The cyclic production of hormones that culminates in the release of a mature egg (ovum) is called the menstrual cycle, which begins during puberty and ends at menopause. The first menstrual cycle is called menarche.
Hormones that control the menstrual cycle are produced by the hypothalamus, pituitary gland, and ovaries. The beginning of a menstrual cycle is marked by the maturation of an egg in an ovary and preparation of the uterus (womb) to establish pregnancy. Menstruation occurs when pregnancy has not been achieved.
The menstrual cycle is divided into four phases and is, on average, 28 days long (21–45 days). The onset of menstruation, called a period, monthly, menses, or menstrual period, begins a new menstrual cycle and is considered day one.
This first phase usually lasts five days. Menstruation occurs in response to drops in the level of the hormone progesterone. It is estimated that a woman will have 500 menstrual periods in her lifetime.
The second phase of the menstrual cycle is called the follicular or proliferative phase. The ovary, in response to increasing levels of follicle stimulating hormone, begins the egg maturation process.
Although 10–20 eggs begin to develop within follicles of the ovaries, usually only one egg reaches maturity. Follicles are clusters of cells that encase a developing egg, hence the name “follicular phase.”
Developing follicles release the hormone estrogen that stimulates the lining of the uterus, called the endometrium, to grow (proliferate) in preparation to receive an embryo (an egg that has been fertilized and begun dividing) and establish pregnancy. This is why the second phase is also called the “proliferative phase.” This phase usually lasts through day 13.
The ovulation phase occurs in response to a surge in luteinizing hormone and is marked by the release of a mature egg from the follicle. Ovulation usually occurs on day 14.
The fourth phase is called the luteal, secretory, premenstrual, or postovulatory phase, and usually lasts from days 15–28. During this phase, the empty follicle, now called the corpus luteum, releases the hormone progesterone which further prepares the uterus for implantation of an embryo.
The endometrium thickens because of cell growth, changes in blood vessels and glands, and increases in fluid. If pregnancy does not occur, the fall in progesterone levels initiates the onset of a new menstrual cycle. However, if pregnancy does occur, progesterone levels remain high and the endometrium is not shed.
In the United States, menstruation typically begins at 12.8 years of age in Caucasian girls and 12.4 years of age for African American girls. Factors that help to dictate the age at which menarche occurs include race, mother’s age at menarche, nutritional status, body fat, as well as climate and elevation. Studies have shown that a body fat level of 17% is necessary for menstruation to begin.
Women who live together or work in close proximity tend to find that their cycles begin to coincide. During the menstrual cycle, the body releases hormones called pheromones, which may signal surrounding women’s cycles to begin.
Puberty signals the maturation of a young woman’s reproductive hormones. As a girl reaches puberty, the pituitary gland in the brain starts to produce the hormones that signal the ovaries to begin functioning.
The interaction between these hormones and the hormones estrogen and progesterone causes the lining of the uterus to swell and thicken in anticipation of a fertilized egg. If the egg is not fertilized, the lining is discharged through the vagina, resulting in menstrual bleeding.
Menstrual problems
Women may also experience emotional distress or wide mood swings during the luteal phase of the menstrual cycle. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV, lists premenstrual dysphoric disorder (PMDD) in an appendix of criteria sets for further study.
To meet full criteria for PMDD, a patient must have at least five out of 11 emotional or physical symptoms during the week preceding the menses for most menstrual cycles over the previous 12 months.
Although the DSM-IV definition of PMDD as a mental disorder is controversial because of fear that it could be used to justify prejudice or job discrimination against women, there is evidence that a significant proportion of premenopausal women suffer emotional distress or impairment in job functioning in the week before their menstrual period.
One group of researchers estimates that 3–8% of women of childbearing age meet the strict DSM-IV criteria for PMDD, with another 13–18% having symptoms severe enough to interfere with their normal activities.
Causes and symptoms
Menstruation is not an illness, but a normal part of the menstrual cycle. However, menstrual problems do occur, and are due to varying causes.
Amenorrhea
Amenorrhea is the absence of menstruation, and can be either primary or secondary. Primary amenorrhea is failure to menstruate by age 16 years in girls who have normal puberty, by age 14 years in those with delayed puberty, or two years after sexual maturation has occurred.
Primary amenorrhea may be caused by genetic disorders, hormonal imbalance, brain defects, or physical abnormality of the reproductive organs. In 2003, a group of researchers reported on a new genetic mutation associated with primary amenorrhea. In addition, certain systemic diseases may delay puberty and menstruation.
Delayed menstruation may occur in athletes, especially gymnasts, ballerinas, and long-distance runners because of insufficient body fat. Amenorrhea associated with athletic training and professional dance is a growing health concern, however, because it often occurs together with eating disorders and a loss of bone mass that can lead to early osteoporosis.
Secondary amenorrhea refers to the absence of menstruation after an interval of normal menstruation. It is identified as not menstruating for three months in females with irregular menstrual cycles, six months in females with normal menstrual cycles, and 18 months in females who had just started menstruating.
Secondary amenorrhea can be caused by pregnancy, weight loss, excessive exercise, breast feeding, disease, or menopause. Menopause takes place when the ovaries stop producing estrogen, causing periods to become irregular and then stop. It generally occurs when a woman is between 48 and 52 years of age.
Dysfunctional and abnormal uterine bleeding
Abnormal uterine bleeding is excessive bleeding during menstruation, frequent bleeding, and/or irregular bleeding. Abnormal bleeding can be caused by fibroids (noncancerous uterine growths), endometriosis (when endometrium spreads outside of the uterus), uterine infections, hypothyroidism, clotting problems, intrauterine devices (IUD), or cancer.
Dysmenorrhea
Dysmenorrhea is painful and difficult menstruation. Studies have found that 60–92% of adolescents suffer from dysmenorrhea. It usually begins six to 12 months following menarche.
Symptoms may be severe enough to miss work or school, and prevent participation in normal activities. Risk factors for developing dysmenorrhea may include long menstrual periods, obesity, early age at menarche, smoking, and alcohol use.
Primary dysmenorrhea is believed to be caused by high levels of prostaglandins (fatty acids that stimulate muscle contractions, among other activities) which cause painful uterine muscle spasms.
Symptoms of primary dysmenorrhea occur when bleeding starts and may include moderate to severe menstrual pain (crampy, spasmodic, and labor-like or a dull ache), nausea, vomiting, headache, fatigue, low back pain, thigh pain, and diarrhea.
Secondary dysmenorrhea is caused by conditions such as endometriosis, abnormalities of the pelvic organs, pelvic inflammatory disease, fibroids, ovarian cysts, tumors, inflammatory bowel disease, and salpingitis (inflammation of the fallopian tube).
Symptoms of secondary dysmenorrhea usually occur a few days before bleeding starts. The symptoms depend upon the specific cause of dysmenorrhea, but pain is the hallmark symptom.
Heavy periods
Women suffering from menorrhagia may lose up to 92% of their total fluid and tissue in the first three days of their cycle. Heavy menstruation is common in young girls who have just started their periods.
Menorrhagia is often caused by a failure to ovulate, which leads to a deficiency of progesterone. Without progesterone, the uterine lining becomes unstable and periods tend to be longer and unpredictable. Toxins in the bloodstream tend to settle in the endrometrial tissue. When this tissue is shed each month, so are the toxins. Heavy periods may be a toxin-excretion technique.
A deficiency in vitamin A or iron, or hypothyroidism may also cause heavy periods. Painful heavy periods may be linked to endometriosis, fibroids, pelvic inflammatory disease, or the use of an intrauterine device (IUD). A single heavy period that takes place later in the cycle may be a miscarriage.
Tampon use
Many women use tampons to absorb their monthly flow. It has been estimated that the average tampon user will use 11,400 in her lifetime. There has been much controversy over the safety of tampons.
The use of high-absorbency tampons has been shown to cause toxic shock syndrome (TSS), a bacterial infection caused when tampons left in too long create tiny breaks in the vaginal lining and allow bacteria to enter the blood stream. Symptoms of TSS are high fever, rash, muscle and joint aches, and diarrhea. TSS is now uncommon, but women have died from it in the past.
To reduce the risk of TSS, the United States Food and Drug Administration (FDA) recommends that women use the lowest absorbency tampon required to meet their needs.
It is also suggested that tampons be left in for no longer than four to eight hours. Alternatives to tampons are sanitary pads, reusable menstrual collection cups, and washable cloth pads.
A more recent controversy was sparked in the early 1990s over the use of dioxin in tampons. Dioxin is a chemical byproduct of bleach that is a carcinogen. Tampons in the United States are bleached with chlorine during production so they will have a fresher appearance. Research conducted using monkeys has shown that dioxin exposure may be linked to endometriosis.
In 1992, an investigation revealed that FDA scientists had found trace amounts of dioxin in some tampons. Further FDA research has determined that the tampons currently manufactured are done so through the use of a dioxin-free process.
However, trace amounts of dioxin may be absorbed from the air, water, or ground. These levels are generally nondetectable, and according to the FDA, do not pose a health risk.
Premenstrual syndrome
Emotional and mental symptoms include fatigue, mood swings, irritability, nervousness, confusion, depression, tearfulness, and anxiety. Physical symptoms are bloating, discomfort, breast tenderness, cravings, weight gain, acne, change in bowel movements, joint pains, and dizziness.
Other menstrual problems
- A missed period can be caused by pregnancy, stress, increased exercise, emotions, grief, and illness, among others.
- Metrorrhagia is bleeding in between normal episodes of menstruation. It may be caused by ovulation, hormonal factors, cervical lesions, or uterine cancer.
- Polymenorrhoea is bleeding associated with menstrual cycles that are shorter than 21 days. It may be caused by hormonal or ovulatory problems.
- Oligomenorrhea is infrequent menstruation with 35 days to six months between menstrual cycles. Researchers have discovered that women with a menstrual cycle of 40 days or longer are twice as likely as women with average-length cycles to develop type II (adult onset) diabetes mellitus. It is thought that long or highly irregular menstrual cycles may be associated with insulin resistance.
Diagnosis
Menstrual problems can be diagnosed and treated by gynecologists. Most menstrual problems would be diagnosed by performing a detailed medical history (with an emphasis on menstrual history) and a physical exam, which would include a pelvic exam.
Pelvic exams have two components: the manual exam and the speculum exam. During the manual exam, the doctor inserts one or two fingers into the vagina and presses his or her other hand on the lower abdomen to feel the uterus and ovaries.
A speculum exam involves inserting a speculum (a metal or plastic tool for opening the vagina) to allow viewing of the vagina and cervix, and to obtain smears for Pap testing (sampling of cervical cells) or culture if an infection is suspected.
Ultrasound exam, in which internal organs are visualized using sound waves, may be performed. Abnormal findings from the examination and laboratory tests may warrant laparoscopy in which a thin, wand like instrument is inserted into an incision in the belly button to visualize abdominal organs.
Urine tests may be performed to diagnose pregnancy or infection. Blood tests to determine hormone levels, as well as other blood parameters, may be performed. Patient history and physical exam findings may suggest specific illnesses that would require additional laboratory testing.
The patient may be asked to fill out a diary in which daily menstrual symptoms are recorded over a period of three to six months. In some cases, the patient may be referred to a psychiatrist for evaluation for PMDD.
Treatment
There are many alternative treatments for menstrual problems. Because menstrual difficulties may be due to a serious condition, patients should consult a doctor before self-treating.
Diet
Phytoestrogens are estrogen-like compounds produced by certain plants. Food sources of phytoestrogens include soy products, flaxseeds, chick peas, pinto beans, french beans, lima beans, and pomegranates.
Phytoestrogens can lighten menstruation and lengthen menstrual cycles. On the other hand, researchers have found that women who were fed soy-based formulas in infancy instead of cow’s milk are more likely to report heavy menstrual bleeding and painful periods in adult life.
PMS symptoms may be relieved by avoiding caffeine, sugar, salt, white flour, red meat, dairy, butter, monosodium glutamate (MSG), fried foods, and processed foods during the two weeks prior to menstruation.
Food that help to fight PMS include steamed green vegetables, salad, beans, grains, and fruit. To obtain essential fatty acids (omega-3 and omega-6) women can eat flaxseeds, sesame seeds, pumpkin seeds, salmon, mackerel, and tuna.
Herbal remedies and Chinese medicine
A variety of herbal remedies may alleviate symptoms associated with menstrual problems. These include:
- black cohosh (Cimicifuga racemosa): mood swings, tension, establishing ovulation (an important source of phytoestrogens). The German Commission E, however, states that women should not take black cohosh for menstrual problems for longer than six months because of the risk of side effects.
- black haw (Viburnum prunifolium): cramps
- chamomile (Matricaria recutita): mood swings, tension, and cramps
- cramp bark (Viburnum opulus): cramps
- dandelion (Taraxacum dang gui): fluid retention and bloating
- dong quai (Benincasa cerifera): PMS symptoms, cramps, irregular cycles, heavy bleeding, or bleeding in between cycles
- fenugreek (Trigonella foenum-graecum): irregular bowel movements
- feverfew (Chrysanthemum parthenium): headaches and PMS symptoms
- ginger (Zingiber officinale): cramps, irregular cycles, heavy bleeding, or bleeding in between cycles
- goldenseal (Hydrastis canadensis): heavy bleeding
- horsetail (Equisetum arvense ): heavy bleeding
- licorice: PMS symptoms
- milk thistle (Silybum marianum) extract: heavy bleeding
- nettle (Urtica dioica) extract: heavy bleeding
- peppermint (Mentha piperita): mood swings and tension
- raspberry tea: cramps, irregular cycles, heavy bleeding, or bleeding in between cycles
- red clover (Trifolium pratense): phytoestrogen source
- rosemary (Rosmarinus officinalis): cramps
- shepherd’s purse (Capsella bursa–pastoris): heavy bleeding
- St. John’s wort (Hypericum perforatum): depression associated with PMS
- valerian (Valeriana officinales): mood swings and tension
- vitex: PMS symptoms
- wild yam: phytoestrogen source
- yarrow (Achillea millefolium): cramps
Supplements
The following supplements may treat menstrual problems:
- Calcium deficiency may be associated with PMS
- Iron supplementation can treat anemia
- Magnesium pidolate supplementation reduced dysmenorrhea symptoms by up to 84%, especially on days two and three
- Niacin may help to relieve cramps
- Omega-3 fatty acids deficiency is associated with dysmenorrhea pain (in one small study, patients taking omega-3 fatty acids had lower pain scores)
- Thiamine (vitamin B1) cured dysmenorrhea in 87% of the patients for up to two months after treatment
- Vitamin A may be useful to treat heavy bleeding in women who have vitamin A deficiencies
- Vitamin B complex may help hormonal function, prevent anemia, reduce water retention, and relieve stress
- Vitamin E may reduce mood swings and menstrual cramps
Other treatments
Other treatments for menstrual problems include:
- Acupressure. Acupressure can relieve pain, reduce stress, and improve circulation.
- Acupuncture. Treatment is associated with improvement or cure of dysmenorrhea and PMS and decreased use of pain medications. A National Institutes of Health (NIH) panel concluded that acupuncture may be a useful treatment for menstrual cramps.
- Aromatherapy. Massage with the essential oils rose, ylang-ylang, bergamot, and/or geranium oils for mood swings; lavender, sandalwood, and clary sage oils for menstrual cramps; and chamomile, cypress, melissa, lavender, and jasmine oils for irregular menstruation or amenorrhea.
- Biofeedback. Weekly biofeedback therapy for 12 weeks led to significant reduction in PMS symptoms.
- Chiropractic. Spinal manipulation can help to ease cramps.
- Exercise. Regular, moderate aerobic exercise reduces or eliminates menstrual pain, improves PMS, reduces the amount of menstrual bleeding, reduces the risk for endometriosis, and reduces cyclic breast pain and cysts. Yoga stretching can relieve back and thigh pain.
- Homeopathy. Homeopathic remedies include: lachesis or sepia for PMS, cimicifuga, colocynthis, or magnesia phosphorica for cramps, and pulsatilla or aconitum for irregular menstruation or amenorrhea.
- Hydrotherapy. Soaking in a hot tub or using a moist heating pad relaxes uterine muscles which relieves cramping.
- Reflexology. Ear, hand, and foot reflexology led to a significant decrease in PMS symptoms that lasted for several months following treatment.
- Transcutaneous electric nerve stimulation (TENS). In four small studies using TENS for the treatment of dysmenorrhea, 42%–60% of the patients experienced at least moderate relief of symptoms. TENS worked faster than naproxen and there was less need for NSAIDs.
Allopathic treatment
The treatment for amenorrhea depends upon the cause. Primary amenorrhea may require hormonal therapy.
Patients with dysfunctional or abnormal uterine bleeding may be prescribed iron supplements to treat anemia. Naproxen sodium (Aleve) reduces excessive blood loss. Oral contraceptives are often prescribed to treat abnormal bleeding.
High doses of estrogens may cause vomiting, which means that antiemetics (drugs to prevent vomiting) may also be necessary. Excessive bleeding may require hospitalization for observation and treatment.
Primary dysmenorrhea is usually successfully treated with nonsteroidal anti-inflammatory drugs (NSAIDs); aspirin is not strong enough to be effective. NSAIDs are numerous and include ibuprofen (Advil, Motrin, Nuprin), Naproxen (Aleve), and fenamates (Meclomen).
Oral contraceptives (birth control pills) may be used if NSAIDs fail. Treatment of secondary dysmenorrhea involves treating the causative condition and may involve medications or surgery.
Because the cause(s) of PMS are unclear, treatment usually focuses on relieving symptoms. With regard to PMDD, medications that have been reported to be effective in treating it include the tricyclic antidepressants and the selective serotonin reuptake inhibitors (SSRIs).
Effective treatments other than medications include cognitive behavioral therapy (CBT), aerobic exercise, and dietary supplements containing calcium, magnesium, and vitamin B6.
Expected results
Most menstrual problems can be successfully treated using conventional or alternative treatments.
Prevention
Avoiding sodium and caffeine may reduce some menstrual symptoms. Regular moderate aerobic exercise or yoga is often beneficial for menstruation difficulties. Getting yearly pelvic exams and Pap smears will help to identify problems before they become advanced.
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