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Menstruation is the periodic shedding of the uterine lining (endometrium). It starts (menarche) at or before sexual maturity, maturation, in females of certain mammal species, and ceases at or near menopause (commonly considered the end of a female's reproductive life). The periodicity of menstruation gives rise to commonly used euphemisms like "period" and "monthly". This article focuses on human menstruation.

Women typically stop menstruating if they conceive or if they are breastfeeding. When menstruation stops for longer than about 90 days in the absence of pregnancy or breastfeeding, a medical evaluation should occur, as a number of health problems can result in absent menstruation. Menstruation lasts from puberty until menopause among non-pregnant women.

Overview

Regular menstruation (also called eumenorrhea) lasts for a few days, usually 3 to 5 days, but anywhere from 2 to 7 days is considered normal. The average menstrual cycle is 28 days long from the first day of one menstrual period to the first day of the next. A normal menstrual cycle in adult women is between 21 and 35 days.In adolescents, there is wider variation, and cycles are normally between 21 and 45 days. Menstrual symptoms occurring in the time prior to menstruation, such as breast pain, swelling, bloating, acne are termed premenstrual molimina .

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 menstrual flow, although many people prefer to refer to it as menstrual blood. Menstrual fluid in fact 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.

Many women also notice blood clots during menstruation. These appear as clumps of blood that may look like tissue. If there is a 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. 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 via menstrual fluid is relatively small for most women. 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. Heavy menstrual bleeding, occurring monthly, can result in anemia.

The first experience of a menstrual period occurs after the onset of pubertal growth, and is called menarche. The average age of menarche is around 12-13 (occurring earlier in African American than Caucasian girls), but menarche can typically occur between ages 9 and 15. Premature or delayed menarche should be investigated; many older sources state that this should be done if menarche begins before 10 yrs or is delayed after 16 years, while newer, more evidence-based sources state that it should be done if menarche begins before 9 yrs, 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. Perimenopause is when fertility in a female declines, and menstruation may occur 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 the late 40s and early 50s in Western countries.

Physical experience

In most females, various physical changes are brought about by natural fluctuations in hormone levels during the menstrual cycle, and by muscle contractions (menstrual cramping) involving the uterus that can precede or accompany menstruation. Some may notice water retention, changes in sex drive, fatigue, breast tenderness, or nausea. Breast swelling and discomfort may be caused by water retention during menstruation. Usually, such sensations are mild, and some people notice very few physical changes associated with menstruation. A healthy diet, reduced consumption of salt, caffeine and alcohol, and regular exercise are may be effective for women in controlling these physical changes. The sensations experienced vary from person to person and from cycle to cycle. Severe symptoms that disrupt daily activities and functioning may be diagnosed as premenstrual dysphoric disorder.

Painful menstrual cramps

Many women experience painful uterine cramps during menstruation. The muscles of the uterus surrounding the uterus, contract spasmodically to push the menstrual fluid out of the uterus. The contractions are the release of an excess of fatty acids called prostaglandins, leading to contractions. Dysmenorrhea is the medical term for painful periods. 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. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen and hormonal contraceptives such as combination birth control pills block the production and actions of prostaglandins, and provide pain relief that targets the mechanism of pain, rather than just its effects. These drugs are typically more effective than acetaminaphen or other over-the-counter medications, even those that advertise their potential benefits for menstrual pain. It may continue until menopause, but many people find that their symptoms of dysmenorrhea gradually subside after their mid-20s. Secondary dysmenorrhea is different from primary dysmenorrhea in that there is another cause for pain, such as endometriosis or uterine fibroids. Severe symptoms may include pain spreading to hips, lower back and thighs, nausea and frequent diarrhea or constipation. If the pain occurs between menstrual periods, or lasts longer than the first few days of the period, or is not well-relieved by the use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen or hormonal contraceptives, these additional causes for pain should be investigated. .

Emotional and psychological experience

Some women experience emotional disturbances associated with their menstruation. These range from irritability, to tiredness, or "weepiness" (i.e. easily provoked tearfulness). A similar range of emotional effects and mood swings is associated with pregnancy. The prevalence of PMS is estimated to be between 3% and 30%. More severe symptoms of anxiety or depression may be signs of premenstrual syndrome. Rarely, in individuals susceptible to psychotic episodes, menstruation may be a trigger (menstrual psychosis).

Premenstrual syndrome

In some cases, stronger physical and emotional or psychological sensations may become debilitating, and include significant menstrual pain (dysmenorrhea), migraine headaches, and severe depression. Dysmenorrhea, or severe uterine pain, is particularly common for adolescents and young females (one study found that 67.2% of girls aged 13–19 suffer from it). This phenomenon is called premenstrual syndrome. More severe symptoms may be classified as premenstrual dysphoric disorder (PMDD).

Menstrual disorders

There is a wide spectrum of differences between how people may experience menstruation. There are several ways that a person's menstrual cycle can differ from the norm, any of which should be discussed with a doctor to identify the underlying cause:

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:

• Cycle regularity (irregular, regular, or absent)
• Frequency of menstruation (frequent, normal, or infrequent)
• Duration of Menstrual flow (prolonged, normal, or shortened)
• Volume of menstrual flow (heavy, normal, or light)

Dysfunctional uterine bleeding is a hormonally caused bleeding abnormality. Dysfunctional uterine bleeding typically occurs in premenopausal females 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.

Menstruation and sex

Sexual intercourse during menstruation does not cause damage in of itself, but the woman's body is more vulnerable during this time. Vaginal pH is higher and less acidic than normal, 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 and STD transmission during menstruation.

Sexual intercourse may also shorten the menstrual period. Some sources say that achieving orgasm helps the uterus to contract and expel the lining. However, it is more likely that because semen contains luteinizing hormone (LH) and follicle stimulating hormone (FSH), and the vagina easily absorbs these hormones, the woman's hormone balance is slightly offset and the follicular phase of the menstrual cycle begins earlier. Similarly, levonorgestrel-releasing intrauterine devices and oral birth control pills alter the default hormone-release cycle, although by different mechanisms such as maintaining a high progestin level throughout a woman's cycle.

Menstruation and pregnancy

Menstruation is the most visible phase of the menstrual cycle, and corresponds closely with the hormonal cycle, and is therefore used as the limit between cycles; Menstrual cycles are counted from the first day of menstrual bleeding, a point in time commonly termed last menstrual period (LMP). The time from LMP until ovulation is, on average, 14.6 days, but with substantial variation both between people and between cycles in any single person, with an overall 95% prediction interval of 8.2 to 20.5 days.

During pregnancy and for some time after childbirth, menstruation is normally suspended; this state is known as amenorrhoea, i.e. absence of the menstrual cycle. 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.

Use of synthetic hormones to control menstruation

Since the late 1960s, many women have chosen to control the frequency of menstruation with long-acting hormonal birth control, often simply called 'the pill'. 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 person menstruates. Hormonal contraception acts by using low doses of hormones to prevent ovulation, and thus prevent conception in sexually active females. 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 person to completely eliminate menstrual periods. 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, the menstrual period is eliminated entirely. Some people do this simply for convenience in the short-term, while others prefer to eliminate periods altogether when possible.

Menstrual suppression

Some people use hormonal contraception in this way to eliminate their periods for months or years at a time, a practise 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. There is debate among medical researchers about the potential long-term impacts of these practises 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. These researchers believe that the higher number of menstrual periods experienced 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.

Menstrual products

Something to absorb or catch menses may be used; there are a number of different methods available.

Reusable items

• Reusable cloth pads — Pads that are made of cotton (often organic), terrycloth, or flannel, and may be handsewn (from material or reused old clothes and towels) or storebought.
• Menstrual cups — A firm, flexible bell-shaped device worn inside the vagina to catch menstrual flow. Reusable versions include rubber or silicone cups. Sterilised after each period.
• Sea sponges — Natural sponges, worn internally like a tampon to absorb menstrual flow.
• Padded panties — Reusable cloth (usually cotton) underwear with extra absorbent layers sewn in to absorb flow.
• Blanket, towel — (also known as a draw sheet) — large reusable piece of cloth, most often used at night, placed between legs to absorb menstrual flow.

Disposable items

• Sanitary napkins (Sanitary towels) or pads — Somewhat rectangular pieces of material worn in the underwear to absorb menstrual flow, often with "wings," pieces that fold around the undergarment and/or an adhesive backing to hold the pad in place. Disposable pads may contain wood pulp or gel products, usually with a plastic lining and bleached. Some sanitary napkins, particularly older styles, are held in place by a belt-like apparatus, instead of adhesive or wings.
• Tampons — Disposable cylinders of treated rayon/cotton blends or all-cotton fleece, usually bleached, that are inserted into the vagina to absorb menstrual flow.
• Padettes — Disposable wads of treated rayon/cotton blend fleece that are placed within the inner labia to absorb menstrual flow.
• Disposable menstrual cups — A firm, flexible cup-shaped device worn inside the vagina to catch menstrual flow. Disposable cups are made of soft plastic.

In addition to products to contain the menstrual flow, pharmaceutical companies likewise provide products — commonly non-steroidal anti-inflammatory drugs (NSAIDs) — to relieve menstrual cramps. Some herbs, such as dong quai, raspberry leaf and crampbark, are also claimed to relieve menstrual pain; however there is no documented scientific evidence to prove this.

Culture and menstruation

Many religions have menstruation-related traditions. These may be bans on certain actions during menstruation (such as sexual intercourse in some movements of Judaism and Islam), or rituals to be performed at the end of each menses (such as the mikvah in Judaism and the ghusl in Islam). Some traditional societies sequester females in residences called "menstrual huts" that are reserved for that exclusive purpose.

In Hinduism, it is also frowned upon to go to a temple and do pooja (i.e., prayer) or do pooja at religious events if you are a woman who is menstruating. Saraswati, the Hindu goddess of knowledge, is associated with menstruation; the literal translation of her name is "flow — woman". Metaformic Theory, as proposed by cultural theorist Judy Grahn and others, places menstruation as a central organizing idea in the creation of culture and the formation of humans' earliest rituals.

Evolution

All female placental mammals have a uterine lining that builds up when the animal is fertile, but 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. 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).

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.

Beginning in 1971, some research suggested that menstrual cycles of co-habiting 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. However, there is currently significant dispute as to whether menstrual synchrony exists.

Further reading

• Howie, Gillian; Shail, Andrew (2005). Menstruation: A Cultural History. Palgrave Macmillan. ISBN 1-4039-3935-7.
• Knight, Chris (1995). Blood Relations: Menstruation and the Origins of Culture. New Haven and London: Yale University. ISBN 0-300-04911-0.
• Museum of Menstruation

See also

• Endometrium
• Male menstruation
• Menstrual cup
• Menstrual synchrony
• Menstrual taboo
• Niddah, a Hebrew term describing a menstruating woman
• Ovary
• Ovulation

Footnotes

1. Logan, Carolyn (15 April 1997). "Take Your Choice". Counterbalance: Gendered Perspectives on Writing and Language. p. 41. ISBN 1551111276. Retrieved 18 February 2013.
2. Jurgens, Janice J.; Powers, Bethel A. (1992). "An Exploratory Study of the Menstrual Euphemisms, Beliefs and Taboos of Head Start Mothers". In Sampselle, Carolyn M. (ed.). Violence Against Women: Nursing Research, Education, and Practice Issues. p. 37. ISBN 1560322179. Retrieved 18 February 2013.
3. "Menstruation and the Menstrual Cycle". Womenshealth.gov. November 2002. Archived from the original on 2 March 2007. Retrieved 11 June 2005.
4. ^ Ziporyn, Karen J. Carlson, Stephanie A. Eisenstat, Terra (2004). The new Harvard guide to women's health. Cambridge, Mass.: Harvard University Press. ISBN 0-674-01343-3.{{cite book}}: CS1 maint: multiple names: authors list (link)
5. American Congress of Obstetricians and Gynecologists. "Menstruation in girls and adolescents: Using the menstrual cycle as a vital sign". ACOG.
6. https://en.wiktionary.org/molimina
7. "Menstrual blood problems: Clots, color and thickness". WebMD. Retrieved 20 September 2011.
8. Clancy, Kate (27 July 2011). "Iron-deficiency is not something you get just for being a lady". SciAm. {{cite web}}: External link in |author= (help)
9. Kepczyk T, Cremins JE, Long BD, Bachinski MB, Smith LR, McNally PR (1999). "A prospective, multidisciplinary evaluation of premenopausal women with iron-deficiency anemia". Am. J. Gastroenterol. 94 (1): 109–15. doi:10.1111/j.1572-0241.1999.00780.x. PMID 9934740. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
10. Anderson SE, Dallal GE, Must A (2003). "Relative weight and race influence average age at menarche: results from two nationally representative surveys of US girls studied 25 years apart". Pediatrics. 111 (4 Pt 1): 844–50. doi:10.1542/peds.111.4.844. PMID 12671122. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
11. Al-Sahab B, Ardern CI, Hamadeh MJ, Tamim H (2010). "Age at menarche in Canada: results from the National Longitudinal Survey of Children & Youth". BMC Public Health. 10. BMC Public Health: 736. doi:10.1186/1471-2458-10-736. PMC 3001737. PMID 21110899.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
12. Hamilton-Fairley, Diana. "Obstetrics and Gynaecology" (PDF) (Second ed.). Blackwell Publishing. {{cite journal}}: Cite journal requires |journal= (help)
13. http://www.patient.co.uk/doctor/Normal-Menstruation.htm
14. American Congress of Obstetricians and Gynecologists Committee Opinion. "Menstruation in Girls and Adolescents: using the menstrual cycle as a vital sign". ACOG. Retrieved 02/02/13. {{cite web}}: Check date values in: |accessdate= (help)
15. PMID 6580290
16. "Water retention: Relieve this premenstrual symptom". Mayo Clinic. Retrieved 20 September 2011.
17. Review: Marjoribanks J, Proctor M, Farquhar C et al. Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. Cochrane Database Syst Rev 2010;(1):CD001751.
18. Giannini AJ, Price WA, Loiselle RH (1984). "beta-Endorphin withdrawal: a possible cause of premenstrual tension syndrome". Int J Psychophysiol. 1 (4): 341–3. doi:10.1016/0167-8760(84)90028-X. PMID 6094401. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
19. "NIH Press Release-Hormones Trigger PMS Symptoms — 21 January 1998". http://www.nih.gov/news/pr/jan98/nimh-21.htm. Retrieved 28 February 2008
20. Dean BB, Borenstein JE, Knight K, Yonkers K (2006). "Evaluating the criteria used for identification of PMS". J Womens Health (Larchmt) 15 (5): 546–55. doi:10.1089/jwh.2006.15.546. PMID 16796482
21. Sharma P, Malhotra C, Taneja DK, Saha R (2008). "Problems related to menstruation amongst adolescent girls". Indian J Pediatr 75 (2): 125–9. doi:10.1007/s12098-008-0018-5. PMID 18334791
22. Fraser,, Ian (2007). "Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding?". Hum Reprod. 22 (3): 635–43. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)CS1 maint: extra punctuation (link)
23. Ann Intern Med. 1982 Jun;96(6 Pt 2):921-3. Vaginal physiology during menstruation.
24. "WAYS TO SHORTEN A MENSTRUAL CYCLE".
25. Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.3109/01485018308990176, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.3109/01485018308990176 instead.
26. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1046/j.1469-0705.1991.01030212.x, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1046/j.1469-0705.1991.01030212.x instead.
27. "Delaying your period with birth control pills". Mayo Clinic. Retrieved 20 September 2011.
28. "How can I delay my period while on holiday?". National Health Service, United Kingdom. Retrieved 20 September 2011.
29. "Do you really need to have a period every month?". Discovery Health. Retrieved 20 September 2011.
30. Amy Lind, Stephanie Brzuzy (2007). Battleground: Women, Gender, and Sexuality: Volume 2: M-Z. Greenwood. p. 348. ISBN 978-0-313-34039-0.
31. Kam, Katherine. "Eliminate periods with birth control?". WebMD. Retrieved 20 September 2011.
32. Clark-Flory, Tracy. "The end of menstruation". Salon. Retrieved 20 September 2011.
33. "Herbs For Premenstrual Syndrome". HerbalRemedies.com. 2004. Retrieved 8 August 2006.
34. "Why do women menstruate?". ScienceBlogs. 2011. Retrieved 15 January 2013.
35. ^ PMID 8693059
36. Kathleen O'Grady (2000). "Is Menstruation Obsolete?". The Canadian Women's Health Network. Retrieved 21 January 2007. {{cite journal}}: Cite journal requires |journal= (help)
37. Desmond Morris (1997). "The Human Sexes". Cambridge University Press. {{cite journal}}: Cite journal requires |journal= (help)
38. Chris Knight (1991). Blood relations: menstruation and the origins of culture. New Haven, Conn: Yale University Press. ISBN 0-300-06308-3.
39. Adams, Cecil (20 December 2002). "Does menstrual synchrony really exist?". The Straight Dope. The Chicago Reader. Retrieved 10 January 2007.

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