Menstrual Cycle

Question 1

Key terms

Answer 1

• Menstrual cycle - the monthly series of changes a woman’s body goes through in preparation for the possibility of pregnancy.
• Period/menses/menstruation – the days bleeding occurs.
• Menarche – an individual’s first menses.
• Ovarian cycle - the preparation of endocrine tissues and release of eggs.
• Perimenopause - the time during which your body makes the natural transition to menopause.
  Menopause - when a female stops having periods.

Question 2

the menstrual cycle

Answer 2

• There are approximately 36 reproductive years. (Harlow et al., 2000)
• Cycle length is usually 28 days with a range of 25-34 days. (Mihm et al., 2011)
• Menses duration is usually 3-6 days with a range of 2-12 days. Average blood loss during this is 33.2ml. (Mihm et al., 2011)
• Four key phases:
  
  • Menses
  • Follicular phase
  • Luteal phase
    Premenstrual

Question 3

why we have a menstrual cycle

Answer 3

• Ovulation occurs to ensure an individual has the chance to reproduce and therefore pass on their genes to the next generation.
• Some species ovulate only when copulating or when they are “in season”. Whereas, humans ovulate monthly and have the associated menstrual cycle.
• Theories for why humans have a menstrual cycle:
  
  • Menses is a cleansing mechanism to flush out any potential infections from intercourse (Profet, 1993)
  • Egg implantation is deep and invasive, and requires a thick lining which when not used needs to be shed due to its large volume (Jarrell, 2018)
    The thickening of the uterine lining is a defence mechanism as foetuses are parasites (Emera et al., 2012)

Question 4

key stages of menstrual development (menarche)

Answer 4

• Menarche typically occurs between ages 11 and 14, but can happen as early as age 9 or as late as 15.
• Globally, the average age of menarche is 13 years old.
• Menarche also signals that an individual can now get pregnant (even in the month before their first period starts).
• There are many factors that affect when menarche is experienced:
  
  • Bodyweight: Overweight and obese children are more likely to experience early menarche, according to research.
  • Wealth: Girls from higher socio-economic backgrounds and those who live with both parents are less likely to experience early periods.
  • Nutrition: Not being breast-fed and poor nutrition may affect the average age.
  • Health: Children who have a low birth weight, exercised little as children, or were exposed to smoking are more likely to experience menstruation early.
    Life experiences: Children who have been sexually abused, come from families with significant levels of conflict or have high levels of stress are more likely to experience early menarche.

Question 5

menarche- a western education

Answer 5

• According to the Department of Education in England, menstrual education is part of the national curriculum. However, this only came into place in 2020
• “Statutory guidance: Know about menstrual wellbeing including the key facts about the menstrual cycle.”
• Primary education should include:
  
  • The menstrual cycle is the process where lining of the uterus thickens for pregnancy and the body releases an egg (for pregnancy). If there is no pregnancy, the body releases the lining through the vagina/cervix. This is called menstruation (or ‘a period’).
  • What menstrual blood looks like; average cycle length; average period length; spotting; PMS symptoms; types of menstrual products
  • “Period pain is common.”
  • See NHS website for more information.
• Secondary education should include:
• Menstrual wellbeing:
  
  • Menstrual conditions, such as endometriosis, can have a significant impact, both physically and mentally.
  • Understand what is ‘normal’ during menstruation, so they can recognise problems and seek help.
  • Teachers may revisit content about menstruation from the primary curriculum part of this presentation, so that they are able to advise pupils on when they should seek help - and who to speak to
  • See NHS website for more information
• Good practice:
  
  • LGBT-relevant knowledge and examples.
  • Avoid segregating by gender.
  • Opportunities to ask teachers questions.
    Address stigma and embarrassment and avoid referring to menstrual products as ‘sanitary’ or ‘hygiene’ products as it could give the impression that periods are dirty.

Question 6

menarche- an eastern education

Answer 6

• The narrative in developing countries is not how to educate about menstruation, it is about missing education due to menstruation.
• One study in India showed that 40% of girls remained absent from school during their menstruation. Of these, 65% reported that they had to miss classes and tests as a result of pain, anxiety, shame, anxiety about leakage, and staining of their uniform. (Vashisht et al., 2018)
• In Kenya, restrictions are largely due to the taboos surrounding menstruation. (MacLean et al., 2018)
  
  • e.g. it is considered unclean and disgusting; it leads social distancing due to aversions to menstrual blood; and girls/women are differentially treated to the normative and privileged male body. (Johnston-Robledo & Chrisler, 2013)
• A review by Chandra-Mouli & Patel (2020) was conducted looking at knowledge and understanding of menarche in low and middle income countries (LMIC). They found:
  
  • Girls have limited knowledge and understanding about menstruation prior to reaching menarche
  • 75% of Chinese girls surveyed rated their menstrual knowledge as inadequate or very inadequate
  • 6% of girls surveyed in Nepal recognised menstruation as a physiological process while 82% believed it was a curse
  • Mothers were often the most frequently cited source of information and advice for girls regarding menstruation
    The roles of teachers and/or health professionals as providers of menstrual information was ranked the least common sources

Question 7

menarche- communication

Answer 7

• A lot of women report that their communication with mothers about menarche is overall negative e.g. “grin-and-bear-it”. (Costos et al., 2002)
• Menarche and menstruation are largely constructed as embarrassing, shameful and something to be hidden, specifically within the school context; which need to be challenged. (Burrows & Johnson, 2005)
  Girls who were prepared for the physical changes at menarche are able to acknowledge and accept the bodily changes. Also, they are more likely to describe pleasurable aspects associated with this transition. (Teitelman, 2004)

Question 8

transgender menarche

Answer 8

• Transgender males and gender non-binary adolescents are distressed by their periods. (Schwartz et al., 2022)
• There is a strong desire for menstrual suppression in this population, with a primary goal of achieving amenorrhea. (Schwartz et al., 2022)
• Menarche can also lead to increased gender dysphoria in transgender males. (Eisenberg et al., 2021)
  Further research is necessary to determine whether the potential harm that could result from prolonging the distress associated with menses. (Eisenberg et al., 2021)

Question 9

menses- symptoms

Answer 9

• Physical symptoms include:
  
  • Bloating and breast tenderness (caused by progesterone and oestrogen). (NHS, 2019)
  • Menstrual cramps (prostaglandins trigger uterine contractions). (NHS, 2019)
• Psychological symptoms include:
  
  • Low mood and/or mood swings (rapid changes in hormone levels).
  • Insomnia (drops in progesterone). (Baker & Lee, 2018)
  • Poor concentration (usually because of the other symptoms). (Sundström Poromaa & Gingnell, 2014)
    Food cravings.

Question 10

menstrual reactivity hypothesis

Answer 10

• Some women may be more focused on bodily changes. (Sigmon et al., 1997)
• Individual interpretations of these changes could be influenced by actual experiences as well as cultural and bodily expectations. (Sigmon et al., 1997)
• High anxiety sensitivity women may be more susceptible according to this hypothesis as many menstrual symptoms are similar to symptoms of panic attacks (e.g., dizziness, heart pounding, cold sweats). (Sigmon et al., 2000)
  Being sensitive to anxiety can have more of an impact on experiencing bodily changes than menstrual phase itself. (Sigmon et al., 2000)

Question 11

menses- impact and absenteeism

Answer 11

• 38% of individuals report not being able to perform all regular daily tasks as a result of menstrual symptoms. (Schoep et al., 2019)
• The physical symptoms can lead to changes in daily activities (i.e., going out with people, fulfilling school and work obligations, and engaging in sports) which then predicts depressed mood and cognitive symptoms. (Van Iersel et al., 2016)
  Absenteeism (time away from work or school) - 13.8% of women reported absenteeism during their menstrual periods or decreased productivity of 23.2 days per year on average. (Schoep et al., 2019)

Question 12

menses- period poverty

Answer 12

• “the state in which people who menstruate find themselves without the financial resources to access suitable menstrual products”. (Bobel et al., 2020)
• Period poverty is a global issue:
  
  • It is estimated that currently over 137,000 children across the UK have missed school days due to period poverty. (Plan International UK, 2018)
  • In the US, 14.2% of women had experienced period poverty ever in the past-year; and these individuals were at a higher risk of moderate/severe depression. (Cardoso et al., 2021)
    In a study of low-middle income families, older women went without pads to ensure that their daughters could continue using these. (Garikipati & Phillips-Howard, n.d.)

Question 13

follicular phase and ovulation

Answer 13

• As hormone levels rise, energy levels increase. Individuals may feel more optimistic and energised at this point of the cycle.
  In the later part of the FP, approaching ovulation, women are more likely to wear makeup (Guéguen, 2012) and wear more revealing clothes. (Durante et al., 2008)

Question 14

luteal phase

Answer 14

• Positive moods continue into the were pronounced in the early luteal phase. (O’Reilly & Reilly, 1990)
• Exercise can be sustained for longer during the luteal phase. (Reilly & Whitley, 1994)
  Women increasingly initiate sex in the luteal phase when they perceive their partners’ investment to be lower. (Grebe et al., 2013)

Question 15

premenstrual phase

Answer 15

• Pierson and colleagues (2021) analysed app data from 3.3 million women across countries. They found:
  
  • Contrary to previous theories that premenstrual effects are culturally specific, they found them to be directionally consistent across countries.
  • The premenstrual decrease in happiness occurs across all 87 countries.
  • Other large premenstrual effects in mood, sexual behaviour and vital signs also remain directionally consistent across countries.
  • The premenstrual negative mood effect increases with age.
• Premenstrual dysphoric disorder (PMDD) is a very severe form of premenstrual syndrome (PMS).
• Azoulay et al. (2020) were interested in childhood trauma as a predictor of PMDD.
  
  • 112 students completed a survey.
  • Findings: The number and severity of premenstrual symptoms increased with more childhood trauma
  • This relationship was completely mediated by emotion regulation difficulties.
    Abuse predicted greater emotion dysregulation, whereas, neglect did not

Question 16

how hormonal contraception affects menstruation

Answer 16

• Preventing ovulation
• Thickening cervical mucus
• Thinning the uterine lining
• Positives
  
  • Women who use HC have lower levels cases of absenteeism related with menstruation, compared with those who did not use HC. (FernándezMartínez et al., 2020)
  • There is no clear association between HCs and depression BUT (Fruzzetti & Fidecicchi, 2020)
  • They may promote improved mental health in particular psychiatric disorders such as PMDD. (Robakis et al., 2019)
• Negatives
  
  • There are subgroups of women that may be more vulnerable to hormonal changes which must be taken into consideration at the time of prescription. (Fruzzetti & Fidecicchi, 2020)
    Some individuals appear susceptible to negative mood effects from some types of HC. (Robakis et al., 2019)

Question 17

primary amenorrhea

Answer 17

• Primary amenorrhoea is the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics, or by 13 years of age in girls with no secondary sexual characteristics.
• Iwami et al. (2021) interviewed individuals about their experiences of primary amenorrhea. They found 6 themes:
  
  • Increasing doubt about gender identity, questioning and exploratory behaviours,
  • Feelings of loneliness and confusion,
  • Searching for self with the help of support resources,
  • Control for coexistence in society,
  • Living at peace with one’s body,
    Liberation from a sense of alien existence.

Question 18

secondary amenorrhea

Answer 18

• Secondary amenorrhea is when periods reduce (missing period/s) or stop altogether
• They can be caused by:
  
  • Stress.
  • Sudden weight loss OR being overweight.
  • Doing too much exercise.
  • Polycystic ovary syndrome (PCOS).
  • As a result of a medical condition, such as heart disease, uncontrolled diabetes, an overactive thyroid, or premature menopause.
• Alzubaidi et al. (2002) used semi-structured interviews to explore the needs of women with secondary amenorrhea. They found:
  
  • Changes to menstrual pattern was the most common initial symptom.
  • It took a long time for diagnosis – 3+ doctor visits before being sent for testing.
  • 25% of women waited 5+ years for a diagnosis.
    90% of participants were college graduates, and 40% had graduate degrees.

Question 19

menorrhagia

Answer 19

• Also known as “heavy periods”. Diagnosed when menstrual blood loss is excessive and accompanied by a negative impact on a woman’s quality of life.
• Diagnosed with:
  
  • Needing to change a pad or tampon every 1 to 2 hours, or empty your menstrual cup more often than is recommended.
  • Have periods lasting more than 7 days.
  • Avoid daily activities, like exercise, or take time off work because of your periods.
• They can be caused by:
  
  • Conditions affecting your womb, ovaries or hormones, such as polycystic ovary syndrome, fibroids, endometriosis and pelvic inflammatory disease.
  • Some medicines and treatments, including some anticoagulant medicines and chemotherapy medicines.
  • Stress and depression.
• The estimated prevalence of HMB is approximately one-third of women aged 15–49 years. (Lethaby & Farquhar, 2003)
• 67% have associated anaemia and fatigue. (Hickey et al., 2007)
• No underlying anatomical cause is found in 40–60% of patients. (Hickey et al., 2007)
• Bauman and colleagues (2020) conducted a cross-sectional survey study with 422 females. They found:
  
  • The use of NSAIDs (pain killers) during menstruation was associated with a higher rate of menorrhagia.
  • Those with menorrhagia suffered from higher pain levels.
  • They had moderate to severe negative effects on activity during the days of menstruation compared to those without menorrhagia.
  • A trend for lower QoL was found in those with menorrhagia.
    Menorrhagia is under-recognized and under-treated

Question 20

endometriosis

Answer 20

• Endometriosis is a condition where tissue similar to the lining of the womb starts to grow in other places, such as the ovaries and fallopian tubes.
• Endometriosis can affect women of any age.
• It’s a long-term condition that can have a significant impact on life, but there are treatments that can help.
• Prevalence of clinically confirmed endometriosis is 6% by age 40–44 years*. (Rowlands et al., 2021)
• 11.4% when combined with clinically suspected endometriosis. (Rowlands et al., 2021)
• Rowe and colleagues (2019) conducted interviews with 46 individuals (12 GPs; 1 gynaecologist; 33 women with endometriosis). They found:
  
  • Endometriosis can have debilitating consequences.
  • Healthcare providers may dismiss symptoms, lack essential knowledge and provide inconsistent advice.
  • Treatments are seldom successful or without adverse side-effects.
  • Health professionals acknowledged limitations in expertise, persistent myths, and challenges in achieving best practice.
    Enhancing collaborative care skills, individualized treatment plans, and local referral pathways to multi-disciplinary care may improve satisfaction with endometriosis care-giving and receiving.

Question 21

perimenopause

Answer 21

• “Perimenopause means “around menopause” and refers to the time during which your body makes the natural transition to menopause, marking the end of the reproductive years. Perimenopause is also called the menopausal transition”. (Mayo Foundation, 2017)
• Symptoms:
  
  • Irregular periods.
  • Hot flashes.
  • Sleep problems.
  • Mood changes.
  • Vaginal and bladder problems.
  • Changes in sexual function.
• Süss & Ehlert (2020) conducted a review into the psychological adjustment through perimenopause. They reported:
  
  • They identified 15 different resilience factors, grouped into six categories:
  • core resilience,
  • spirituality,
  • control,
  • optimism,
  • Emotion
  • self-related resilience.
• They are associated with a better adjustment to menopausal symptoms, milder physical symptoms, a better quality of and satisfaction with life, better well-being, less perceived stress and fewer depressive symptoms compared with women with lower levels of the respective resilience factors.
• Perimenopause can also affect spousal relationships, depending on symptoms.
• Symptoms correlated positively with participants’ feelings about the relationship and sexual intimacy with their partner (more symptoms led to lower sexual desire and higher resentment).
• However, divorced women did not experience the same loss of sexual desire or feel anger or resentment toward their partner.
  Education related to perimenopause may provide a better understanding to women and their partner should be included in this education, as many men do not understand the changes associated with perimenopause and menopause.

Question 22

perimenopause management

Answer 22

• Marnocha and colleagues (2021) found that women in the present study felt unprepared
  for perimenopause and menopause and sought information from others. Surprisingly, mothers of these participants did not share information about their menopausal transition.
  A careful individualised assessment is important, and psychotherapists should address physical experiences along with the psychological interpretations and sociocultural experiences that influence meaning and coping strategies. (Derry, 2008)

Question 23

perimenopause cross culturally

Answer 23

• 732 perimenopausal women was recruited from 3 communities of Jinan City, Shandong Province, China.
• Menopausal symptoms vary across different substages of perimenopause.
  
  • Severity of symptoms was lowest during early menopausal transition and highest during the early postmenopausal.
  • Higher family support and resilience were significantly associated with fewer menopausal symptoms.
• This should be considered by medical staff to identify symptoms and seek appropriate preventive intervention.
• Sixteen Filipina-American women who had not menstruated in the past 6 months or who identified themselves as perimenopausal.
• A grounded theory analysis was conducted.
  The women experienced perimenopause as a normal process of aging rather than as symptomatic of disease.

Question 24

key stage of menstrual development (menopause)

Answer 24

• Perimenopause leads us up to menopause which is defined as a point in time 12 months after a woman’s last period.
• So, menopause itself is essentially this one day that marks the 12 months after the last period.
• Although, people frequently use the terms menopause to describe perimenopause.
  But, what happens after menopause?

Question 25

transgender menopause

Answer 25

• *It is important to note that not every trans or non-binary person take hormones. A person can change their gender expression without any medical intervention whatsoever.
• Anyone with a female reproductive system who identifies as a man, but has not undergone any medical interventions, is likely to go through menopause eventually.
• As menopause is triggered by the body’s drop in oestrogen production, it’s possible trans women will experience similar symptoms if their hormones are interrupted.
• The hormone disruption can cause sleeplessness, fatigue, lack of concentration, mood swings, hot sweats… all similar to those which can be experienced during menopause.
• Mohamed and Hunter (2019) recruited 67 transgender women to complete a questionnaire.
• Responses were analysed using a mixed-methods approach.
• They found:
  
  • Positive views about hormonal therapy (HT) were expressed including mental health benefits.
  • There were concerns about long-term effects, side effects, and maintaining access to the treatment.
    Views about menopause included uncertainty and questioning of its relevance; some mentioned changes to HT dosage, but most expected to use HT indefinitely

Question 26

post menopause

Answer 26

• Bodily changes include:
  
  • Osteoporosis
  • cardiovascular disease
  • depression and other mental health conditions
    changes in vaginal health, such as vaginal dryness

Question 27

post menopause management

Answer 27

• Hormone replacement therapy (HRT).
• Supplements like calcium will boost bone health, while Vitamin E can help with vaginal dryness.
• Evening primrose oil has been used for centuries to treat menopause-related problems such as bloating, breast discomfort and irritability.
• Stop smoking as nicotine and other toxins in cigarettes interfere with the absorption of nutrients such as calcium that are vital during the menopause.
• Eat healthily: Foods that contain phytoestrogens e.g. Tofu, mimic oestrogen. Oily fish contains Omega-3 fatty acids that can protect the heart and Vitamin E-rich products such as wholewheat bread and cereals can reduce the symptoms of the menopause.
• Regular exercise will strengthen bones and reduce the risk of osteoporosis.
  Acupuncture treatments can result in the same changes in hormone levels as HRT.

Question 28

post menopause life

Answer 28

• Positives:
  
  • No fears of pregnancy.
  • Individuals can see most clearly how they might like to spend the rest of their life.
  • Most people have more money than they ever had before, and more leisure time
• The biggest driving factor is the significant drop in oestrogen levels which can lead to:
  
  • Brain and nervous system – mood swings, memory loss, irritability, hot flashes, fatigue, night sweats, anxiety, and depression.
  • Urinary system – The lining of the urethra becomes dry, thin and less elastic, leading to frequency, incontinence and urinary tract infections.
  • Vagina – The same issues of dryness, thinness, and elasticity affect the vaginal tissue, causing inflammation, irritation, discomfort, less lubrication and pain with sex.
  • Some symptoms are those that have continued from perimenopause.
• Woods and Mitchell (2011) conducted a longitudinal study looking at:
  
  • menstrual calendars.
  • annual health reports.
  • morning urine samples.
  • symptom diary ratings several times each year.
• They found:
  
  • Interference with work was significantly associated with: perceived health; stress; depressed mood; anxiety; reduced sleep and sleep quality; backache and joint pain; and cognitive issues (forgetfulness and difficulty concentrating).
    Interference with relationships was significantly associated with: perceived health; estrone (type of oestrogen); stress; depressed mood; anxiety; reduced sleep and sleep quality; backache and joint pain; and cognitive issues (forgetfulness and difficulty concentrating).