Menstruation

Menstrual cycle

Menstruation is the shedding of the uterine lining (endometrium). It occurs on a regular basis in reproductive-age females of certain mammal species. Overt menstruation (where there is bleeding from the uterus through the vagina) is found primarily in humans and close evolutionary relatives such as chimpanzees.^[1] The females of other placental mammal species have estrous cycles, in which the endometrium is reabsorbed by the animal (covert menstruation) at the end of its reproductive cycle. Many zoologists regard this as different from a "true" menstrual cycle.

Overview

Eumenorrhea expresses normal, regular menstruation that lasts for a few days (usually 3 to 5 days, but anywhere from 2 to 7 days is considered normal).^[2] The average blood loss during menstruation is 35 millilitres with 10-80 mL considered normal;^[3] many women also notice shedding of the endometrium lining that appears as tissue mixed with the blood. (Sometimes this is erroneously 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. Because of this blood loss, premenopausal women have higher dietary requirements for iron to prevent iron deficiency. Many women experience uterine cramps, also referred to as dysmenorrhea, during this time, caused largely by the contractions of the uterine muscle as it expels the endometrial blood from the woman's body. A vast industry has grown to provide drugs to aid in these cramps, as well as sanitary products to help manage menses.

As part of the menstrual cycle

Menstruation is the most visible phase of the menstrual cycle. Menstrual cycles are counted from the first day of menstrual bleeding, because the onset of menstruation corresponds closely with the hormonal cycle.

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.

Evolution

All female placental mammals have a uterine lining that builds up when the animal is fertile, but is dismantled (menstruated) when the animal is infertile. 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).^[1][4] However, even in humans, much of it is re-absorbed.

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.

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.^[5][6] However, there is currently significant dispute as to whether menstrual synchrony exists.^[7]

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 completely reabsorb. Strassman correlates species that have overt menstruation to those that have a large uterus relative to the adult female body size.^[1]

Culture and menstruation

Common usage refers to menstruation and menses as a period, a contraction of "menstrual period". A woman might say that her "period is late," or simply "I'm late," when an expected menstrual period has not started. Delay or cessation of menstruation is commonly expected to be the first indication to a woman that she may be pregnant. However, this cannot be taken as certainty. Irregular cycles are common in the first few years of menstruation. Regularity of the menstrual cycle may also be affected by physical or emotional stress. Moreover, continued menstruation in early pregnancy is not uncommon.^[8]

Many religions have menstruation-related traditions. These may be bans on certain actions during menstruation (such as intercourse in orthodox 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, "menstrual huts", that are reserved for that exclusive purpose until the end of their menstrual period.

Since the late 1960s, some women have chosen to control the frequency of menstruation with long-acting hormonal birth control. This allows women to plan months in advance when she will menstruate as combined hormone pills are taken in 28 day cycles, 21 hormonal pills with either a 7 day break from pills, or 7 placebo pills during which the woman menstruates. 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.

Characteristics

Span

Menstruation will start at the onset of puberty and end at the beginning of menopause.

Physical experience

In many women, various intense sensations brought about by the involved hormones and by cramping of the uterus can precede or accompany menstruation. Stronger sensations may include significant menstrual pain (dysmenorrhea), abdominal pain, migraine headaches, depression, emotional sensitivity, feeling bloated, changes in sex drive and nausea. Dysmenorrhea, or severe uterine pain, is particularly common for adolescents and young women (one study found that 67.2% of girls aged 13–19 suffer from it)^[9]. Breast swelling and discomfort may be caused by premenstrual water retention. Binge eating occurs in a minority of menstruating women.^[10] This may be due to fluctuation in beta-endorphin levels. More severe symptoms may be classified as premenstrual dysphoric disorder (PMDD). The sensations experienced vary from woman to woman and from cycle to cycle.

Emotional reactions

Some women experience emotional disturbances associated with menstruation. These range from the irritability popularly associated with premenstrual syndrome (PMS), to tiredness, or "weepiness" (i.e. tears of emotional closeness). A similar range of emotional effects and mood swings is associated with pregnancy.^[11] The prevalence of PMS is estimated to be between 3%^[12] and 30%^[13]. Rarely, in individuals susceptible to psychotic episodes, menstruation may be a trigger (menstrual psychosis).

Flow

The normal menstrual flow follows a "crescendo-decrescendo" pattern; that is, it starts at a moderate level, increases somewhat, and then slowly tapers. Sudden heavy flows or amounts in excess of 80 mL (hypermenorrhea or menorrhagia) may stem from hormonal disturbance, uterine abnormalities, including uterine leiomyoma or cancer, and other causes. Doctors call the opposite phenomenon, of bleeding very little, hypomenorrhea.

Duration

The typical woman bleeds for two to seven days at the beginning of each menstrual cycle.^[2][14] Prolonged bleeding (metrorrhagia, also meno-metrorrhagia) no longer shows a clear interval pattern. Dysfunctional uterine bleeding is hormonally caused bleeding abnormalities. Dysfunctional uterine bleeding typically occurs in premenopausal women who do not ovulate normally (i.e. are anovulatory). All these bleeding abnormalities need medical attention; they may indicate hormone imbalances, uterine fibroids, or other problems. As pregnant patients may bleed, a pregnancy test forms part of the evaluation of abnormal bleeding.

Menstrual products

Most women use something to absorb or catch their menses. There are a number of different methods available.

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.

Reusable items:

• Reusable cloth pads 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.
• 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.

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;^[15] however there is no documented scientific evidence to prove this.

Further reading

• Howie, Gillian; Shail, Andrew (2005). Menstruation: A Cultural History. Palgrave Macmillan. ISBN 1-4039-3935-7. http://us.macmillan.com/menstruation. 
• Knight, Chris (1995). Blood Relations: Menstruation and the Origins of Culture. New Haven and London: Yale University. ISBN 0-300-04911-0. http://www.chrisknight.co.uk/publications/. 
• Museum of Menstruation

Footnotes