For nearly two decades starting in middle school, Sallie Sarrel, DPT, believed the soul-crushing cramps she experienced around her period were just a part of her life that she had to accept. “I was ashamed that I hurt so badly. The bloating made me hate myself,” she says. “I felt like a failure.” Sarrel says that she went to over 14 different OB/GYNs to understand what was going on, only to be told that everything was fine. She was finally diagnosed with endometriosis 10 years ago, and went into surgical menopause at the age of 34.

Now a pelvic health physical therapist who specializes in treating women with endometriosis and the co-founder of The Endometriosis Summit, Sarrel, 45, has a different take on periods. “Here I am all these years later, surviving the torment from the hormonal ups and downs, never able to have a child, not realizing the last time I had cramps was my last time ever. I am happy to be off the rollercoaster that my period put me on, but I am devastated that at such a young age I have all the menopause symptoms of a 50-year-old,” she says.

By opening up the discussion around periods and increasing awareness around conditions like endometriosis, the period positivity movement has taken some of the stigma out of menstruation. That’s been positive for the endometriosis community, Sarrel says, and for other people who suffered with periods in silence. But the sometimes unabashedly positive talk can be alienating for many people who have a complex relationship with menstruation.

The real challenges of period stigma

Think of the horror on Seth’s face in Superbad when he realizes that the stain on his jeans was his dance partner’s period blood, and you have a pretty good idea of how society generally views periods: with disgust mixed with laughter and embarrassment. That’s exemplified in a million different ways, from the fact that we have over 5000 different euphemisms for the term menstruation (as if it’s a dirty or bad word), or that ads for tampons and pads still use blue liquid to represent period blood (although that’s slowly changing). Some places around the world even require menstruating people to stay in separate shelters during their periods and in some cases, not interact with anyone for the duration of their bleeding.

The period positivity movement was born around about five years ago to combat these very real taboos that impact the lives of people with periods. Organizations like Period, which supplies women in need with period hygiene products, and the period-proof underwear company Thinx, which launched a controversial ad campaign on NYC subways showing suggestive imagery to depict vulvas and menstrual fluid, initiated public discussion around menstruation in unprecedented ways.

Period positivity advocates wanted menstruation to be seen as normal parts of people’s lives, not a shameful thing to be dealt with in secret. And it seemed to be working. A more open discussion about period pain points (like quality of products) laid the groundwork for an onslaught of sustainable, natural options for period management, including menstrual cups like Lunette, organic tampons like Lola, and “cupaware” parties. Marathon runner Kiran Gandhi made headlines for free-bleeding during the 2016 London Marathon. Instagram accounts like Pink Bits and Bloody Good Period were launched explicitly to celebrate women’s bodies and monthly cycles.

Advocates also pushed back against some of the negative language about periods. Troll the #periodpositivity tag on Instagram and you can find people sharing beautiful art devoted to all things periods, with captions asking people to “fully embrace” their cycles or associating periods with ancient religious rites and self-help manifestos. Hormonal experts like Alissa Vitti have long preached the liberating power of tracking one’s cycle. Author and photographer Rupi Kaur likened her period to a religious experience in a 2016 post: “I bleed each month to help make humankind a possibility. my womb is home to the divine. A source of life for our species.”

“Women were suffering in silence. [The period positivity movement] been very freeing for a lot of women,” says Aimee Raupp LAc, an herbalist and acupuncturist in NYC specializing in women’s health and fertility.

The limitations of period positivity

Yet for all of the talk about the “magic” of periods, some people have a more complicated relationship with their menstrual cycles that can be overlooked by the emphasis on positivity. “Some people dread it due to physical and emotional discomfort, which is understandable and shouldn’t be considered abnormal,” says Alyssa Dweck, M.D., an OB/GYN in New York.

Such was the case for Sarrel, who had endometriosis—a condition known for making monthly menstruation particularly agonizing. Similarly, Stephanie Ross, 27, says severe cramping and a heavy, clot-ridden flow kept her from being a normal 12-year-old. Debilitating monthly cramps, mood swings, hot flashes, nausea, and headaches prompted a string of doctor visits before she was finally diagnosed with endometriosis and PCOS. “My relationship with the women in my family became strained because they just didn’t understand that I was at one of my lowest points, emotionally,” she says.

For others, hormonal shifts around periods can lead to premenstrual dysphoric disorder (PMDD): severe, sometimes debilitating emotional symptoms before menstruation including anxiety, depression, social withdrawal, and insomnia. “It causes great distress and marked impairment in overall functioning,” says Sabrina Khan, MD, a clinical assistant professor in the NYU School of Medicine Department of Psychiatry.

Even without a diagnosable condition, many people just have unpleasant period symptoms that make their monthly bleeding far from a celebratory occasion. Sophia Reed, Ph.D., 35, hesitates to travel on her period because she risks bleeding through her clothes if she’s stuck on a plane for even a few hours. “I have felt frustrated because I cannot relate [with period positivity],” Reed says. “For [people] with heavy periods, we don’t want to bond with it. We just have to deal with it.”

There are other issues that can come up that might make someone feel less than empowered by their menstrual bleeding. People struggling to concieve, for example, might be devastated to get their periods. “Some women got their period because they just miscarried,” adds Raupp. “It [can be] a reminder of how their bodies are not functioning and how they can improve.” Plus, transgender men and gender non-binary or gender non-conforming people can have uteruses and thus may have periods—which can cause mixed emotions. “My period is another reminder that I’m not who society tells me to be and that I’ll never be seen as someone who isn’t a woman,” says Remy D’Agnillo, 23, who does not identify as a woman.

And although the period positivity movement has encouraged people to learn more about their bodies, that doesn’t always mean they’re accessing reliable information. “Instagram influencers tell [women with endometriosis] that if we’re not having a happy period, it’s because we have misplaced energy with our fathers, or we don’t eat right, or we need to purchase their expensive coaching programs,” Sarrel says as an example. It’s a reason why she considers the period positivity movement “a double-edged sword.”

A different approach

This isn’t to say that period positivity is a bad thing—far from that. But for people who have a complicated relationship with their cycles, a better way to truly reduce stigma maybe be to embrace being period neutral. “People shouldn’t be ashamed of their period but also shouldn’t be forced to be excited about it,” argues D’Agnillo.

What does this look like, exactly? Period neutrality, in our humble view, is talking about one’s cycles openly and without shame, but not necessarily with celebration or excitement if that’s not true to one’s experience. It’s understanding that your period is a normal biological process that happens to many people with uteruses. Yet it doesn’t require anyone to assign a forced sense of joy or empowerment if that doesn’t feel true to them.

You may never love your period, and that’s okay. But for the aspects about one’s period that could make it miserable, there are many knowledgeable experts—OB/GYNs, psychiatrists, pelvic floor physical therapists, naturopaths—who offer evidence-based treatments that can help a person regain control over their lives and their symptoms. By being aware that PMDD exists, for example, people can significantly reduce symptoms by getting diagnosed and treated, Dr. Khan says. “Most of the time, there’s something we can do to help,” adds Dr. Dweck.

The bottom line: While we’re all for cheering on the beauty and mind-blowing capacities of our bodies, let’s aim to be informed and sensitive, too. “It’s not just about heralding menstruation,” says Sarrel. “Good care is out there, but we have to be talking about it all, good and bad, in order to access that care,” says Sarrel. At the end of the day, opening up the conversation about periods to fully include people who have a mixed relationship with theirs moves the fight against stigma forward.

Your menstrual cycle is so much bigger than just your period—here’s what to know about every single stage of the process. And here are six common period FAQ’s, answered by doctors.