Week 6-Menstruation Matters

Question 1

Define menstrual cycle

Answer 1

The monthly series of changes a woman’s body goes through in preparation for the possibility of pregnancy.

Question 2

Define Period/menses/menstruation

Answer 2

The days bleeding occurs.

Question 3

Define Menarche

Answer 3

An individual’s first menses (i.e., period)

Question 4

Define Ovarian cycle

Answer 4

The preparation of endocrine tissues and eggs being released.

Question 5

Define Perimenopause

Answer 5

The time where your body makes the natural transition to menopause.

Question 6

Define Menopause

Answer 6

When a female stops having periods.

Question 7

What is the menstrual cycle?

Answer 7

• 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. The average blood loss during this is 33.2ml (Mihm et al., 2011). (BUT unless you’re using a menstrual cup, how do we know how much blood is truly lost?)

Four key phases:
1. Menses
2. Follicular phase (1st 2 weeks)
3. Luteal phase (2nd 2 weeks)
4. Premenstrual

Question 8

Why do we have a menstrual cycle?

Answer 8

• Ovulation occurs to ensure a chance of reproduction and passing genes into the next generation (not all animals have menstrual cycles).
• 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) (We know this is false due to women still getting STIs)
* 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 9

What is the Key stage of menstrual
development (menarche)?

Answer 9

• 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; therefore, people can technically get pregnant before they start)

There are many factors that affect when menarche is experienced:
* Bodyweight: Overweight and obese children are more likely to experience early menarche (In theory, lots of nutrition, so lots of resources to reproduce)

• 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. (Message is abundant that body can reproduce in this environment but in this case do it quickly before you “die”)
• 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 (Could be related to dangerous environment and not knowing if they will “die”, so should reproduce)

Question 10

True or false: Basal body temperature increases during ovulation (Isometrik, 2009)

Answer 10

True! This is likely due to increased progesterone levels

Question 11

What is menstrual education like in Western education?

Answer 11

• 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.”

Question 12

Primary education should include what? (UK Government, 2020)

Answer 12

• The menstrual cycle is the process where the 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

Question 13

Secondary education should include what? (UK Government, 2020)

Answer 13

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 14

What is menstrual education like in Eastern Cultures?

Answer 14

• 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).

Question 15

What did Chandra-Mouli & Patel (2020)find when looking at knowledge and understanding of menarche in low and middle-income countries (LMIC)?

Answer 15

-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 (not necessarily reliable as could be passing on generational stigmas).
• The roles of teachers and/or health professionals as providers of menstrual information was ranked the least common sources (yet would typically have the education to teach this)

Question 16

What is communication like in relation to menstrual education?

Answer 16

• 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 needs 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 e.g., excited (Teitelman, 2004)

Question 17

What are the typical menstrual experiences of those who are transgender?

Answer 17

• 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 the potential harm that could result from prolonging the distress associated with menses. (Eisenberg et al., 2021) (e.g., the longer it takes to reach amenorrhea, the bigger impact they may have long term)

-Dates of research highlights how we only acknowledge this now despite periods existing for centuries (there could be a major gap that research has not yet addressed)

Question 18

What are the physical symptoms of Menses?

Answer 18

• Bloating and breast tenderness (caused by fluctuating progesterone and oestrogen). (NHS, 2019)
• Menstrual cramps (prostaglandins trigger uterine contractions and shedding of the lining. Also affects the intestines as prostaglandins affects all over the body, causing diarrhoea). (NHS, 2019)

Question 19

What are the psychological symptoms of Menses?

Answer 19

• 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. (cramping causes energy, causes carb cravings)

Question 20

What is the Menstrual Reactivity Hypothesis?

Answer 20

• 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) (Sort of suggests PMS is in your head?)
• 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 the menstrual phase itself. (Sigmon et al., 2000)

Question 21

How can Menses impact individuals and absenteeism?

Answer 21

• 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 22

What is the effect of period poverty?

Answer 22

• “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 23

What occurs during the Follicular Phase & Ovulation?

Answer 23

-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) (in a phase where body wants to reproduce)

Question 24

What occurs during the Luteal Phase?

Answer 24

• Positive moods continue into 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) (basically don’t want to lose that mate during this time unless you know you’re not pregnant)

Question 25

What was found to occur during the Premenstrual Phase? (Pierson & Colleagues, 2021)

Answer 25

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.

Question 26

What is a negative aspect of the Premenstrual Phase? (Azoulay et al., 2020)

Answer 26

• 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, leading to worse PMD whereas, neglect did not. (shows its not just in your head showing emotional dysregulation can impact management of PMD symptoms)

Question 27

How does hormonal contraception work?

Answer 27

• Prevents ovulation
• Thickening of the cervical mucus
• Thinning of the uterine lining

-Depends on the type taken due to different levels of hormones

Question 28

What are the positives of HC?

Answer 28

• Women who use HC have lower levels cases of absenteeism related with menstruation, compared with those who did not use HC (Fernández-Martínez et al., 2020) (likely due to not ovulating so lining is not there to house a fetus).
• There is no clear association between HCs and depression (Fruzzetti & Fidecicchi, 2020)
• BUT they may promote improved mental health in particular psychiatric disorders such as PMDD (Robakis et al., 2019).

-Contraceptives act as a plaster for lots of possible issues

Question 29

What are the negatives of HC?

Answer 29

• 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 30

What is Amenorrhea?

Answer 30

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

Question 31

What 6 themes did Iwami et al. (2021) find when interviewing individuals about their experiences of primary amenorrhea?

Answer 31

1. Increasing doubt about gender identity, questioning and exploratory behaviours,
2. Feelings of loneliness and confusion,
3. Searching for self with the help of support resources
4. Control for coexistence in society
5. Living at peace with one’s body
6. Liberation from a sense of alien existence

-They also measured the interrelationships between these themes

Question 32

What is Secondary amenorrhea?

Answer 32

• 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.

Question 33

What did Alzubaidi et al. (2002) find when using semi-structured interviews to explore the needs of women with secondary amenorrhea?

Answer 33

• 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.

-Do those who are highly educated tend to get the diagnosis? Is this due to researching themselves and being aware of this?

Question 34

What is Menorrhagia?

Answer 34

• 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

Question 35

What can Menorrhagia be caused by? and what is the prevalence?

Answer 35

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 (affects the heaviness of the periods).
• Stress and depression.

Prevalence:
* The estimated prevalence of heavy menstrual bleeding (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)

Question 36

What did Bauman and colleagues (2020) find when conducting a cross-sectional survey study with 422 females on menorrhagia?

Answer 36

• The use of NSAIDs (painkillers) 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 37

What is Endometriosis?

Answer 37

• 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 (can be damaging as causes unnecessary blood loss).
• 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).

Question 38

What did Rowe and colleagues (2019) find when conducting interviews with 46 individuals (12 GPs; 1 gynaecologist; 33 women with endometriosis?

Answer 38

• Endometriosis can have debilitating consequences.
• Healthcare providers may dismiss symptoms, lack essential knowledge and provide inconsistent advice (not necessarily intentional but more due to being uneducated as some medical courses don’t have female health).
• Treatments are seldom successful or without adverse side-effects (key hole surgery to remove the endometriosis tissue).
• 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 (However huge cut in NHS so seems unlikely it will be soon)

Question 39

What is Perimenopause and its symptoms?

Answer 39

• “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

Question 40

What did Süss & Ehlert (2020) report when conducting a review into the psychological adjustment through perimenopause?

Answer 40

• 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.

Question 41

How can Perimenopause affect relationships? (Caico, 2013)

Answer 41

• 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 (so what is mediating this link?)
• Education related to perimenopause may provide a better understanding to women and their partners should be included in this education, as many men do not understand the changes associated with perimenopause and menopause + helps to better navigate situations.

Question 42

What was found in Perimenopause management? (Marnocha & colleagues, 2021)

Answer 42

• 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 43

How does Perimenopause differ cross-culturally? (Zhao et al., 2019)

Answer 43

• 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 (i.e., social support acts as a mediator).
• This should be considered by medical staff to identify symptoms and seek appropriate preventive intervention.

Question 44

How does Perimenopause differ cross-culturally? (Hautman, 1996)

Answer 44

*16 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 a symptomatic of disease

Question 45

What is the key stage of menstrual development (menopause)? (Marnocha et al., 2021)

Answer 45

• 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 46

What is the experience of transgender individuals experiencing menopause?

Answer 46

• 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.

*It is important to note that not every trans or non-binary person takes hormones. A person can change their gender expression without any medical intervention whatsoever.

Question 47

What did Mohamed and Hunter (2019) find in relation to transgender menopause?

Answer 47

-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 48

What bodily changes are seen in those experiencing post-menopause?

Answer 48

• osteoporosis
• cardiovascular disease
• depression and other mental health conditions
• changes in vaginal health, such as vaginal
  dryness

Question 49

What can be used for Post-menopause management?

Answer 49

• 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 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 50

What are the positives of Post-menopause life?

Answer 50

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

Question 51

What was Woods and Mitchell (2011) study on post-menopause life? + findings?

Answer 51

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: relationship satisfaction, sex life, relationships with friends and children 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).