Menstruation
Menstruation is the periodic discharge
of blood and tissue from the lining of the uterus, occurring about every 28 days
in women of reproductive age.
The first menstrual cycle occurs at
puberty and repeats throughout life until menopause, unless interrupted by
pregnancy or long-acting hormonal contraception.
Most
girls get their first menstrual period, called menarche, between the ages of
nine and 16.
Some of the common menstrual problems,
such as cramps, can often be relieved effectively with home remedies.
Menstruation has a typical pattern of duration, frequency and associated
symptoms for each woman. When there is noticeable deviation from this pattern, a
menstrual disorder may be present requiring medical attention.
Alternative names
menses, menstrual periods
What is
menstruation?
Menstruation is the normal, periodic discharge of blood and tissue
from the lining of the uterus (womb), occurring about every 28 days in women of
reproductive age. The onset of menstruation, called menarche, happens at
puberty. The menstrual cycle will repeat throughout life, unless interrupted by
pregnancy or long-acting hormonal contraception, until menopause (cessation of
menstruation, around age 52).
There
have been many myths and taboos associated with menstruation. Some cultures
continue, as many have in the past, to isolate or constrain menstruating women
and consider menstrual flow to be shameful or "unclean". However, in general,
attitudes are now becoming much more positive and open towards this natural
process.
The
reason why women menstruate is linked to reproduction and the rather short
lifetime of an unfertilised egg once it has been released from the ovary at
ovulation. If the egg would become fertilised, the endometrium, which undergoes
changes in preparation for the implantation of the developing embryo, would not
be shed but would form an integral part in the growth of the pregnancy. If the
egg is not fertilised, the egg dissolves followed by the shedding of the
endometrium. A new endometrium will be built up with the next egg in the next
cycle.
Menarche
The onset of menstruation is called menarche.
A girl
is born with her full complement of eggs stored in her ovaries. Usually, one egg
is released each month from the time of ovulation which occurs 14 days before
the next menstrual period. At puberty (which starts between the ages of about
eight and 14), several events follow in a pre-programmed sequence under the
influence of brain hormones, hormones from the pituitary gland, the adrenal
glands and the ovaries. This leads to a spurt in growth, the beginning of breast
development followed by the development of pubic and axillary hair.
The
ovaries start functioning by producing eggs and hormones called oestrogens and
progesterone which influence the body to take up the typical female shape and
prepare various organs for a possible pregnancy.
Menarche
is a relatively late occurrence in this sequence of events and the first period
is usually very light - only a few spots of blood or a brown sticky stain.
Menstrual periods are often irregular for the first few years after menarche.
The intervals may be shorter (about three weeks) or longer (about six weeks)
than average, or there may be only three or four periods a year. The menstrual
cycle will become more regular with time, although several women continue to
have irregular periods as adults.
The
reason for this is that young girls after menarche do not necessarily ovulate
right from the beginning, and it may take up to two years before their menstrual
cycles with regular ovulations followed by menstruations become established. A
similar event in reversed order occurs in women close to their menopause, when
ovulations become irregular although menstruations may still be at regular
intervals for some months.
Most
girls get their first menstrual period between the ages of nine and 16, usually
about one-and-a-half to two years after their breasts begin to develop, and
after the appearance of pubic hair and the growth spurt. Genetics seem to be a
determining factor: many girls have their first period at roughly the same age
as the time of menarche of their mothers. About six months before her first
period, a girl might notice an increased amount of clear vaginal discharge.
The
menstrual cycle
The two ovaries, each containing thousands of ova (eggs), are
positioned on either side of the uterus in the pelvis. The fallopian tubes form
the connecting passage from the ovaries to the uterus.
Every
month, either the left or the right ovary produces a follicle, a little
fluid-filled blister. This is done under the influence of a follicle stimulating
hormone (FSH) from the pituitary gland in the brain. The follicle
contains an egg and surrounding fluid consisting of oestrogens. The egg will be
released during ovulation which occurs 14 days before the next menstrual period.
After ovulation, the empty follicle is filled up again, initially with blood,
which later changes into progesterone, the dominating hormone of the second half
of the menstrual cycle.
Oestrogen and progesterone cause certain changes in the endometrium, the lining
of the uterus. In the first phase (proliferative phase) of each menstrual cycle,
the endometrium undergoes rapid proliferation of cells and blood vessels. The
lining of the uterus becomes thick in preparation for a potential pregnancy.
Midway through the cycle, ovulation occurs which is triggered by the pituitary
hormone LH (luteinising hormone): the walls of a follicle in one
of the ovaries open and a single mature ovum (egg) is released and taken up by
the fallopian tube of the corresponding side. If the ovum is fertilised by a
sperm, the fertilised egg is passively moved down the fallopian tube toward the
uterus, a travel which takes about four to five days. It will then implant in
the uterine lining which has been further prepared by progesterone during the
secretory phase, the second phase of the menstrual cycle. After implantation the
developing embryo will turn into a fetus which will be born as a baby.
If the
ovum is not fertilised, it will start to disintegrate about 24 hours after
ovulation. Oestrogen and progesterone levels decline and the reduction of these
hormones causes the endometrium to become thin and its blood flow to decrease.
14 days after ovulation, the unused uterine lining breaks down and is shed
during menstruation, along with some blood through the cervix and the vagina.
The
endometrium then begins to thicken once again. This cycle (an egg being released
once a month and the uterine lining thickening and then being shed) will
continue to occur almost every month until interrupted by pregnancy or until
ovulation ceases at menopause. Menstruation may or may not cease during
lactation (breastfeeding).
A
menstrual cycle lasts from the first day of one period to the first day of the
next. The typical cycle of an adult female is 28 days, although cycles can range
between 22 and 35 days. Only 15 percent of women have a 28-day cycle.
The
length of the menstrual cycle is determined by the number of days it takes for
an ovary to allow a follicle and egg to become mature and to release an egg. The
second half of the cycle, ovulation to menstruation, is fairly consistently the
same length: menstruation occurs about 14 days after ovulation, for nearly all
women. The first part of the cycle varies from person to person and from cycle
to cycle.
The
duration of each menstrual period can also vary: most last for about five days,
but some women menstruate for only two or three days, and others for up to eight
days.
The
menstrual blood loss varies among different individuals too, from about
one-and-a-half tablespoons to one-third of a cup (20 to 80 ml) of menstrual
fluid. About seventy percent of menstrual fluid is produced by the second day of
a period, and 90 percent by the third day. Menstrual flow and duration may also
change from month to month in the same individual, and may vary over the course
of a lifetime.
The
rhythm of the menstrual cycle may be interrupted by hormonal imbalance,
malnutrition, illness or emotional stress.
Common
menstrual problems
There are several problems which can occur with menstruation. They
can vary in severity and some of them can effectively be relieved with home
remedies.
Dysmenorrhoea (cramps, menstrual pain)
Over half of women who menstruate have cramps during the first few
days of their period. The pain can be a dull ache or sharp and intense or
colicky. Menstrual pain is classified as primary or secondary dysmenorrhoea.
Primary dysmenorrhoea (cramping) is probably caused by prostaglandins, hormones
produced before the beginning and during the first two days of menstruation
which affect tension of the uterine muscle.
Menstrual cramps usually start 6-24 months after menarche and tend to become
less uncomfortable and sometimes disappear completely as a girl gets older.
Methods
to relieve cramping:
An
over-the-counter pain medication, (e.g. containing a nonsteroidal
anti-inflammatory drug, NSAID) can provide relief within 30 – 60 minutes.
However, NSAIDs should not be taken for prolonged times since there are certain
contraindications, and a doctor should be consulted.
A hot water bottle or heating pad
placed over the lower abdomen.
Exercise improves oxygen supply and
blood circulation throughout the body, including the pelvis.
Relaxation
techniques such as massage or deep breathing.
A
diet with increased intake of magnesium, calcium and omega 3 fatty acid
containing food such as fish and fish-oil is helpful.
Premenstrual syndrome (PMS)
Premenstrual syndrome (PMS) is a common condition that refers to a
group of symptoms experienced as a result of changing hormone levels before and
sometimes during menstruation. Symptoms, which may be psychological, behavioural
and physical, usually become apparent in the week preceding menstruation. The
difference between dysmenorrhoea and PMS can often be made according to the
history. In general, the pain with PMS is related to breast tenderness and the
feeling of having a bloated abdomen, while in dysmenorrhoea, the pain is a
cramping sensation in the lower abdomen. As a rule, PMS abates soon after the
start of the period.
The
exact mechanism how the monthly change in hormone levels causes PMS, is unknown.
There are no hormonal differences in women with or without PMS, and it is
assumed that women with PMS may have a different response of their central
nervous system to the cyclical variation of their hormones.
There is
a large variety of psychological and emotional symptoms which have been
described with PMS. Some women experiencing anger, tension, fatigue and
depression will have temporary relief by eating food rich in carbohydrates.
Caffeine-containing beverages such as coffee, tea and cola should be avoided
since their stimulating effect may worsen tension, irritability and also
insomnia (sleeplessness).
Furthermore, food having a high content in salt should also be avoided since it
promotes water retention. The retention of fluid may be responsible for some
women feeling bloated premenstrually which is often described subjectively
despite the fact that there is no measurable increase in weight or abdominal
circumference. One of the explanations for this is a possible redistribution of
body fluid into the abdomen or into the intestinal walls.
Other
menstrual disorders
Amenorrhoea:
absence of periods, classified as primary or secondary. Primary amenorrhoea is
no menstruation by age 14 (if combined with lack of development of secondary
sexual characteristics), or no menstruation by age 16.5, or no menstruation two
years after development of breasts and/or pubic/axillary hair. Primary
amenorrhoea may also occur in young athletes or girls with eating disorders who
experience delayed puberty.
Secondary amenorrhoea is the absence of periods for at least three months in a
woman who has previously had regular monthly periods, and for at least six to 12
months in a woman who normally experiences irregular periods. Absence of periods
for a shorter period of time than this is called "delayed menses."
Oligomenorrhoea: scanty
menstrual flow, when the interval between periods exceeds 35 days but is not
long enough to qualify as amenorrhoea. Most women with oligomenorrhoea also have
cycles in which no eggs are released. Oligomenorrhoea can progress to
amenorrhoea.
Oligomenorrhoea may develop as a result of excessive weight gain or loss,
stress, excessive exercise, medical problems such as thyroid or liver
dysfunction, or certain medications. Women engaging in seasonal sports may have
irregular periods for the months they are involved in sport. In these cases,
oligomenorrhoea results from suppressed oestrogen production.
Menorrhagia is defined by
unusually heavy and/or prolonged menstruations but the menstrual cycle is still
regular. This may be caused by an underlying organic disorder or hormonal
problems.
How to
handle menstrual flow
The most commonly used products to handle menstrual flow are sanitary
pads (or towels) and tampons. Both of them have advantages and disadvantages.
Sanitary
pads have the advantage that menstrual blood is collected outside the vagina.
There is less risk of disturbing the eco-system of the normal vaginal bacterial
flora which, if changed, may lead to infection. Excessive bleeding and an
unnatural odour are noticed earlier which is important for women who previously
suffered from heavy periods or vaginal infections. Sanitary pads are also
advisable for young girls who, in the years soon after menarche when the hymenal
ring in virgins is still intact and the vagina is still growing, would feel
uncomfortable by inserting and removing tampons.
Tampons
have the advantage of allowing women to “hide” their menstruation under various
circumstances, such as swimming or other types of sport, or wearing
tight-fitting clothes. The disadvantage of tampon use is the potential change in
the vaginal microflora. If abnormal bacteria are harboured in the vagina (either
sexually transmitted or due to selfcontamination with rectal germs), menstrual
blood which is accumulated inside the vagina above and within a tampon, can act
as a culture medium allowing micro-organisms to multiply, thus promoting
infection.
This
also explains why tampon use is associated with a slightly increased risk for
toxic shock syndrome (TSS), caused by a bacterial infection. Although serious,
toxic shock occurs very infrequently. The risk of TSS can be reduced by
maintaining good hygiene, changing tampons regularly (every four hours or more
often if the menstrual flow is heavy) and by alternating wearing tampons with
pads.
Although
good hygiene is important during menstruation, there is no need to use douches
or "intimate" deodorant sprays, and most medical experts advise against such
products as they can irritate the genital area and increase the risk for
infection.
When to
call the doctor
A doctor should be consulted with any of the following menstrual
problems:
No menstruation by age 16, or three
years after the development of secondary sexual characteristics
No menstruation by age 14 and absent
development of secondary sexual characteristics
Absent menstruation for three months
in a woman who previously has menstruated regularly and has a negative pregnancy
test. (Pregnant women should consult their doctor already after two months
amenorrhoea.)
Menstrual
pain and cramps (dysmenorrhoea) not alleviated by home remedies, or other
menstrual problems interfering with normal daily life.
