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Menstruation
the process in a woman of discharging blood and other material from the lining of the uterus at intervals of about one lunar month from puberty until the menopause, except during pregnancy.
Menstruation, also known as a period or monthly,[1] is the regular discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina.[2] Up to 80% of women report having some symptoms prior to menstruation.[3] Common signs and symptoms include acne, tender breasts, bloating, feeling tired, irritability, and mood changes.[4] These may interfere with normal life, therefore qualifying as premenstrual syndrome, in 20 to 30% of women. In 3 to 8%, symptoms are severe.[3]
The first period usually begins between twelve and fifteen years of age, a point in time known as menarche.[1] However, periods may occasionally start as young as eight years old and still be considered normal.[2] The average age of the first period is generally later in the developing world, and earlier in the developed world. The typical length of time between the first day of one period and the first day of the next is 21 to 45 days in young women, and 21 to 31 days in adults (an average of 28 days).[2][5] Menstruation stops occurring after menopause, which usually occurs between 45 and 55 years of age.[6] Bleeding usually lasts around 2 to 7 days.[2]
The menstrual cycle occurs due to the rise and fall of hormones. This cycle results in the thickening of the lining of the uterus, and the growth of anegg, (which is required for pregnancy). The egg is released from an ovary around day fourteen in the cycle; the thickened lining of the uterus providesnutrients to an embryo after implantation. If pregnancy does not occur, the lining is released in what is known as menstruation.[2]
A number of problems with menstruation may occur. A lack of periods, known as amenorrhea, is when periods do not occur by age 15 or have not occurred in 90 days. Periods also stop during pregnancy and typically do not resume during the initial months of breastfeeding. Other problems includepainful periods and abnormal bleeding such as bleeding between periods or heavy bleeding.[2] Menstruation in other animals occurs in primates, such asapes and monkeys, as well as bats and the elephant shrew.[7][8]
The first menstrual period occurs after the onset of pubertal growth, and is called menarche. The average age of menarche is 12 to 15.[1][9] However, it may start as early as eight.[2] The average age of the first period is generally later in the developing world, and earlier in the developed world.[5] The typical length of time between the first day of one period and the first day of the next is 21 to 45 days in young women and 21 to 31 days in adults (an average of 28 days).[2][5] The average age of menarche has changed little in the United States since the 1950s.[5]
Menstruation is the most visible phase of the menstrual cycle and its beginning is used as the marker between cycles. The first day of menstrual bleeding is the date used for the last menstrual period (LMP). The typical length of time between the first day of one period and the first day of the next is 21 to 45 days in young women, and 21 to 31 days in adults (an average of 28 days).[2][5]
Perimenopause is when fertility in a female declines, and menstruation occurs less regularly in the years leading up to the final menstrual period, when a female stops menstruating completely and is no longer fertile. The medical definition of menopause is one year without a period and typically occurs between 45 and 55 in Western countries.[6][10]:p. 381
During pregnancy and for some time after childbirth, menstruation does not occur; this state is known as amenorrhoea. If menstruation has not resumed, fertility is low during lactation. The average length of postpartum amenorrhoea is longer when certain breastfeeding practices are followed; this may be done intentionally as birth control.
Painful menstrual cramps that result from an excess of prostaglandin release are referred to as primary dysmenorrhea. Primary dysmenorrhea usually begins within a year or two of menarche, typically with the onset of ovulatory cycles.[13] Treatments that target the mechanism of pain include non-steroidal anti-inflammatory drugs (NSAIDs) and hormonal contraceptives. NSAIDs inhibit prostaglandin production. With long-term treatment, hormonal birth control reduces the amount of uterine fluid/tissue expelled from the uterus. Thus resulting in shorter, less painful menstruation.[14] These drugs are typically more effective than treatments that do not target the source of the pain (e.g. acetaminophen).[15] Risk factors for primary dysmenorrhea include: early age at menarche, long or heavy menstrual periods, smoking, and a family history of dysmenorrhea.[13] Regular physical activity may limit the severity of uterine cramps.[13]
For many women, primary dysmenorrhea gradually subsides in late second generation. Pregnancy has also been demonstrated to lessen the severity of dysmenorrhea, when menstruation resumes. However, dysmenorrhea can continue until menopause. 5–15% of women with dysmenorrhea experience symptoms severe enough to interfere with daily activities.[13]
Secondary dysmenorrhea is the diagnosis given when menstruation pain is a secondary cause to another disorder. Conditions causing secondary dysmenorrhea include endometriosis, uterine fibroids, and uterine adenomyosis. Rarely, congenital malformations, intrauterine devices, certain cancers, and pelvic infections cause secondary dysmenorrhea.[13] Symptoms include pain spreading to hips, lower back and thighs, nausea, and frequent diarrhea or constipation.[16] If the pain occurs between menstrual periods, lasts longer than the first few days of the period, or is not adequately relieved by the use of non-steroidal anti-inflammatory drugs (NSAIDs) or hormonal contraceptives, women should be evaluated for secondary causes of dysmenorrhea.[10]:p. 379
When severe pelvic pain and bleeding suddenly occur or worsen during a cycle, the woman or girl should be evaluated for ectopic pregnancy and spontaneous abortion. This evaluation begins with a pregnancy test and should be done as soon as unusual pain begins, because ectopic pregnancies can be life?threatening.[17]
In some cases, stronger physical and emotional or psychological sensations may interfere with normal activities, and include menstrual pain (dysmenorrhea), migraine headaches, and depression.Dysmenorrhea, or severe uterine pain, is particularly common for young females (one study found that 67.2% of girls aged 13–19 have it).[18]
The medications in the non-steroidal anti-inflammatory drugs (NSAIDs) class are commonly used to relieve menstrual cramps. Some herbs are also claimed to help.
Some women experience emotional disturbances starting one or two weeks before their period, and stopping soon after the period has started.[4] Symptoms may include mental tension, irritability, mood swings, and crying spells. Problems with concentration and memory may occur.[4] There may also be depression or anxiety.[4]
This is part of premenstrual syndrome (PMS) and is estimated to occur in 20 to 30% of women. In 3 to 8% it is severe.[3]
More severe symptoms of anxiety or depression may be signs of premenstrual dysphoric disorder (PMDD). Rarely, in individuals who are susceptible, menstruation may be a trigger for menstrual psychosis.
The average volume of menstrual fluid during a monthly menstrual period is 35 milliliters (2.4 tablespoons of menstrual fluid) with 10–80 milliliters (1–6 tablespoons of menstrual fluid) considered typical. Menstrual fluid is the correct name for the flow, although many people prefer to refer to it as menstrual blood. Menstrual fluid contains some blood, as well as cervical mucus, vaginal secretions, and endometrial tissue. Menstrual fluid is reddish-brown, a slightly darker color than venous blood.[10]:p. 381
Unless a woman has a bloodborne illness, menstrual fluid is harmless. No toxins are released in menstrual flow, as this is a lining that must be pure and clean enough to have nurtured a baby. Menstrual fluid is no more dangerous than regular blood.
About half of menstrual fluid is blood. This blood contains sodium, calcium, phosphate, iron, and chloride, the extent of which depends on the woman. As well as blood, the fluid consists of cervical mucus, vaginal secretions, and endometrial tissue. Vaginal fluids in menses mainly contribute water, common electrolytes, organ moieties, and at least 14 proteins, including glycoproteins.[19]
Many mature females notice blood clots during menstruation. These appear as clumps of blood that may look like tissue. If there are questions (for example, was there a miscarriage?), examination under a microscope can confirm if it was endometrial tissue or pregnancy tissue (products of conception) that was shed.[20] Sometimes menstrual clots or shed endometrial tissue is incorrectly thought to indicate an early-term miscarriage of an embryo. An enzyme called plasmin – contained in the endometrium – tends to inhibit the blood from clotting.
The amount of iron lost in menstrual fluid is relatively small for most women.[21] In one study, premenopausal women who exhibited symptoms of iron deficiency were given endoscopies. 86% of them actually had gastrointestinal disease and were at risk of being misdiagnosed simply because they were menstruating.[22] Heavy menstrual bleeding, occurring monthly, can result in anemia.
There is a wide spectrum of differences in how women experience menstruation. There are several ways that someone's menstrual cycle can differ from the norm, any of which should be discussed with a doctor to identify the underlying cause:
| Symptom | See article |
|---|---|
| Infrequent periods | Oligomenorrhea |
| Short or extremely light periods | Hypomenorrhea |
| Too-frequent periods (defined as more frequently than every 21 days) | Polymenorrhea |
| Extremely heavy or long periods (one guideline is soaking a sanitary napkin or tampon every hour or so, or menstruating for longer than 7 days) | Hypermenorrhea |
| Extremely painful periods | Dysmenorrhea |
| Breakthrough bleeding (also called spotting) between periods; normal in many females | Metrorrhagia |
| Absent periods | Amenorrhea |
There is a movement among gynecologists to discard the terms noted above, which although they are widely used, do not have precise definitions. Many now argue to describe menstruation in simple terminology, including:
Dysfunctional uterine bleeding is a hormonally caused bleeding abnormality. Dysfunctional uterine bleeding typically occurs in premenopausal women who do not ovulate normally (i.e. are anovulatory). All these bleeding abnormalities need medical attention; they may indicate hormone imbalances, uterine fibroids, or other problems. As pregnant women may bleed, a pregnancy test forms part of the evaluation of abnormal bleeding.
Women who had undergone female genital mutilation (particularly type III- infibulation) a practice common in parts of Africa, may experience menstrual problems, such as slow and painful menstruation, that is caused by the near-complete sealing off of the vagina.[24]
Premature or delayed menarche should be investigated if menarche begins before 9 years, if menarche has not begun by age 15, if there is no breast development by age 13, or if there is no period by 3 years after the onset of breast development.[5]
Since the late 1960s, many women have chosen to control the frequency of menstruation with hormonal birth control pills. They are most often combined hormone pills containing estrogen and are taken in 28 day cycles, 21 hormonal pills with either a 7-day break from pills, or 7 placebo pills during which the woman menstruates. Hormonal birth control acts by using low doses of hormones to prevent ovulation, and thus prevent pregnancy in sexually active women. But by using placebo pills for a 7-day span during the month, a regular bleeding period is still experienced.
Injections such as depo-provera became available in the 1960s. Progestogen implants such as Norplant in the 1980s and extended cycle combined oral contraceptive pills in the early 2000s.
Using synthetic hormones, it is possible for a woman to completely eliminate menstrual periods.[25] When using progestogen implants, menstruation may be reduced to 3 or 4 menstrual periods per year. By taking progestogen-only contraceptive pills (sometimes called the 'mini-pill') continuously without a 7-day span of using placebo pills, menstrual periods do not occur. Some women do this simply for convenience in the short-term,[26] while others prefer to eliminate periods altogether when possible.
Some women use hormonal contraception in this way to eliminate their periods for months or years at a time, a practice called menstrual suppression. When the first birth control pill was being developed, the researchers were aware that they could use the contraceptive to space menstrual periods up to 90 days apart, but they settled on a 28-day cycle that would mimic a natural menstrual cycle and produce monthly periods. The intention behind this decision was the hope of the inventor, John Rock, to win approval for his invention from the Roman Catholic Church. That attempt failed, but the 28-day cycle remained the standard when the pill became available to the public.[27]There is debate among medical researchers about the potential long-term impacts of these practices upon female health. Some researchers point to the fact that historically, females have had far fewer menstrual periods throughout their lifetimes, a result of shorter life expectancies, as well as a greater length of time spent pregnant or breast-feeding, which reduced the number of periods experienced by females.[28] These researchers believe that the higher number of menstrual periods by females in modern societies may have a negative impact upon their health. On the other hand, some researchers believe there is a greater potential for negative impacts from exposing females perhaps unnecessarily to regular low doses of synthetic hormones over their reproductive years.[29]
Menstruation is managed by menstruating women to avoid damage to clothing or to accord with norms of public life. Menstrual management practices range from medical suppression of menstruation, through wearing special garments or other items, washing or avoidance of washing, disposal and laundry of stained materials, to separation of menstruators to particular places or activities.
Menstrual products (also called "feminine hygiene" products) are made to absorb or catch menstrual blood. A number of different products are available - some are disposable, some are reusable. Where women can afford it, items used to absorb or catch menses are usually commercially manufactured products. In developing countries, many women may not afford these products and use materials found in the environment or other improvised materials.
Absorption materials that may be used by women who cannot afford anything else include: sand, ash, small hole in earth,[34] cloth - new or re-used, whole leaf, leaf fibre (such as water hyacinth, banana, papyrus, cotton fibre), paper (toilet paper, re-used newspaper, pulped and dried paper),[35] animal pelt e.g. goat skin,[34] double layer of underwear, skirt or sari.[36]
Sexual intercourse during menstruation does not cause damage in and of itself, but the woman's body is more vulnerable during this time. Vaginal pH is higher and less acidic than normal,[41] the cervix is lower in its position, the cervical opening is more dilated, and the uterine endometrial lining is absent, thus allowing organisms direct access to the blood stream through the numerous blood vessels that nourish the uterus. All these conditions increase the chance of infection during menstruation.[citation needed]
Male menstruation is a term used colloquially for a type of bleeding in the urine or faeces of males, reported in some tropical countries. It is actually caused by parasite infestation of the urinary tract or intestines by Schistosoma haematobium, and cases of it are actually schistosomiasis, formerly known as bilharziasis.
All female placental mammals have a uterine lining that builds up when the animal is fertile, but it is dismantled when the animal is infertile. Most female mammals have an estrous cycle, yet only primates (including humans), several species of bats, and elephant shrews have a menstrual cycle.[42] Some anthropologists have questioned the energy cost of rebuilding the endometrium every fertility cycle. However, anthropologist Beverly Strassmann has proposed that the energy savings of not having to continuously maintain the uterine lining more than offsets energy cost of having to rebuild the lining in the next fertility cycle, even in species such as humans where much of the lining is lost through bleeding (overt menstruation) rather than reabsorbed (covert menstruation).[43][44]
Many have questioned the evolution of overt menstruation in humans and related species, speculating on what advantage there could be to losing blood associated with dismantling the endometrium, rather than absorbing it, as most mammals do. Humans do, in fact, reabsorb about two-thirds of the endometrium each cycle. Strassmann asserts that overt menstruation occurs not because it is beneficial in itself. Rather, the fetal development of these species requires a more developed endometrium, one which is too thick to reabsorb completely. Strassman correlates species that have overt menstruation to those that have a large uterus relative to the adult female body size.[43]
Beginning in 1971, some research suggested that menstrual cycles of cohabiting human females became synchronized. A few anthropologists hypothesized that in hunter-gatherer societies, males would go on hunting journeys whilst the females of the tribe were menstruating, speculating that the females would not have been as receptive to sexual relations while menstruating.[45][46] However, there is currently significant dispute as to whether menstrual synchrony exists.[47]
Menstrual hygiene day (MHD or MH Day) is an annual awareness day, on 28 May, that aims to break taboos and raise awareness about the importance of good menstrual hygiene management (MHM) for women and adolescent girls worldwide. It was initiated by the German-based NGO WASH United in 2014. The initiative for Menstrual Hygiene Day has received the support of over 270 global partners who are committed to making good menstrual health and hygiene a priority worldwide. The day complements other important days of the year in relationship to sanitation and hygiene, such as 15 October for Global Handwashing Day or 19 November for World Toilet Day. May 28 was chosen for its symbolism since May is the 5th month of the year and most women average 5 days every month and their cycle is approximately 28 days.[1]
Inadequate menstrual hygiene management is connected with several problems that females face, in particular in developing countries. The current silence about menstruation limits women’s and adolescent girls’ access to relevant and important information about their bodies, directly affecting their health, education, dignityand human rights.[3][4] In a 2014 study conducted in India, the researchers found that as many as 42% of women who participated in the study did not know about sanitary pads or from where in their anatomy menstruation originated from and "most of them were scared or worried on first menstruation."[5] Worldwide, one in three women does not have access to a working toilet at all.[6] Menstrual hygiene management issues have been ignored by professionals in the water, sanitationand hygiene (WASH) sector, and in the health and education sectors, too.[7][8]
Poor MHM may affect the reproductive tract but the specific infections, the strength of effect, and the route of transmission, remain unclear.[8] In India, a majority of girls are at risk for reproductive tract infections (RTI) because of poor MHM and RTI can lead to various disabilities if not treated early on.[9]
Due to prejudices surrounding menstruation, some women in India do not eat during their menstration or take showers.[10]
Girls' self-image may be negatively impacted by adverse attitudes towards menstruation.[11][12]
Menstrual waste is largely ignored in schools in developing countries, despite it being a significant problem. Girls' access to water and sanitation at school is only available at 47% and 46% of all schools globally.[3] Often, school toilets for girls (if they even exist) are missing bins for menstrual waste collection with the result that pads may be spread all around the school compound area.[16] This pollutes the environment and also causes embarrassment for the school girls.
In the United States, girls who are unable to afford feminine hygiene products may miss school in order "to avoid the embarrassment of staining their clothes."[17]
In low-income countries, girls’ choices of menstrual hygiene materials are often limited by the costs, availability and social norms.[18]
Girls and women in the workplace often miss work because they don't have access to sanitary materials and places of employment in some countries don't provide resources for women or even have "proper toilets."[12] Women in Bangladesh who work in factories have reported that due to the cost of sanitary products for menstruation which they could not afford, they have resorted to using "factory-floor rags in place of pads and tampons, leading to dangerous infections and missed work."[19]