Heba Usrof, a young woman in Gaza, is running out of options to deal with her menstrual cycle. Pads have disappeared from pharmacies and stores. It's been this way since the war that began in October, and it's a situation that mirrors how nearly every basic requirement — from food to medical aid — has become harder to find in Gaza over the past three months.

"We go around and around, searching in all the pharmacies for pads, but we can't find any," Usrof says.

Ruba Akkila, whose work in Gaza before the war focused on the protection of women and children, says pads do sporadically appear on shelves, but they are five and six times their normal price when and if they are sold, putting them out of reach for most of Gaza's impoverished and now unemployed households.

The lack of pads is a result of Israel's near-total siege of Gaza, which began following a deadly rampage in Israel by Hamas militants on October 7.

"We're suffering from being hungry, from being thirsty, from being bombed. We're suffering from being displaced," says Bisan Owda, a young woman in Gaza who's been vividly documenting her life throughout the war to her 3.7 million followers on Instagram.

"Now, we're suffering also because there's no pads. It's just a new suffering," she says in a video post about this issue.

A lack of hygiene products — and basic hygiene

The U.N. estimates that some 700,000 women and girls in Gaza experience menstrual cycles but don't have adequate access now to basic hygiene products like pads, toilet paper or even running water and toilets because of the war. These conditions put women and girls in Gaza at risk of reproductive and urinary tract infections, according to the U.N.

A spokesperson for UNICEF told NPR: "This situation is particularly challenging for women and adolescent girls, who lack safe, private and dignified places to manage menstrual hygiene. There are reports this is exacerbating mental health issues."

Jumana Shahin, a women's rights activist in Gaza, says women's needs are being neglected because of the scale of the humanitarian crisis gripping Gaza.

"This situation is not simple. We are talking about a woman's needs," she said. "This situation does not have a solution. You ask if there are alternatives. There are no alternatives."

"The situation is harder than you can imagine," she adds.

How women are coping

Nevertheless, women are trying to find ways to deal with their menstrual cycles.

Usrof says her friends are now taking pills that prevent their periods. She's going to start doing the same, she says. It's either that or "drown,", she says. "This issue is we're moving around a lot. We don't have the luxury of sitting around and relaxing, so it's really hard,' she says, describing how most people have fled from their homes and shelters multiple times in past weeks as Israel expands its offensive.

Meanwhile, not all women can find pills to block their periods or, for underlying health reasons, can take these pills.

With no other choice, Akkila, the gender protection expert, says some women are turning to old clothes, towels or even the corners of their tents to use as pads.

"The only way to do it is just to do with scissors," she says.

"It's messy. It's terrible. And nobody speaks about it," Akkila says, explaining openly talking about menstrual struggles remains taboo, even in wartime.That's partly a reflection of Gaza's traditional society – and because menstruation is a sensitive and private subject everywhere in the world.

The search for running water and toilets

Israel's bombardment and evacuation orders have displaced around 2 million people, more than 85% of Gaza's population.

As a result of this mass displacement, women also have to contend with a lack of privacy and little to no access to bathrooms. Much of Gaza has no access to running water, making showers a rare luxury.

The water crisis is so severe that those in apartments, where extended families are sheltering together, can only flush the toilet when necessary because every drop of water has to be carried up the stairs and rationed.

Most Gazans, however, are living in overcrowded U.N.-run schools, where 400 people or more share a single bathroom.

Others are living in tents and on the streets as Israeli evacuation orders push people further and further south as the Israeli military tries to dismantle Hamas tunnels and expands deeper into Gaza.

Women are waking up early and lining up at hospitals to shower before water runs out for the day, Akkila says. Others are lining up at hospitals just to use the bathroom.

The challenge of trying to find an available bathroom is especially difficult for pregnant women who have pressure on their bladder, and women who've just given birth and are going through weeks of postpartum bleeding.

Owda, the young woman filming videos from Gaza, shared another post two weeks ago showing what the inside of a makeshift bathroom in a tent encampment in Khan Younis looks like.

"There is no water. There is nothing around them. There is no infrastructure. They're living just in a tent, and they need bathroom(s). They're humans," she said, speaking from a small tent that's being used as a bathroom.

She pans to a garbage basket on the ground that doubles as a toilet. She shows a bucket on the ground that is used for washing. Plastic bags with people's belongings are crammed onto a makeshift wooden shelf.

"Can you imagine? This is a bathroom," Owda says.

Gaza is getting aid but hardly enough

Life in Gaza is a struggle for survival, with more than 23,000 Palestinians killed and around 60,000 wounded, according to Gaza's health ministry. A lack of hygiene and the collapse of the health system has led to the spread of disease in overcrowded shelters, according to the World Health Organization. There's a huge spike in cases of diarrhea among young and malnourished children in Gaza, jumping from around 66 cases a day before the war to about 3,200 cases a day last month, according to the UN children's fund, UNICEF.

Only a fraction of the aid that's needed is entering Gaza every day. The U.N. says everyone in Gaza is hungry and that the territory is at risk of famine, with many families already starving. The World Food Program says people in Gaza often go entire days without eating and that many adults go hungry so that children can eat.

In addition, the World Health Organization says just 13 out of Gaza's 36 hospitals are partially functional, with the rest forced to shut down because of bombardment and evacuation orders. WHO and other medical aid organizations say some of these hospitals do not even have basics like anesthesia and antibiotics.

As a result of these crises, aid trucks that do enter are mostly packed with food and medical aid — not necessarily with pads for women.

UNICEF, the U.N. children's fund that also works closely with women and new mothers, told NPR that since the start of the war in October they've distributed more than 41,000 hygiene kits in Gaza, which include pads and other items like soap, wipes, toilet paper, detergent and diapers.

Yet it's a sliver of what's needed. UNICEF says nearly 70 trucks with more of these kits and other essential items, like tents and winter clothes, have been at border crossings for weeks, waiting for Israeli checks to enter.

Marie-Aure Perreaut Revial, emergency coordinator for Doctors Without Borders, was in Gaza last month and says women were coming to one of the main health centers where the group was operating from to request birth control pills in order to block their periods because of the lack of available pads and water.

"They were asking for family planning methods so that they would not be faced with situations where they had to find water and have to choose water either to clean their children or clean themselves," she says. "It's just very, very difficult to find water now in Gaza."

That health center and the area around it in Khan Younis were ordered to evacuate by Israel last month. As a result, says Perreaut Revial, women lost their access to those pills from the clinic.