Beirut (AFP) - Like many women, Huda dreads her menstrual period every month. But it isn't simply inconvenient or painful: She lives under siege near Syria's Damascus, without sanitary pads or even clean water.
"When feminine products started to become rare in 2012, I had a really hard time," says the 23-year-old from Saqba, a rebel-held town in the battered Eastern Ghouta area, which has been besieged since 2013.
Speaking to AFP using a pseudonym, Huda says the very few female hygiene products available in Saqba are too expensive for her and her husband.
"So I had to make do with old cloth," she says.
"But I started getting a lot of infections, so I decided to buy just a few sanitary pads and use one per day so I didn't go through them quickly."
Reusing pads has led to fungal infections, kidney pains, and vaginal and urinary tract problems, Huda says.
"I'm trying to get treatment, but it's going so slow" because of the cost of proper medication.
More than 860,000 people live under siege across war-ravaged Syria, facing shortages of food, water, diesel, and other vital goods.
But women in besieged areas face the additional challenge of struggling each month with limited access to pads as well as clean water, leading to sometimes serious gynaecological complications caused by poor hygiene.
Openly discussing menstrual cycles is taboo across much of Syria, and many of the women who spoke to AFP asked to be identified by a pseudonym.
- 'Everything is hard' -
Aid groups say they include sanitary pads in health packages delivered to besieged areas, but their access to these areas is sporadic and what they can deliver falls far short of needs, women say.
The UN children's agency says it has delivered 84,000 hygiene packs -- each including 10 pads -- to hard-to-reach and besieged locations across Syria in 2016, up from 17,000 last year.
But if even just a third of the 860,000 Syrians under siege were women of menstruating age, they would need more than 10 million sanitary pads per year.
Laila Bakry, who heads the women's centre for Eastern Ghouta, says pads are hard to find or too expensive there.
During their period, many women resort to what Bakry calls "the traditional method" -- reusing old rags.
But they struggle to clean the fabric because "there's often no water and, if there is, it's hard to boil it because there's no electricity or gas".
Rania, an 18-year-old who frequents Bakry's centre, says she first had her period in 2011, when sanitary pads and painkillers, as well as gas and water, were still available.
Since the government siege cut off food, water, and aid access to Douma three years ago, "everything is hard", she says.
"Even when I'm done with the pain of my period, I have to figure out a way to wash... I don't know if we will ever get used to this," Rania says.
- Siege hinders treatment -
Bakry says she has seen a host of complications from the lack of proper hygiene, including fungal infections, dermatological problems, and chronic pain.
Living under siege hinders treatment, with the few gynaecologists with enough experience overwhelmed by cases and medicine hard to obtain.
"Even if a specialised doctor sees her early on, diagnoses the problem and prescribes some medication, the medicine isn't available," Bakry says.
"It will take too long to get it, and some people can't buy it because it's too expensive."
Aid groups involved in deliveries say cultural considerations have prevented them from examining the health complications caused by the absence of feminine hygiene products.
"Because the issue is so sensitive, health assessment teams have not gathered information on potential medical complications," says Ingy Sedky of the International Committee of the Red Cross.
The UN's fund for reproductive health did not respond to requests for comment.
Further north, the opposition-held eastern districts of Aleppo city are facing both a devastating siege and an intensifying government offensive.
Baraa, a nurse who works with a female gynaecologist in the city, says women there also "tear a piece of cloth" to use instead of sanitary pads and often use expired medication out of desperation.
"Without clean water or proper hygiene, we are seeing gynaecological infections," Baraa says.
"The doctor I work with says these cases have increased a lot over the past month."
Since September 22, nearly 500 people have been killed in the eastern districts as government fighters backed by Russian warplanes battle rebel groups there.
The intensity of the fighting has put so much strain on Baraa's patients that they often do not have their period at all or bleed more heavily.
"Instability and anxiety play a huge role," she says.