Facing displacement, overcrowded living conditions, and a lack of access to water and menstrual hygiene products such as sanitary napkins and tampons, women have been taking norethisterone tablets – ordinarily prescribed for conditions such as severe menstrual bleeding, endometriosis, and painful periods – to avoid the discomfort and pain of menstruation.

According to Dr Walid Abu Hatab, an obstetrics and gynaecology medical consultant at the Nasser Medical Complex in the southern city of Khan Younis, the tablets keep progesterone hormone levels raised to stop the uterus from shedding its lining, thus delaying a period.

The pills may have side effects such as include irregular vaginal bleeding, nausea, changes to the menstrual cycle, dizziness and mood swings, according to medical professionals, but some women like Salma Khaled say they have no choice but to take the risk amid Israel’s relentless bombardment and blockade of Gaza.

‘Most difficult days’

Salma fled her home in Gaza City’s Tel al-Hawa neighbourhood two weeks ago and is staying at a relative’s house in Deir el-Balah refugee camp in central Gaza. The 41-year-old says she has been in a constant state of fear, discomfort and depression, which has taken a toll on her menstrual cycle.

“I am experiencing the most difficult days of my life during this war,” Salma says. “I got my period twice this month so far – which is very irregular for me – and suffered heavy bleeding.”

Salma says there are not enough sanitary pads available in the few shops and pharmacies that have remained open. Meanwhile, sharing a house with dozens of relatives amid a water shortage has made regular hygiene a luxury – if not an impossibility. The use of the bathroom must be rationed, and showering is limited to once every few days.

Pharmacies and stores alike are facing dwindling supplies due to the total siege imposed by Israel following an attack by the armed wing of the Palestinian group Hamas on October 7. In addition, Israel’s bombardment of main roads in the Gaza Strip has made transporting products from medical warehouses to pharmacies an impossible task, according to Abu Hatab.

Without the means to manage her menstruation as she usually would, Salma decided to try to find pills to skip her period.

While sanitary napkins are in demand and hard to find, period-delaying tablets are generally more available in some pharmacies as they are not commonly used.

“I asked my daughter to go to the pharmacy and buy pills that delay menstruation,” Salma says. “Perhaps this war will end soon and I will not need to use them more than once,” she added, worried about the possible side effects of the pills on her body.

‘Extreme stress’

More than 1.4 million people have been internally displaced in the Gaza Strip since October 7, living in cramped, unhygienic conditions in United Nations-run schools and in overcrowded spaces with host families or relatives, leaving no room for privacy.

The effects of the Israeli offensive – now in its 25th day – have been devastating. More than 8,500 Palestinians have been killed, the majority of them women and children. Repeated warnings by the Israeli military for residents to leave northern Gaza and Gaza City have seen towns and cities in the centre and south of the territory swell in number, but air attacks have continued to pound the southern Gaza Strip.

According to Nevin Adnan, a psychologist and social worker based in Gaza City, women ordinarily may experience psychological and physical symptoms in the days before and during their periods, such as changes in their mood and lower abdominal and back pain.

These symptoms can worsen during times of stress such as the ongoing war, according to Adnan. “Displacement causes extreme stress and that affects the woman’s body and her hormones,” she explained.

“There can also be an increase of the physical symptoms associated with menstruation, such as abdominal and back pain, constipation and bloating,” she said.

Women may experience insomnia, constant nervousness and extreme tension, Adnan added.

At present, she said more women are open to taking period-delaying pills to avoid embarrassment and shame due to the lack of hygiene, privacy, and available health products.

Still, although she understands the current predicament, Adnan said in normal circumstances consulting a doctor before taking these tablets is important to know what effects these pills and their sustained use might have on a woman’s physical health.

“They could affect the woman’s natural hormonal changes, the date of her menstruation for the following month, the amount of blood she loses, and whether it stops the period,” she told Al Jazeera.

No privacy, water or sanitary napkins

Samira al-Saadi, who is displaced with her family in a UN-run school west of Khan Younis, wishes she could do more for her 15-year-old daughter who got her first period a few months ago.

Her daughter is overwhelmed by both recently starting to menstruate and having to manage her period in a crowded shelter, the 55-year-old says. “She needs sanitary pads and water to wash, but these basic needs are not available.”

Samira is concerned about buying her daughter period-delaying pills as she worries how they might affect her child’s health.

“She just doesn’t understand why she has to go through all of this,” Samira says. “I try to help her, but what she needs is not at hand.”

Ruba Seif is also staying at the shelter with her family.

“There is no privacy, the bathrooms do not have running water, and we cannot go outside easily to look for what we need,” says the 35-year-old.

“I cannot bear the menstrual cramps on top of the intense fear we experience constantly, the lack of sleep, and the cold since there aren’t enough blankets.”

The thought of coping with her period at the shelter has been a constant source of stress for Ruba.

Ruba, who is busy taking care of her four children, the oldest being 10 and the youngest two years old, eventually asked her brother to look for period-delaying pills. After searching in several pharmacies he eventually found them.

“Other women around me in the school have asked me for these pills,” Ruba says. “One of them told me that she had gone through the worst period in her life. I know of their negative side effects, but these pills cannot be more harmful than the missiles, death and destruction all around us.”

Back in the Deir el-Balah refugee camp, Salma rues the psychological and physical effects of the war on women, as many are gripped not only with concerns such as menstrual health but also those of how to take care of their children who look to them as a major source of protection, reassurance, and support.

“In war, we are forced to do everything we can,” she says, referring to the state of suffering. “There is never a choice.”