This study advances the understanding of menstrual health and hygiene (MHH) by integrating access to water, sanitation, and hygiene (WASH) facilities and period product usage. Using a cross-sectional design and data from the National Family Health Survey-5 (n = 205,861 women aged 15–24 years), we examined factors associated with adequate MHH access and its geographical distribution across Indian districts via bivariate and multivariate logistic regression and Fairlie decomposition. We found substantial geographical disparities in access, ranging from 2.3% to 89.4%. Key predictors included household asset index, education, place of residence, and region. These factors, especially asset index, region, and urban/rural residence, explained a large portion of the observed disparities between high (top 25%)- and low-performing (bottom 25%) districts, indicating that socioeconomic disadvantage and geographical inequities significantly shape MHH access. These findings demonstrate the critical need for geographically targeted interventions promoting MHH in India, particularly by improving WASH infrastructure and affordability of products in socioeconomically marginalized areas.