the menstruating body as realizing a reproductive capacity or as associated with a particular brand of femininity.

case one: examInIng exIstIng menstrual trackIng technologIes
In the first case study, I (Epstein) conducted research with Human-Computer Interaction scholars Lee, Kang, Agapie, Schroeder, Pina, Fogarty, Kientz, and Munson to understand how contemporary mobile apps support or neglect those tracking their menstrual cycles-accounts we, in turn, used to inform recommendations for improving the designs . The approach in this work was to characterize people's in situ experiences and challenges tracking their menstrual cycles as a means to critique the design choices of contemporary apps. To do this, we drew from three key streams of data: 2000 app store reviews of the 12 most reviewed Android and iPhone apps, a survey of 687 people who menstruate (recruited via Facebook, Twitter, and Reddit), and 12 interviews with individuals from socioeconomic, race, and identity groups underrepresented in our survey sample. Elsewhere, we discuss in more detail our study's methods, as well as offer longer form descriptions of our findings . In what follows, we summarize our study, describing why participants chose to use mobile applications to track their menstrual cycles and the challenges posed by commercial apps.

Motivations for Monitoring
Many of the participants in our study reported turning to digital methods for tracking their menstrual cycle as part of a broader evolution of digitizing personal data (for example, schedule planning and financial management moving from paper to digital systems). Some respondents described searching for an app immediately after obtaining a smartphone or beginning to use a digital calendar for the rest of their schedule planning. Participants who continued to use paper-based systems such as diaries and journals preferred the flexibility and privacy they associated with paper. Other participants tracked more implicitly by following pill-based hormonal birth control, noticing early symptoms of the arrival of their period, or simply remembering when their period last occurred and counting forward in their head.

Pitfalls of Prediction
To enable preparation, most apps include the ability to send push notifications a day before a person's period is expected to arrive or they are next expected to ovulate. Participants reported finding this feature the most compelling reason for using a digital app. They evaluated an app primarily on its ability to predict where they were in their cycle, such as whether they were about to have their period or were about to ovulate. 18% of app reviews, for instance, mentioned the accuracy or inaccuracy of prediction. This prediction is sometimes presented as a single-day estimate, as with the app Life ( Fig. 54.1a). Other apps, such as Clue, provide a range of possible affected days and describe a sense of uncertainty in their prediction ( Fig. 54.1b) represented by the bubbles at the tail ends of the fertile window and confidence intervals (for example, ±1) in the text description. Participants described switching apps in search of more accurate alternatives, similar to the way people abandon apps and devices they use to track other aspects of their wellbeing (Epstein et al. 2015).
To scaffold prediction, apps often ask people to enter their average cycle length and flow duration upon installation, updating these predictions once the user has experienced their cycle and logged it in the app (Fig. 54.2). Unfortunately, these predictions encode assumptions about the regularity and frequency of a person's cycle. Apps assume minimal cycle variation, when in reality a person's cycle can vary by days or even weeks (Fraser et al. 2007). Moreover, apps fail to account for variations caused by life factors such as stress, sleep, and changing birth control methods. Some apps even fail to account for pregnancy: one survey participant noted that "a pregnancy,  (left) and Period Tracker (right) typically ask for average cycle length and flow duration to aid prediction. Although this prediction may later be improved by journaled data, it is not resilient to variations due to factors such as irregular cycles, stress, birth control, or forgetting to journal (Credit: © StayWell Company LLC 2017 and © ABISHKKING LIMITED 2017) a baby, and a year and a half of breastfeeding later, the app thinks my normal cycle length is about every 700 days!" Apps also assume diligence in use and entry, which is known to be unrealistic in personal tracking (Epstein et al. 2015). Participants noted that logging their period's late arrival, or forgetting to record when their period ended, impacted the app's ability to make future predictions accurately. The realities of everyday use of cycle tracking apps often impede the success of the predictive models which underlie the app's core function and reinforce natural family planning.
To address these discrepancies, designers of menstrual tracking technology could examine additional techniques for modeling and communicating predictions. For example, evaluating interfaces which describe ovulation and period arrival as probabilities, rather than less-reliable binary predictions. At minimum, apps should allow people to correct a prediction when it falls out of line with reality, in order to be resilient to the myriad reasons why a prediction might be inaccurate (for example, changes in cycle, forgetting to track).

Menstrual Tracking Aesthetics
Similar to trends observed in the context of apps to support pregnancy (Peyton et al. 2014), most menstrual tracking apps we analyzed used stereotypically feminine attributes throughout their interfaces, such as predominantly pink color palettes or frequently used images of flowers and hearts (Fig. 54.3). Though some people reported appreciating the particular brand of femininity represented, most viewed it as a negative design trait. One participant described the design as trying to "dumb it down," leading her to wonder "why can't keeping track of my menstruation be a professional and organized task?" Many participants sought out apps which had more neutral color schemes, with 38 out of 200 reviews praising Clue's relatively neutral visual design ( Fig. 54.1, right).
Though some participants felt comfortable sharing their menstrual information, for others, the feminine aesthetics and often-obvious naming of apps (for example, Period Tracker, Period Diary) sometimes interfered with their desire to keep menstruation private. For example, one participant mentioned she "used to be embarrassed when other people looked at my phone and saw a bright pink tracking app," which prompted her to switch to an app with a more neutral aesthetic. Others felt the notifications interfered with their ability to keep their menstruation private, and disabled them as a result. Options for a more neutral design aesthetic and more subtle phrasing in notifications, as well as less conspicuous app names, could respond to this desire to keep menstruation and tracking information private.

Representations of Gender and Sexuality
Further, we observed that the apps we reviewed often make heteronormative assumptions about people tracking their menstruation and reinforce binary conceptions of gender. Participants who identified as non-binary or male struggled to find apps which "didn't misgender me," as one user described, or that featured gender-neutral language. For example, at the time of the study, Glow (Fig. 54.4, left) directed anyone who identified male upon setup to an alternate view of the app which focused on penile and testicular health. The design and language in many menstrual tracking apps encode heteronormative assumptions. In Glow (left), people who identify as male are directed to an alternative view of the app. Clue's iconography (right) suggests a male sexual partner. We note that since conducting this research, Clue has updated their icons for logging sexual activity to be abstract rather than anthropomorphized (Credit: © Glow, Inc. 2017 and © BioWink GmbH 2017) When apps support logging sexual activity or sharing data, they often assume that a person's sexual or relationship partner identifies as male. For example, at the time of the study, Clue provided two options for logging sex, both of which used icons suggesting a male partner (Fig. 54.4, right; we note that since conducting this research in 2016, the icons have been updated to be abstract representations). Other apps, such as My Period Tracker, only support asymmetric sharing of menstrual data (for example, sharing information about one's cycle with exactly one partner who is not also collecting their own data).

Fertility Focus
The emphasis on ovulation information (see Fig. 54.1) and inclusion of fertility tips led participants to feel that apps were primarily designed to support people in trying to conceive, rather than the range of goals they brought to tracking (for example, a general health check or avoiding pregnancy). Beyond feeling their goals were secondary, some participants felt uncomfortable with this focus. For example, some teenage participants stressed that they felt "too young" to care about fertility information. Participants who struggled with infertility, on the other hand, felt the ovulation information served as a reminder of their struggles.

One participant said, "I am no longer trying to get pregnant and I don't like the reminder of TTC [trying to conceive] or the tiny glimmer of hope that maybe by magic this will be the month when a miracle happens."
To design apps that avoid heteronormative and reductive assumptions about gender and sexuality, we suggest a more modular approach, one that allows people to align designs with their identity and goals. We believe more people would benefit from a gender-agnostic aesthetic that avoids gender-suggestive iconography or text. At minimum, apps should offer multiple themes or profiles from which to choose. Designs should also enable users to hide or remove ovulation and sexual activity markers, to allow those who do not wish to see this information to avoid it.
As they are currently designed, apps and tools for menstrual tracking fall short of addressing the needs and expectations people have expressed are important, including prediction, aesthetics, and tracking goals. The desire for alternatives is expressed succinctly by a respondent who lamented "I've tried 4 apps. They all suck . . . I would think a creative woman would've created something better by now." case two: reImagInIng menstrual trackIng through PartIcIPatory desIgn To pursue avenues for challenging narrow conceptions of menstrual tracking, I (Fox) collaborated with information scholars Menking and Eschler and bioinformatics scholar Backonja to conduct a multipart research program, described here as the second case Fox et al. 2020).
During the initial stages of research, we first reviewed perspectives on menstrual literacy from popular and publicly available health information-related websites, alongside the data collection techniques and interface characteristics of a sample of menstrual tracking apps (described in more detail in Eschler et al. 2019). One of the most striking disconnects between the menstrual literacy resources and the apps we examined concerned the focus on fertility (echoing the fertility focus highlighted in the previous case). To further explore design potentials in the space of menstrual tracking, we then took up collaborative methods of design (described further below) to imagine how tracking technologies might be developed differently to incorporate the concerns of a multiplicity of menstruators. In what follows, we focus on the results of these participatory encounters.

Period Packets: Reimagining the App Protocol
Inviting further reimagination of the menstrual tracking app protocol, we released a set of participatory design objects in the form of design packets (Gaver et al. 2001; Pierce and DiSalvo 2017)-here called Period Packetsasking participants to make their own sense of menstruation through a series of open activities. Drawing on the methodological tradition of research through design (Zimmerman, Forlizzi, and Evenson 2007), and more specifically the approach of cultural probes (Gaver et al. 2001), we took up ambiguity and provocation as a resource for conversation and collaborative design. In an early example of this method, design researchers Bill Gaver and Tony Dunne's design team used packages of materials with postcards and disposable cameras to engage with groups of older adults across three geographically distant retirement communities. In doing so, the design team aimed to reverse the promise of improving social life through technology, a promise "that tries so hard to be rational" (Gaver et al. 2001, 7). Instead, they sought a means of supporting the idiosyncrasies of everyday life, from chatting to creative expression. The outgrowths of these encounters are meant to be "generative of design potentials and possibilities, ones loosely directed toward more preferred states" (Pierce and DiSalvo 2017), rather than discrete solutions for all. In the Period Packets, we asked how respondents formed their own sense of the menstrual process, including prompts such as: "How do you know your period is coming? What does it mean to know your period? How does your period fit into your life? Record a week of your period, focusing on what's interesting to you." With the physical packets, we included markers, paint, and other craft materials, as well as a link to an online folder meant to receive digital text, image, video, and audio files, offering opportunity for expression through any means respondents saw fit-from sketches to sound files.
We distributed the packets online, via the project's own website, Instagram account, 2 and through email, sending the call for participation to our own personal and professional networks and snowballing from there. We also circulated the packets through the physical mail-initially, sending sets of packets to queer and feminist bookstores across the country and later fulfilling requests for physical packets received through the project's website. Ten people completed and returned the packet, either through an online form or physical mail, offering long-form responses to the open-ended questions and describing their own mechanisms for menstrual sensemaking both visually and textually (Fig. 54.5).
Through their reflections, respondents troubled notions of the body that configure it as wholly knowable and controllable, or presuppose that women's bodies, in particular, are primarily for reproduction. For instance, some described existing methods they used to collect information about their menstrual experience that did not match the data types and forms of capture that are featured in tracking apps. One respondent noted regularly, "[recording] the amount of fluid captured in my diva cup or pad or underwear throughout the day, color, viscosity, presence of any clots or cervical fluid" in order to compare relative volume across their cycle. Others suggested they had a general sense for where they were in their cycle based on corporeal experience and avoided formal data collection. One respondent reported being able to " [. . .] Fig. 54.5 Circulated online and through the mail, the Period Packet invited participants to reimagine the period tracking app by illustrating their own menstrual sensemaking practices, through both textual description and craft techniques responses suggest existing practices of sensemaking that might evade current apps, but could complement and extend them by allowing for more flexibility and variability across individuals' experiences.

tell based on discharge and other bodily changes. I don't take my temp each morning cuz [Sic] i am the worst at consistency but i can tell other ways, like body aches, getting emotional, etc." These
In what follows, we highlight two vignettes to illustrate expanded notions of monitoring menses introduced and illustrated across the pages of the packets we received.

Modes of Reflection
One respondent, Jenna, 3 reported charting and journaling on her menstrual cycle experience every day (see Fig. 54.6) and described, "organizing my life around my cycle." She further noted that this recognition of the body in daily practice fostered existential exploration and reflection:

I think knowing my period involves understanding why I get it, and situating it in the context of other female-bodied people/creatures and the elements. I used to think that ovulation happened during a period and that the whole deal was just a pain in the butt. Now I understand the process a lot better and feel glad when I shed my uterine lining because it means my body is working as it should. Like the cycles of birth, death, and rebirth that we see in nature (phases of the moon, tide, seasons) with each cycle I am letting go of old stuff my body doesn't need and beginning anew.
Here, Jenna gestures toward forms of sensemaking practice that currently fall outside of what designers and technologists developing apps recognize. Rather than tracking to find optimal days for conception, for instance, she hoped to foster a relational perspective through recordkeeping-a practice as much about making sense of her place in the world as it was about predicting a next period.

Affirmative Design
For others, prediction played a crucial role; not necessarily for the ways in which Levchin and others might imagine (such as ovulation, for those trying to conceive), but with no less consequence. One respondent, Robert, who identified as a transgender man, detailed through text and imagery his traumatic experiences with menstruation (see Fig. 54.7), which he described as causing "the most most dysphoria" for him. Tracking, to Robert, was a means to prepare, both materially and emotionally for what was to come with his period: [My period] used to be a thing I had to emotionally prepare for (either by closing off entirely and pointedly not thinking about it much more than "okay time to change tampons, don't look at it, etc.") So knowing when it was coming via when I realized the aching correlation, using a tracker app, etc. made it a lot easier on me since I could reliably know when and not have to look at a calendar in dread.
Yet, feelings of dread had not totally subsided, even with transition, Robert noted. Instead, he described having occasional periods since beginning testosterone shots, which could be more frequent if for some reason he was not able to take the prescription: In the above statement, Robert moved through his changing relationship to menstruation, one that had triggered intense experiences throughout his life, but was becoming easier to handle as it became more sporadic. This might seem paradoxical, at first: how would an "accidental period" be easier to deal with? That it was occasional and accidental made all the difference to Robert. It was not a constant trauma anymore. If anything, it was a reminder to take care of himself and to take time to get the testosterone he needed.
Through the circulation of the Period Packets we aimed to acknowledge a sense that no two menstruators are the same, while also recognizing all are experts of their own experience. Queer, unpartnered, infertile women, those uninterested in procreation, and transgender folks are all too often left from consideration in the design of menstrual tracking apps. Yet, throughout their packets, respondents offered new types of data and forms of interaction such as recording endometriosis pain and charting testosterone levels alongside period frequency. In doing so, respondents introduced new layers of depth and understanding to the period app protocol. This depth, we argue, should not be limited by technological prescription, but rather supported through further design experimentation.
conclusIon Across the two cases detailed in this chapter, we call for more and different sorts of designs in the space of menstrual tracking-ones that might be more reflective of the variety of interests and needs of menstruators (concerns only partially embodied in the accounts we have shared here). With the first case, we aimed to identify points where existing menstrual tracking apps do not match people's needs, preferences, and identities. Through analysis of app reviews, survey responses, and interviews, we uncovered a range of characteristics that cause people discomfort or feelings of exclusion, including assumptions about tracking goals (fertility), aesthetic preferences (pink and flowery imagery), gender identity (female), and sexual partner (one male partner). Rather than modeling an application on a particular understanding of the menstrual experience or set of attributes, we argue future technology should opt for design defaults which avoid such assumptions by, for instance, offering adaptability in the data presented. With the second case, we sought to highlight forms of menstrual recordkeeping and sensemaking already in active use, alongside or beyond the app. Through the form of the Period Packet, we invited respondents to engage and express these sometimes-implicit practices-ranging from recognizing growing aches and pains to daily journaling. The responses they returned suggest that though their existing practices of sensemaking might evade current apps, technologies may have a place if carefully managed. Using flexible and dynamic sorts of accounting, for instance, would allow technology to complement and extend existing practices.
Though it may seem that there is a long way to go before mainstream technological development supports varying approaches to monitoring, our two case studies suggest there may be productive overlaps, ways in which menstrual tracking technology can better align with people's needs and preferences. By critiquing existing technologies, our aim is not to point at a problem and walk away, but rather to offer generative openings on the sorts of designs that could exist alongside the existing terrain of apps.
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