Dictionary:

menstruation

  (mĕn'strū-ā'shən)

The process or an instance of discharging the menses.

Periodic sloughing of the uterine lining in women of reproductive age. Menstrual bleeding indicates the first day of the menstrual cycle, which lasts an average of 27–30 days, although ranges of 21–60 days have been recorded. Menarche, the onset of menstruation, occurs between the ages of 9 and 16. The majority of females begin menstruating at ages 12–14. During the first few years, the duration and intensity of menstrual flow and the total cycle length may be quite variable, but regularity is gradually established. Cessation of menses, or menopause, occurs at an average age of 51, with a range of 42–60 years.

The menstrual cycle consists of cyclic changes in both the ovary and the uterus. These changes are controlled by the interaction of several hormones including follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which are secreted by the anterior pituitary, and the steroid hormones estrogen and progesterone, which are secreted by follicles in the ovary. At the beginning of the cycle, the follicle is stimulated by FSH. In response, it grows and secretes estrogen. The amount of estrogen secretion increases rapidly near the middle of the cycle. Estrogen, in turn, stimulates growth of the uterine lining (mucosa), which becomes thicker and fills with blood vessels. In midcycle, the rapid increase in estrogen causes a massive surge of LH release and a smaller release of FSH from the pituitary. This surge causes ovulation, which is the release of the ovum from the follicle. After ovulation, the follicle undergoes rapid changes and is then called a corpus luteum, which secretes progesterone in response to LH stimulation. Progesterone and estrogen together cause a further thickening of the uterine mucosa, preparing the uterus for pregnancy. If pregnancy does not occur, the corpus luteum degenerates, the uterine mucosa sloughs off, and the cycle begins again.

There is no menstrual bleeding during pregnancy, as the uterine mucosa is needed for the maintenance of pregnancy. This amenorrhea, or lack of normal ovarian function, sometimes continues during nursing.

Menstruation is the periodic shedding of the endometrium (lining of the uterus) accompanied by blood loss, that identifies the reproductive years of a woman's life. The first menstruation (menarche) usually occurs at puberty (typically between the ages of 11 and 16) and menstrual periods continue until the menopause around the age of 45-50. However, menstruation does not occur during pregnancy and can be suppressed or disrupted in women who are breast-feeding. This was noted by the scientist and philosopher, Aristotle (384-22 bc), who believed that pregnant women did not menstruate because the seed of the male caused blood to coagulate into an egg from which the fetus developed. Milk was also thought to be formed from menstrual blood because of the absence of menstruation in lactating women.

The old ideas as to why women menstruate stemmed from the teachings of Hippocrates (c.400 bc) who believed that health was governed by the balance of the four body fluids or humours — blood, phlegm, black bile, and yellow bile. Thus menstruation was seen as a means of getting rid of excess blood to prevent the body filling with this humour, upsetting the balance and causing illness. This theory was finally disproved by John Davidge in 1814, who pointed out that a woman might only lose a few teaspoons of blood in a typical menstrual flow, while the loss of a much greater amount of blood through blood-letting (cutting the veins) did not prevent menstruation. He concluded that menstruation, rather than being a means of getting rid of excess blood, could be attributed to some odd condition of the ovaries which excited the blood vessels of the womb. In essence his premise was correct.

Menstruation is the culmination of a complex series of hormonal events associated with the cyclical production of a mature egg within the ovary and the release of this egg for fertilization. In the first half of the menstrual cycle, ovarian follicles, containing an egg, develop, and produce increasing amounts of oestrogen. This sex hormone stimulates a build-up of the lining of the womb and the growth of spiral arteries into this thickened lining. After ovulation, which occurs around day 14 of the cycle, the empty follicle in the ovary becomes a corpus luteum. This produces high concentrations of progesterone and some oestrogen. The progesterone further increases the thickness of the uterine lining and causes it to secrete a fluid which will nourish a fertilized egg and encourage implantation of the embryo. If fertilization does not occur the corpus luteum breaks down towards the end of the cycle and so the endometrium loses its hormonal support from the ovary. As a consequence the endometrium literally dies, and the cells of this lining are shed along with some loss of blood from the spiral arteries which have grown into the lining of the womb. Menstrual bleeding usually lasts 3-7 days, although endometrial regeneration can begin as early as the third day after the beginning of menstruation. Interestingly, only in man, apes, and Old World monkeys is the endometrium shed. In most other mammals the endometrium is resorbed at the end of each cycle and there is no bleeding — this is probably related to the absence of spiral arteries.

While the shedding of the uterine lining actually signifies the end of each reproductive cycle, the first day of menstruation is defined for convenience and accuracy as the beginning of a new menstrual cycle. Typically each cycle lasts between 25 and 34 days in 95% of women, with 28 days being the average. Hence the term ‘menstruation’, since it tends to recur at monthly intervals. Total blood loss during each menstruation varies from cycle to cycle, and in different women at different stages of their reproductive life. However, the average blood loss is about 50-60 ml (a teaspoon holds about 5 ml), although it can vary from about 10-80 ml. Excessive loss of blood (menorrhagia) can lead to iron-deficiency anaemia.

Many myths, legends, and taboos have grown up around menstruation throughout the centuries, but all with the underlying sentiment that menstruating women are unclean and capable of producing bad effects on the world about them. It became a focus of religious observance. For example, Hindu women are not supposed to prepare their husbands' food when they are menstruating. Those Moslem women who are normally allowed to pray in a Mosque may not do so during menstruation. Some Buddhists think it is wrong to enter a temple during menstruation and Jews are supposed to refrain from sexual intercourse during this time. In medieval times menstruating women were excluded from going to church and the Church of England has a service for ‘The Churching of Women’, a ceremony to be performed when a woman has had her first menstruation after the birth of a child. And so from the early teaching of Hippocrates, right through the centuries menstruation has been seen as a way of getting rid of something undesirable, unclean and potentially harmful. No wonder such derogatory terms as ‘the curse’ came into existence.

— Saffron Whitehead

The discharge of blood and fragments of the uterine wall at approximately monthly intervals during the menstrual cycle. The cycles begin at puberty and end at menopause. During menstruation, most women experience feelings of lassitude or fatigue. Women who exercise strenuously are particularly susceptible to iron-deficiency anaemia because of blood losses. They need higher than normal levels of haemoglobin to carry the oxygen they require for exercise. Athletes can take hormones, such as oestrogen, progesterone, and progestogens, to adjust the time of menstruation. Although most sports women perform less well during menstruation, a few perform better. World and Olympic titles have been won at all stages of the menstrual cycle.

The effects of exercise on menstruation varies from one individual to another but reported effects include the following:

• delayed onset of the first menstruation, common in participants in sports such as gymnastics that require a slim physique
• shortening of cycle by up to 4 days
• reduced menstrual pain associated with regular aerobic exercise
• increased failure to ovulate or menstruate in up to 50 per cent of competitive track and field athletes.

See also amenorrhoea and premenstrual tension.

The shedding of the necrotic mucosa of the endometrium and associated bleeding that occurs in the final phase of the menstrual cycle. The average duration of menstruation is 5 days, in which approximately 30 ml of blood is lost.

Definition

Menstruation refers to the monthly discharge through the vagina of the blood and tissues that were laid down in the uterus in preparation for pregnancy.

Description

The cyclic production of hormones that culminates in the release of a mature egg (ovum) is called the menstrual cycle, which begins during puberty and ends at menopause. The first menstrual cycle is called menarche.

Hormones that control the menstrual cycle are produced by the hypothalamus, pituitary gland, and ovaries. The beginning of a menstrual cycle is marked by the maturation of an egg in an ovary and preparation of the uterus (womb) to establish pregnancy. Menstruation occurs when pregnancy has not been achieved.

The menstrual cycle is divided into four phases and is, on average, 28 days long (21–45 days). The onset of menstruation, called a period, monthly, menses, or menstrual period, begins a new menstrual cycle and is considered day one. This first phase usually lasts five days. Menstruation occurs in response to drops in the level of the hormone progesterone. It is estimated that a woman will have 500 menstrual periods in her lifetime.

The second phase of the menstrual cycle is called the follicular or proliferative phase. The ovary, in response to increasing levels of follicle stimulating hormone, begins the egg maturation process. Although 10–20 eggs begin to develop within follicles of the ovaries, usually only one egg reaches maturity. Follicles are clusters of cells that encase a developing egg, hence the name "follicular phase." Developing follicles release the hormone estrogen that stimulates the lining of the uterus, called the endometrium, to grow (proliferate) in preparation to receive an embryo (an egg that has been fertilized and begun dividing) and establish pregnancy. This is why the second phase is also called the "proliferative phase." This phase usually lasts through day 13.

The ovulation phase occurs in response to a surge in luteinizing hormone and is marked by the release of a mature egg from the follicle. Ovulation usually occurs on day 14.

The fourth phase is called the luteal, secretory, premenstrual, or postovulatory phase, and usually lasts from days 15–28. During this phase, the empty follicle, now called the corpus luteum, releases the hormone progesterone which further prepares the uterus for implantation of an embryo. The endometrium thickens because of cell growth, changes in blood vessels and glands, and increases in fluid. If pregnancy does not occur, the fall in progesterone levels initiates the onset of a new menstrual cycle. However, if pregnancy does occur, progesterone levels remain high and the endometrium is not shed.

In the United States, menstruation typically begins at 12.8 years of age in Caucasian girls and 12.4 years of age for African American girls. Factors that help to dictate the age at which menarche occurs include race, mother's age at menarche, nutritional status, body fat, as well as climate and elevation. Studies have shown that a body fat level of 17% is necessary for menstruation to begin.

Women who live together or work in close proximity tend to find that their cycles begin to coincide. During the menstrual cycle, the body releases hormones called pheromones, which may signal surrounding women's cycles to begin.

Puberty signals the maturation of a young woman's reproductive hormones. As a girl reaches puberty, the pituitary gland in the brain starts to produce the hormones that signal the ovaries to begin functioning. The interaction between these hormones and the hormones estrogen and progesterone causes the lining of the uterus to swell and thicken in anticipation of a fertilized egg. If the egg is not fertilized, the lining is discharged through the vagina, resulting in menstrual bleeding.

Menstrual Problems

Women may experience menstrual cycles that fall outside of the norm as described above. Menstrual problems include missing a period, change in the length of the cycle, changes in the flow, color, or consistency of menstrual blood, and extreme pain or other menstrual symptoms.

Women may also experience emotional distress or wide mood swings during the luteal phase of the menstrual cycle. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV, lists premenstrual dysphoric disorder (PMDD) in an appendix of criteria sets for further study. To meet full criteria for PMDD, a patient must have at least five out of 11 emotional or physical symptoms during the week preceding the menses for most menstrual cycles over the previous 12 months. Although the DSM-IV definition of PMDD as a mental disorder is controversial because of fear that it could be used to justify prejudice or job discrimination against women, there is evidence that a significant proportion of premenopausal women suffer emotional distress or impairment in job functioning in the week before their menstrual period. One group of researchers estimates that 3–8% of women of childbearing age meet the strict DSM-IV criteria for PMDD, with another 13–18% having symptoms severe enough to interfere with their normal activities.

Causes & Symptoms

Menstruation is not an illness, but a normal part of the menstrual cycle. However, menstrual problems do occur, and are due to varying causes.

Amenorrhea

Amenorrhea is the absence of menstruation, and can be either primary or secondary. Primary amenorrhea is failure to menstruate by age 16 years in girls who have normal puberty, by age 14 years in those with delayed puberty, or two years after sexual maturation has occurred. Primary amenorrhea may be caused by genetic disorders, hormonal imbalance, brain defects, or physical abnormality of the reproductive organs. In 2003, a group of researchers reported on a new genetic mutation associated with primary amenorrhea. In addition, certain systemic diseases may delay puberty and menstruation. Delayed menstruation may occur in athletes, especially gymnasts, ballerinas, and long-distance runners because of insufficient body fat. Amenorrhea associated with athletic training and professional dance is a growing health concern, however, because it often occurs together with eating disorders and a loss of bone mass that can lead to early osteoporosis.

Secondary amenorrhea refers to the absence of menstruation after an interval of normal menstruation. It is identified as not menstruating for three months in females with irregular menstrual cycles, six months in females with normal menstrual cycles, and 18 months in females who had just started menstruating. Secondary amenorrhea can be caused by pregnancy, weight loss, excessive exercise, breast feeding, disease, or menopause. Menopause takes place when the ovaries stop producing estrogen, causing periods to become irregular and then stop. It generally occurs when a woman is between 48 and 52 years of age.

Dysfunctional and Abnormal Uterine Bleeding

Dysfunctional uterine bleeding is excessive or irregular bleeding from the uterus. It is caused by uncontrolled estrogen production that leads to excessive build up of the endometrium.

Abnormal uterine bleeding is excessive bleeding during menstruation, frequent bleeding, and/or irregular bleeding. Abnormal bleeding can be caused by fibroids (noncancerous uterine growths), endometriosis (when endometrium spreads outside of the uterus), uterine infections, hypothyroidism, clotting problems, intrauterine devices (IUD), or cancer.

Dysmenorrhea

Dysmenorrhea is painful and difficult menstruation. Studies have found that 60–92% of adolescents suffer from dysmenorrhea. It usually begins six to 12 months following menarche. Symptoms may be severe enough to miss work or school, and prevent participation in normal activities. Risk factors for developing dysmenorrhea may include long menstrual periods, obesity, early age at menarche, smoking, and alcohol use.

Primary dysmenorrhea is believed to be caused by high levels of prostaglandins (fatty acids that stimulate muscle contractions, among other activities) which cause painful uterine muscle spasms. Symptoms of primary dysmenorrhea occur when bleeding starts and may include moderate to severe menstrual pain (crampy, spasmodic, and labor-like or a dull ache), nausea, vomiting, headache, fatigue, low back pain, thigh pain, and diarrhea.

Secondary dysmenorrhea is caused by conditions such as endometriosis, abnormalities of the pelvic organs, pelvic inflammatory disease, fibroids, ovarian cysts, tumors, inflammatory bowel disease, and salpingitis (inflammation of the fallopian tube). Symptoms of secondary dysmenorrhea usually occur a few days before bleeding starts. The symptoms depend upon the specific cause of dysmenorrhea, but pain is the hallmark symptom.

Heavy Periods

Many women experience heavy menstrual bleeding during their periods, called menorrhagia. Heavy periods cause more blood loss than normal periods or may last longer than seven days. Women suffering from menorrhagia may lose up to 92% of their total fluid and tissue in the first three days of their cycle. Heavy menstruation is common in young girls who have just started their periods.

Menorrhagia is often caused by a failure to ovulate, which leads to a deficiency of progesterone. Without progesterone, the uterine lining becomes unstable and periods tend to be longer and unpredictable. Toxins in the bloodstream tend to settle in the endrometrial tissue. When this tissue is shed each month, so are the toxins. Heavy periods may be a toxin-excretion technique.

A deficiency in vitamin A or iron, or hypothyroidism may also cause heavy periods. Painful heavy periods may be linked to endometriosis, fibroids, pelvic inflammatory disease, or the use of an intrauterine device (IUD). A single heavy period that takes place later in the cycle may be a miscarriage.

Tampon Use

Many women use tampons to absorb their monthly flow. It has been estimated that the average tampon user will use 11,400 in her lifetime. There has been much controversy over the safety of tampons. The use of high-absorbency tampons has been shown to cause toxic shock syndrome (TSS), a bacterial infection caused when tampons left in too long create tiny breaks in the vaginal lining and allow bacteria to enter the blood stream. Symptoms of TSS are high fever, rash, muscle and joint aches, and diarrhea. TSS is now uncommon, but women have died from it in the past.

To reduce the risk of TSS, the United States Food and Drug Administration (FDA) recommends that women use the lowest absorbency tampon required to meet their needs. It is also suggested that tampons be left in for no longer than four to eight hours. Alternatives to tampons are sanitary pads, reusable menstrual collection cups, and washable cloth pads.

A more recent controversy was sparked in the early 1990s over the use of dioxin in tampons. Dioxin is a chemical byproduct of bleach that is a carcinogen. Tampons in the United States are bleached with chlorine during production so they will have a fresher appearance. Research conducted using monkeys has shown that dioxin exposure may be linked to endometriosis.

In 1992, an investigation revealed that FDA scientists had found trace amounts of dioxin in some tampons. Further FDA research has determined that the tampons currently manufactured are done so through the use of a dioxin-free process. However, trace amounts of dioxin may be absorbed from the air, water, or ground. These levels are generally nondetectable, and according to the FDA, do not pose a health risk.

Premenstrual Syndrome

Premenstrual syndrome (PMS) is a condition that occurs during the premenstrual phase of the menstrual cycle. The cause is unclear but theories include: abnormal hormone levels, other biochemical abnormalities, inappropriate diet, nutrient deficiencies, psychological factors, or a combination of many factors.

Emotional and mental symptoms include fatigue, mood swings, irritability, nervousness, confusion, depression, tearfulness, and anxiety. Physical symptoms are bloating, discomfort, breast tenderness, cravings, weight gain, acne, change in bowel movements, joint pains, and dizziness.

Other Menstrual Problems

• A missed period can be caused by pregnancy, stress, increased exercise, emotions, grief, and illness, among others.
• Metrorrhagia is bleeding in between normal episodes of menstruation. It may be caused by ovulation, hormonal factors, cervical lesions, or uterine cancer.
• Polymenorrhoea is bleeding associated with menstrual cycles that are shorter than 21 days. It may be caused by hormonal or ovulatory problems.
• Oligomenorrhea is infrequent menstruation with 35 days to six months between menstrual cycles. Researchers have discovered that women with a menstrual cycle of 40 days or longer are twice as likely as women with average-length cycles to develop type II (adult-onset) diabetes mellitus. It is thought that long or highly irregular menstrual cycles may be associated with insulin resistance.

Diagnosis

Menstrual problems can be diagnosed and treated by gynecologists. Most menstrual problems would be diagnosed by performing a detailed medical history (with an emphasis on menstrual history) and a physical exam, which would include a pelvic exam. Pelvic exams have two components: the manual exam and the speculum exam. During the manual exam, the doctor inserts one or two fingers into the vagina and presses his or her other hand on the lower abdomen to feel the uterus and ovaries. A speculum exam involves inserting a speculum (a metal or plastic tool for opening the vagina) to allow viewing of the vagina and cervix, and to obtain smears for Pap testing (sampling of cervical cells) or culture if an infection is suspected.

Ultrasound exam, in which internal organs are visualized using sound waves, may be performed. Abnormal findings from the examination and laboratory tests may warrant laparoscopy in which a thin, wand like instrument is inserted into an incision in the belly button to visualize abdominal organs.

Urine tests may be performed to diagnose pregnancy or infection. Blood tests to determine hormone levels, as well as other blood parameters, may be performed. Patient history and physical exam findings may suggest specific illnesses that would require additional laboratory testing.

The patient may be asked to fill out a diary in which daily menstrual symptoms are recorded over a period of three to six months. In some cases, the patient may be referred to a psychiatrist for evaluation for PMDD.

Treatment

There are many alternative treatments for menstrual problems. Because menstrual difficulties may be due to a serious condition, patients should consult a doctor before self-treating.

Diet

Phytoestrogens are estrogen-like compounds produced by certain plants. Food sources of phytoestrogens include soy products, flaxseeds, chick peas, pinto beans, french beans, lima beans, and pomegranates. Phytoestrogens can lighten menstruation and lengthen menstrual cycles. On the other hand, researchers have found that women who were fed soy-based formulas in infancy instead of cow's milk are more likely to report heavy menstrual bleeding and painful periods in adult life.

PMS symptoms may be relieved by avoiding caffeine, sugar, salt, white flour, red meat, dairy, butter, monosodium glutamate (MSG), fried foods, and processed foods during the two weeks prior to menstruation. Food that help to fight PMS include steamed green vegetables, salad, beans, grains, and fruit. To obtain essential fatty acids (omega-3 and omega-6) women can eat flaxseeds, sesame seeds, pumpkin seeds, salmon, mackerel, and tuna.

Herbal Remedies and Chinese Medicine

A variety of herbal remedies may alleviate symptoms associated with menstrual problems. These include:

• black cohosh (Cimicifuga racemosa): mood swings, tension, establishing ovulation (an important source of phytoestrogens). The German Commission E, however, states that women should not take black cohosh for menstrual problems for longer than six months because of the risk of side effects.
• black haw (Viburnum prunifolium): cramps
• chamomile (Matricaria recutita): mood swings, tension, and cramps
• cramp bark (Viburnum opulus): cramps
• dandelion (Taraxacum dang gui): fluid retention and bloating
• dong quai (Benincasa cerifera): PMS symptoms, cramps, irregular cycles, heavy bleeding, or bleeding in between cycles
• fenugreek (Trigonella foenum-graecum): irregular bowel movements
• feverfew (Chrysanthemum parthenium): headaches and PMS symptoms
• ginger (Zingiber officinale): cramps, irregular cycles, heavy bleeding, or bleeding in between cycles
• goldenseal (Hydrastis canadensis): heavy bleeding
• horsetail (Equisetum arvense): heavy bleeding
• licorice: PMS symptoms
• milk thistle (Silybum marianum) extract: heavy bleeding
• nettle (Urtica dioica) extract: heavy bleeding
• peppermint (Mentha piperita): mood swings and tension
• raspberry tea: cramps, irregular cycles, heavy bleeding, or bleeding in between cycles
• red clover (Trifolium pratense): phytoestrogen source
• rosemary (Rosmarinus officinalis): cramps
• shepherd's purse (Capsella bursa–pastoris): heavy bleeding
• St. John's wort (Hypericum perforatum): depression associated with PMS
• valerian (Valeriana officinales): mood swings and tension
• vitex: PMS symptoms
• wild yam: phytoestrogen source
• yarrow (Achillea millefolium): cramps

Supplements

The following supplements may treat menstrual problems:

• Calcium deficiency may be associated with PMS
• Iron supplementation can treat anemia
• Magnesium pidolate supplementation reduced dysmenorrhea symptoms by up to 84%, especially on days two and three
• Niacin may help to relieve cramps
• Omega-3 fatty acids deficiency is associated with dysmenorrhea pain (in one small study, patients taking omega-3 fatty acids had lower pain scores)
• Thiamine (vitamin B₁) cured dysmenorrhea in 87% of the patients for up to two months after treatment
• Vitamin A may be useful to treat heavy bleeding in women who have vitamin A deficiencies
• Vitamin B complex may help hormonal function, prevent anemia, reduce water retention, and relieve stress
• Vitamin E may reduce mood swings and menstrual cramps

Other Treatments

Other treatments for menstrual problems include:

• Acupressure. Acupressure can relieve pain, reduce stress, and improve circulation.
• Acupuncture. Treatment is associated with improvement or cure of dysmenorrhea and PMS and decreased use of pain medications. A National Institutes of Health (NIH) panel concluded that acupuncture may be a useful treatment for menstrual cramps.
• Aromatherapy. Massage with the essential oils rose, ylang-ylang, bergamot, and/or geranium oils for mood swings; lavender, sandalwood, and clary sage oils for menstrual cramps; and chamomile, cypress, melissa, lavender, and jasmine oils for irregular menstruation or amenorrhea.
• Biofeedback. Weekly biofeedback therapy for 12 weeks led to significant reduction in PMS symptoms.
• Chiropractic. Spinal manipulation can help to ease cramps.
• Exercise. Regular, moderate aerobic exercise reduces or eliminates menstrual pain, improves PMS, reduces the amount of menstrual bleeding, reduces the risk for endometriosis, and reduces cyclic breast pain and cysts. Yoga stretching can relieve back and thigh pain.
• Homeopathy. Homeopathic remedies include: lachesis or sepia for PMS, cimicifuga, colocynthis, or magnesia phosphorica for cramps, and pulsatilla or aconitum for irregular menstruation or amenorrhea.
• Hydrotherapy. Soaking in a hot tub or using a moist heating pad relaxes uterine muscles which relieves cramping.
• Reflexology. Ear, hand, and foot reflexology led to a significant decrease in PMS symptoms that lasted for several months following treatment.
• Transcutaneous electric nerve stimulation (TENS). In four small studies using TENS for the treatment of dysmenorrhea, 42%–60% of the patients experienced at least moderate relief of symptoms. TENS worked faster than naproxen and there was less need for NSAIDs.

Allopathic Treatment

The treatment for amenorrhea depends upon the cause. Primary amenorrhea may require hormonal therapy.

Patients with dysfunctional or abnormal uterine bleeding may be prescribed iron supplements to treat anemia. Naproxen sodium (Aleve) reduces excessive blood loss. Oral contraceptives are often prescribed to treat abnormal bleeding. High doses of estrogens may cause vomiting, which means that antiemetics (drugs to prevent vomiting) may also be necessary. Excessive bleeding may require hospitalization for observation and treatment.

Primary dysmenorrhea is usually successfully treated with nonsteroidal anti-inflammatory drugs (NSAIDs); aspirin is not strong enough to be effective. NSAIDs are numerous and include ibuprofen (Advil, Motrin, Nuprin), Naproxen (Aleve), and fenamates (Meclomen). Oral contraceptives (birth control pills) may be used if NSAIDs fail. Treatment of secondary dysmenorrhea involves treating the causative condition and may involve medications or surgery.

Because the cause(s) of PMS are unclear, treatment usually focuses on relieving symptoms.

With regard to PMDD, medications that have been reported to be effective in treating it include the tricyclic antidepressants and the selective serotonin reuptake inhibitors (SSRIs). Effective treatments other than medications include cognitive behavioral therapy (CBT), aerobic exercise, and dietary supplements containing calcium, magnesium, and vitamin B₆.

Expected Results

Most menstrual problems can be successfully treated using conventional or alternative treatments.

Prevention

Avoiding sodium and caffeine may reduce some menstrual symptoms. Regular moderate aerobic exercise or yoga is often beneficial for menstruation difficulties. Getting yearly pelvic exams and Pap smears will help to identify problems before they become advanced.

Resources

Books

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.

"Menstrual Abnormalities and Abnormal Uterine Bleeding." Section 18, Chapter 235 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, "CAM Therapies for Specific Conditions: Menstrual Symptoms, Menopause, and PMS." New York: Simon & Schuster, 2002.

Trickey, Ruth. Women, Hormones and the Menstrual Cycle: Herbal and Medical Solutions from Adolescence to Menopause. St. Leonards, Australia: Allen & Unwin, 1998.

Wolf, A.S., K. Marx, and U. Ulrich. "Athletic Amenorrhea." In Adolescent Gynecology and Endocrinology: Basic and Clinical Aspects. Edited by George Creatsas, et al. New York: The New York Academy of Sciences: 1997.

Ying, Zhou Zhong, and Jin Hui De. "Menstrual Disorders." In Clinical Manual of Chinese Herbal Medicine and Acupuncture. New York: Churchill Livingston, 1997.

Periodicals

Aegerter, Ch., D. Friess, and L. Alberio. "Menorrhagia Caused by Severe Hereditary Factor VII Deficiency. Case 1." Hämostaseologie 23 (August 2003): 99–102.

Chez, Ronald A., and Wayne B. Jonas. "Complementary and Alternative Medicine. Part II: Clinical Studies in Gynecology." Obstetrical and Gynecological Survey 52 (1997): 709–715.

Donaldson, M. L. "The Female Athlete Triad. A Growing Health Concern." Orthopedic Nursing 22 (September-October 2003): 322–324.

"Exposure to Soy-Based Formula in Infancy." British Journal of Ophthalmology 85 (November 2001): 1396.

Halbreich, U., J. Borenstein, T. Pearlstein, and L. S. Kahn. "The Prevalence, Impairment, Impact, and Burden of Premenstrual Dysphoric Disorder (PMS/PMDD)." Psychoneuroendocrinology 28 (August 2003) (Suppl 3): 1–23.

McDonald, Claire, and Susan McDonald. "A Woman's Guide to Self–Care: Everything You Need to Know to Treat the Symptoms of Menstruation, Pregnancy, and Menopause Safely and Naturally." Natural Health (January–February 1998): 121+.

Meduri, G., P. Touraine, I. Beau, etc. "Delayed Puberty and Primary Amenorrhea Associated with a Novel Mutation of the Human Follicle-Stimulating Hormone Receptor: Clinical, Histological, and Molecular Studies." Journal of Clinical Endocrinology and Metabolism 88 (August 2003): 3491–3498.

Rapkin, A. "A Review of Treatment of Premenstrual Syndrome and Premenstrual Dysphoric Disorder." Psychoneuroendocrinology 28 (August 2003) (Suppl 3): 39–53.

Solomon, Caren G., Frank B. Hu, Andrea Dunaif, et al. "Long or Highly Irregular Menstrual Cycles as a Marker for Risk of Type 2 Diabetes Mellitus. Journal of the American Medical Association 286 (November 21, 2001): 2421–2426.

Organizations

American College of Obstetricians and Gynecologists (ACOG). 409 12th Street, SW, P. O. Box 96920, Washington, DC 20090-6920. .

American Psychiatric Association (APA). 1400 K Street, NW, Washington, DC 20005. (888) 357-7924. .

Feminist Women's Health Center. 106 East E Street, Yakima, WA 98901. (509) 575-6473 x112. Info@fwhc.org. .

National Women's Health Network. 514 10th Street NW, Suite 400, Wash., DC 20004. (202) 628-7814. .

[Article by: Belinda Rowland; Rebecca J. Frey, PhD]

Definition

Menstruation is the vaginal bleeding that occurs in adolescent girls and women as a result of hormonal changes. It normally happens in a predictable pattern, once a month.

Description

Menstruation is part of the menstrual cycle, which helps a woman's body prepare for the possibility of pregnancy each month. The parts of the body involved in the menstrual cycle include the uterus and cervix, the ovaries, fallopian tubes, the brain and pituitary gland, and the vagina. Certain body chemicals known as hormones rise and fall during the month, causing the menstrual cycle to occur.

In the first half of the menstrual cycle, estrogen levels rise, causing the lining of the uterus to grow and thicken. This lining is called the endometrium. The two small, grape-shaped organs inside the abdomen on either side of the uterus, known as the ovaries, are filled with hundreds of thousands of eggs and are the organs that allow pregnancy to occur. When a girl reaches puberty, the ovaries respond to a rise in follicle-stimulating hormone and cause one of the eggs to mature. About half way through the menstrual cycle, a surge of luteinizing hormone takes place, and the egg is released. This mature egg is called an ovum, and its release is called ovulation. When the egg is released it travels through one of the two fallopian tubes and down towards the uterus. If the ovum is fertilized by a sperm at this time, pregnancy occurs. However, if a sperm does not fertilize the egg, the body no longer needs the uterine lining to support the fertilized egg. Estrogen and progesterone levels then drop, triggering the uterine lining to gently fall away from the wall of the uterus, and to be shed through the vagina. The discharge of this lining is the menstrual flow. The entire process is called menstruation.

A "normal" menstrual period usually occurs every 28 days, from the first day of a period to the first day of the next. However, this can vary from 22 to 36 days. Each period usually lasts from three to seven days, with the average being five. It may take several years from the start of menstruation for periods to settle into a pattern. Irregular periods are common in early adolescence. Even after adolescence, many factors can throw off the timing of menstruation. These include weight changes, starting a new job or school, and relationship problems.

Menstrual Hygiene Products

Once a girl begins menstruating, she needs to choose from the various menstrual hygiene products which are available. Menstrual hygiene products can be divided into two basic categories: sanitary pads and tampons. Absorbency and a comfortable fit are the main features girls need to look for when purchasing menstrual products. Because a girl's menstrual flow may vary from day to day during the cycle, she may want to use different types of products during her period.

Sanitary pads are worn inside the underwear where they collect the menstrual flow. They come in different sizes, thicknesses, and styles. Some pads have flaps or "wings" that wrap around and attach to the underside of underwear. Others have deodorant and contain perfume. Some girls find that the perfume irritates their skin.

Tampons are the another option for absorbing menstrual flow. Tampons come in various absorbency categories and should be chosen based on the amount of flow experienced. The absorbency of a tampon can be determined by how often it needs to be changed. Girls should use the tampon with the least absorbency necessary to absorb the flow. Tampons should be changed every four to six hours. Tampons also come with a variety of applicators, including plastic and cardboard. Tampons are comfortable to wear and may be a good choice for active girls. They should be inserted carefully to avoid any irritation. A rare, but serious, condition called toxic shock syndrome (TSS) can be connected to tampon use. The higher the absorbency of tampons used, the higher the risk for TSS. To decrease the risk of TSS, girls should choose the lowest absorbency necessary.

Problems With Menstruation

DYSMENORRHEA.Dysmenorrhea is the medical term for menstrual cramps, the dull or throbbing pain in the lower abdomen that many women experience just before and during their menstrual periods. It can be primary or secondary. Primary dysmenorrhea involves no abnormality. Secondary dysmenorrhea involves an underlying physical cause, such as uterine fibroids, pelvic inflammatory disease, or endometriosis. Signs and symptoms of dysmenorrhea, whether it is primary or secondary, may include the following:

• dull, throbbing pain in the lower abdomen
• radiating pain to the lower back and thighs
• nausea, loose stools, sweating, and dizziness (though these are much less common)

If menstrual cramps become severe enough to keep a girl from going about her day-to-day routine, she should see a doctor. The doctor will perform a medical history and physical examination, including a pelvic exam, where he or she will look for any abnormalities, signs of infection, and possible causes of secondary dysmenorrheal. In addition, the doctor may request a variety of diagnostic tests, such as imaging tests, laparoscopy, and hysteroscopy.

Complications can arise from secondary dysmenorrhea. If pelvic inflammatory disease is present, the fallopian tubes may become scarred and possibly cause later infertility or other reproductive problems. Endometriosis can also lead to fertility problems as well.

Many experts believe that prostaglandins, hormone-like substances involved in pain and inflammation and which trigger uterine muscle contractions, are responsible for causing menstrual cramping. Whether the dysmenorrhea is primary or secondary, there are effective ways to treat menstrual pain. Nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen or naproxen, may block the production of prostaglandins and can be very effective in the treatment of menstrual cramps. In the case of severe cramping, doctors may recommend a low-dose oral contraceptive to prevent ovulation, which may reduce the release of prostaglandins and the severity of the cramps.

DYSFUNCTIONAL UTERINE BLEEDING. Dysfunctional uterine bleeding (DUB) is prolonged or heavy bleeding that often occurs in a menstrual cycle where ovulation did not occur. Heavy bleeding is defined as more than 15 soaked pads or tampons per period, and prolonged bleeding is that which lasts for more than 8 to 10 days. Although DUB is quite common in the first few years after menstruation starts, it can be frightening and should always be reported to a physician. DUB that is accompanied by dizziness and a low blood pressure should be considered a medical emergency. DUB is usually caused by hormonal imbalances. Other causes of bleeding are sexually transmitted disease, an ectopic pregnancy, ovarian cysts, and uterine fibroids or polyps. Young women within the first menstrual period are not usually treated unless symptoms are exceptionally severe or if anemia develops.

Demographics

Girls may start their menstrual period as early as nine years of age and as late as 16 years old. The average age a girl begins menstruating is 12. Girls who are very active in sports or who are quite thin may not develop until a later age. Losing weight while experiencing a growth spurt may also delay menstruation.

In the early 2000s, some people have voiced concern about girls starting their periods at younger and younger ages. However, a study reported in 2003 found that overall, girls in the United States are not beginning menstruation earlier than in the past. Less than 10 percent of girls start their periods before 11 years of age, and 90 percent of all U.S. girls are menstruating by age 14. This age is not significantly different than that reported for girls in 1973. African-American girls on average begin menstruating before Caucasian- and Hispanic-American girls.

Causes and Symptoms

The menstrual cycle takes place each month in response to the hormonal changes which occur when pregnancy does not take place. A number of symptoms can occur just before and during a girl's period which may cause discomfort. These include:

• having pelvic area cramps
• feeling bloated or puffy
• breast tenderness or swelling
• headaches and backaches
• acne breakouts
• mild nausea

These symptoms usually stop or lessen a day or two after the period begins.

Diagnosis

There are several reasons why a girl should see her healthcare provider regarding her menstrual cycle. These include:

• if menstruation has not started by the age of 16
• if a menstrual period lasts for more than seven days
• if periods suddenly stop
• if she is experiencing excessive bleeding
• if she feels suddenly ill while using tampons
• if she bleeds more than a few drops between periods
• if she experiences excessive pain during her period

Treatment

No specific medical treatment is necessary for an uncomplicated menstrual cycle, as it is a normal, healthy process in girls and women.

Alternative Treatment

Some girls may find relief from menstrual discomfort through meditation, yoga, or massage. These stress-relieving activities are unlikely to cause any harm.

Parental Concerns

Though menstruation is no longer the taboo subject it once was, many parents still find that discussing the issue with their daughters can be uncomfortable. This is especially common in families in which the mother is not present. Still, it is important to discuss menstruation with girls when they are preteens, so that they do not experience the potential embarrassment or trauma if they start their first period without knowledge about what is happening to their bodies. Taking the time to prepare may help to make this discussion less awkward.

Resources

Books

Loulan, JoAnn, and Bonnie Worthen. Period: A Girl's Guide to Menstruation. Minnetonka, MN: Book Peddlers, 2001.

Periodicals

Chumlea, William Cameron, et al. "Age at Menarche and Racial Comparisons in U.S. Girls." Pediatrics 111 (January 2003): 110–14.

Organizations

American College of Obstetricians and Gynecologists. 409 12th Street, SW, PO Box 96920, Washington, DC 20090–6290. Web site: www.acog.org.

The Center for Young Women's Health. 300 Longwood Avenue, Box 310, Boston, MA 02115. Web site: www.youngwomenshealth.org.

Web Sites

"Frequently Asked Questions about Menstruation and the Menstrual Cycle." 4woman.gov-The National Women's Health Information Center, November 2002. Available online at www.4woman.gov/faq/menstru.htm (accessed October 25, 2004).

"Period Talk: Preparing Your Preteen for Menstruation." Available online at www.mayoclinic.com/invoke.cfm?id=FL00040 (accessed October 25, 2004).

[Article by: Deanna M. Swartout-Corbeil, RN]

For more information on menstruation, visit Britannica.com.

The Bible taught (Leviticus 15: 19-24) that a menstruating woman was not only ‘unclean’ in herself but polluted others. The scientific authority of Pliny's Natural History (AD 77), and many later medical writers, added that she could shrivel plants, kill bees, taint food, and cloud mirrors by her touch, her glance, her breath, or her mere presence—let alone her actual blood. Though many folklore collections avoid this topic, those that do mention it record beliefs and taboos which seem similar everywhere, some of which were still current in the mid-20th century. During her period, a woman must not handle raw meat or go near ham that is being cured, for she will taint it; she must not enter the dairy, or milk will sour and butter-making will fail.

Theologians disagreed on how rigorously to apply to women the Leviticus rule that anyone ‘unclean’ must not approach ‘the tabernacle or any holy thing’; some said they must not even enter a church, but in 579 Pope Gregory instructed missionaries working in England to let them do so, and even receive Communion, since what was natural was not sinful (Bede, Ecclesiastical History, book I, chapter 27). In the 20th century, the debate was still not over; among Primitive Methodists, no menstruating woman could attend a church service (Porter, 1969: 22), and some Catholic girls thought (wrongly) that to take Communion then was a sin [JS].

Other folkloric warnings, current until recently, protected the woman herself from supposed risks. The best known was never to wash your hair or put your feet in cold water, or ‘the blood will fly to your head and send you daft’; this echoes an outdated medical theory about misdirected menstrual blood reaching the brain and causing melancholia. It was also bad to have a bath or go swimming, either because ‘the water will get inside’ or because ‘the water will turn black’. More unusual was the Lincolnshire rule, ‘Don't walk in long grass, the snakes will smell you’ (Sutton, 1992: 31).

The sudden surge of oestrogen which signals the onset of menstruation affects the sebacious glands, making hair greasy, lanky, and unmanageable. Hairdressers avoid styling or tinting a woman's hair at this time, since the results will probably be poor. The current phrase ‘a bad hair day’ for a day when everything goes wrong may be based on the experience that pre-menstrual irritability, clumsiness, and greasy hair coincide [JS].

Sexual intercourse during menstruation was taboo; according to the Bible, it was a crime incurring the death penalty for both parties (Leviticus 20: 18), though secular law has never enforced this. Scripture also warned that ‘menstruous women bring forth monsters’ (II Esdras 5: 8), and medical writers agreed; a popular handbook, Aristotle's Masterpiece (1684, but often reprinted up to 1890), taught that it would probably result in abnormalities such as hairy infants or those with extra limbs (book I, chapter 5). Nowadays, it is occasionally said babies so conceived are red-haired.

Bibliography
The full bibliography list is available here.

• Porter, 1969: 21-3
• Opie and Tatem, 1989: 247
• Sutton, 1992: 16-32
• Patricia Crawford, Past and Present 91 (May 1981), 47-73

The process or the instance of discharging blood and tissue fragments from the uterine wall. Some sportswomen may be particularly susceptible to iron-deficiency anaemia during menstruation because of heavy blood losses combined with the high oxygen demands of their physical activity. Menstruation does not necessarily preclude exceptional athletic performances. World and Olympic titles have been won during all stages of the menstrual cycle. See also menstrual adjustment.

The periodic discharge of the blood-enriched lining of the uterus through the vagina. Menstruation marks the end of one menstrual cycle and the beginning of another.