Late-night pharmacy runs. Bulky pads. Periods have simply long been an uncomfortable experience.
But now it has become an economic issue, too. Businesses, lawmakers and advertisers, prodded in large part by a frank online discussion of menstrual cycles and backed by calls for gender equality, have sought ways to make menstrual cycles a little less agonizing.
Eight states and the District of Columbia have moved to eliminate sales tax on pads and tampons, and bills have recently passed in the New York and Mississippi state Senates. In New York, Gov. Andrew Cuomo is expected to sign the measure into law in the coming weeks.
New companies are pursuing products to make women more comfortable during their period, including underwear that its manufacturer says will not leak and tampons made from 100 percent cotton.
Even advertisers are taking a bolder approach to menstruation. Instead of displaying blue liquids squirting out of pipettes and women in white dresses frolicking on the beach, they are showing real women doing real activities, like working at a computer.
"There's a sense that this really goes to the heart of women's opportunity to participate fully in school, in the economy, in society, and we need to do something about it," said Jennifer Weiss-Wolf, a vice president at the Brennan Center for Justice at the New York University Law School.
"Menstrual products are expensive, and it's absolutely debilitating if you don't have access to them," she said.
Businesses and politicians are taking their cue from a growing effort to talk more openly about periods, with much of it happening online.
Under pressure from online critics, Instagram, the photo-sharing site, restored a photography series featuring blood from a woman's period after removing the series twice. An online petition calling out the states that tax menstrual products garnered over 60,000 signatures.
And when Donald Trump complained about the tough questions of the Fox News moderator Megyn Kelly at a Republican presidential debate in August, saying that she had "blood coming out of her wherever," hundreds of women and some men responded in force on Twitter using the hashtag #periodsarenotaninsult.
"That to me felt like a watershed moment," said Chris Bobel, an associate professor of women's studies at the University of Massachusetts Boston and president of the Society for Menstrual Cycle Research.
"There was a reframe," she added, "which was: 'Hey, that insult doesn't stick because there's nothing shameful about periods. And by the way, let's fix that.'"
Since the start of the 2016 state legislative calendar, bills to exempt tampons and pads from sales tax have been introduced or resurrected in California, Connecticut, Illinois, Michigan, Ohio, Rhode Island, Virginia, the District of Columbia and Wisconsin, and have passed in Mississippi and New York, largely with bipartisan support. Similar legislation is being discussed in committees in South Carolina and Tennessee. Last month, Chicago passed an ordinance to eliminate the city's portion of the tax. In Utah, an all-male committee of lawmakers shut down a proposal to get rid of the state's tampon tax.
Taking legal action
On March 3, five women filed a class action against the New York Taxation and Finance Department, claiming that the state should classify period pads and tampons as necessities. The suit points out that New York classifies men's products like Viagra, Rogaine and dandruff shampoo as necessities. Failing to protect men and women equally through the tax system, the suit says, violates state tax laws, as well as state and U.S. constitutions.
If the suit is successful, women in New York could receive rebates for the last two years of taxes paid on menstrual products, an amount that most likely adds up to about $28 million overall according to the plaintiffs' lawyers. The women would continue to push for the refunds even after Cuomo repealed the tax, they said.
"Tampons and sanitary pads are a necessity for women, not a luxury," said Zoe Salzman, a lawyer for the women. "There is no way these products would be taxed if men had to use them."
James Gazzale, a spokesman for the New York State Taxation and Finance Department, said he could not comment on continuing litigation.
American women spent $3 billion on sanitary protection in 2014, up 2 percent from 2013, according to the market research company Euromonitor International. But it is a slow-growing industry dominated by a handful of giants like Procter & Gamble.
Johnson & Johnson, which long produced feminine care products, sold its Stayfree pad, Carefree liner and o.b. tampon brands in 2013 to shed businesses that were not growing.
Energizer paid $185 million for the brands but spun them off less than two years later.
"In terms of growth, you're basically just looking at population growth," said Jabel Parayil, an analyst at Euromonitor. "These manufacturers are trying to drive added value through advertising rather than true technological value. The new trends are really coming from the smaller companies."
Yet a variety of startups think there is a window of opportunity. Apps like Clue and Period Tracker help women keep track of their menstruation cycles. In June, CVS started carrying a silicone menstrual cup made by DivaCup. Last month, Whoopi Goldberg announced that she was joining with a California-based producer of edible marijuana products to form a company that would offer products designed to ease menstrual pain.
Thinx, a company that makes absorbent, "period-proof" panties meant to be worn without tampons or pads, has pushed the boundaries of period engineering and advertising, using images of a runny egg yolk or the insides of a grapefruit to evoke menstruation or the female anatomy.
Miki Agrawal, the founder of Thinx, said conventional period products and marketing "make women uncomfortable, not sexy, not like themselves and not in their full power.
The flurry of startup activity has come as fresh competition for the big-name pad and tampon makers. Kanchan Patkar, brand director for Kimberly-Clark's Kotex brand, which logged global sales of more than $1 billion last year, said the traditional brands had not ignored feminine care.
In an interview, Patkar listed a string of Kotex innovations over the years: panty liners for light days, compact tampon applicators, 3-D modeling of pads for a better fit and ultrathin pads that she says have reduced the bulkiness of pads by 67 percent.
Patkar says that Kotex also overhauled how it talks about periods. Its U by Kotex tampons and liners have abandoned their medicinal pale packaging for bold colors and designs.
And the brand has moved away from what Patkar said was frivolous advertising of women with periods frolicking in white dresses. Some of its most recent ads feature women in a college dorm room, at a computer and Skyping with friends.
"We decided to call out the truth," she said. "You have cramps. You have bloating. You don't feel like jumping around in a field or doing extreme sports. And that's OK."
Still, as the some of the startups have found, the topic is still not always easy to discuss.
When Alexandra Friedman and Jordana Kier pitched their idea for a tampon delivery service to a potential investor last year, they found him weary of discussing the intimate product. So Friedman grabbed his glass of water, dunked one of her prototype tampons in it and forced him to look.
They have since raised $4.2 million for their startup, Lola.
"I told him: 'This is what it's doing in a woman's body. It's absorbing liquid, and it's becoming bigger,'" Friedman said. "Then we left it in the middle of the table, and we finished eating."