Abstract
<title>Abstract</title> <p>Background Menstrual health among adolescents in India's high-altitude trans-Himalayan region remains poorly understood. This study examines period poverty as a multidimensional condition among schoolgirls in Leh and Kargil, two districts of Ladakh that differ in geography, culture, and service access. Methods A cross-sectional survey of 310 post-menarcheal schoolgirls across 13 administrative blocks was conducted using a structured questionnaire and an 18-item Likert scale. A composite Menstrual Health Vulnerability Index (MHVI, 0-100) was developed across four domains: knowledge, hygiene practices, product access, and sociocultural restrictions. District differences were assessed using Mann-Whitney U and Welch's t-tests, while associations were examined using Spearman correlation and regression analyses. Results The mean MHVI was 27.3 (SD 14.3), with 38.1% of girls experiencing deficits in two or more domains. Vulnerability was higher in Leh than Kargil (30.2 vs 24.6, p = 0.001), but patterns differed substantially. Leh showed greater sociocultural restriction (65.3 vs 40.0, p < 0.001), whereas Kargil exhibited larger hygiene-practice deficits (11.6 vs 5.2, p < 0.001). Knowledge was associated with lower vulnerability (ρ=-0.17). The four domains were only weakly correlated, suggesting distinct underlying drivers. Conclusions Period poverty in Ladakh is heterogeneous and locally patterned. District-specific interventions are needed: taboo reduction and disposal infrastructure in Leh, and affordability support with hygiene education in Kargil. Domain-targeted strategies may be more effective than uniform approaches in improving menstrual equity in remote mountain regions.</p>