Menstruation

What happens during menstruation?

Menstruation is a woman's monthly bleeding. It is also called menses, menstrual period, or period. When a woman has her period, she is menstruating. The menstrual blood is partly blood and partly tissue from the inside of the uterus. It flows from the uterus through the small opening in the cervix, and passes out of the body through the vagina. Most menstrual periods last from 3 to 5 days.

In the first half of the menstrual cycle, levels of estrogen rise and make the lining of the uterus grow and thicken. In response to follicle-stimulating hormones, an egg in one of the ovaries starts to mature. At about day 14 of a typical 28-day cycle, in response to a surge of luteinizing hormone, the egg leaves the ovary. This is called ovulation.

In the second half of the menstrual cycle, the egg begins to travel through the fallopian tube to the uterus. Progesterone levels rise and help prepare the uterine lining for pregnancy. If the egg becomes fertilized by a sperm cell and attaches itself to the uterine wall, the woman becomes pregnant. If the egg is not fertilized, it either dissolves or is absorbed into the body. If pregnancy does not occur, estrogen and progesterone levels drop, and the thickened lining of the uterus is shed during the menstrual period.

What is PMS?

Premenstrual syndrome is the name of a group of physical and emotional symptoms that start 7 to 14 days before your menstrual period begins. The symptoms usually resolve within a few days after bleeding starts. At least 75% of all menstruating women have some symptoms of PMS. Symptoms may vary from cycle to cycle and may be mild to severe.

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What are common symptoms of PMS?

Physical symptoms may include:

  • Breast engorgement and tenderness
  • Abdominal bloating
  • Constipation or diarrhea, nausea, vomiting
  • Acne
  • Headache
  • Alcohol intolerance
  • Fluid retention and weight gain
  • Clumsiness
  • Crampy pain in the lower abdomen
  • Joint or muscle pain

Emotional symptoms may include

  • Anxiety and panic attacks
  • Insomnia
  • Change in sexual interest and desire
  • Irritability
  • Depression and crying spells
  • Lethargy and fatigue
  • Mood swings ranging from bursts of creative energy to anger/paranoia
  • Inability to concentrate and some memory loss
  • Increased appetite with specific food cravings (especially salt and sugar)
  • Withdrawal and trouble in relationships with family and friends

Symptoms vary from person to person. If you think you have PMS, try keeping track of your symptoms for several menstrual cycles. You can use a calendar to note which symptoms you are having on which days of your cycle, and how bad the symptoms are. If you seek medical care for your PMS, having this kind of record is helpful.

How can I ease my PMS Symptoms?

For many women with mild PMS symptoms, a lifestyle adjustment may be sufficient to control symptoms. Dietary recommendations include drinking plenty of fluids such as juice to reduce bloating, eating frequent small meals including whole grains (breads, pasta and cereals), fresh fruits and vegetables, and avoiding saturated fats and high salt snack foods. Complex carbohydrates as found in whole grains may increase levels of serotonin. Avoid alcohol at this time as it may increase depression. Cut back on caffeine to feel less tense, irritable and to ease breast soreness. In one study, taking 1200 mg. of calcium daily reduced PMS symptoms by nearly half three months. Calcium rich foods include dairy products, dark green vegetables, nuts, grains, beans and canned salmon and sardines (with bones). Calcium supplements may also be used.

Limited clinical evidence suggests that certain vitamins may be helpful in reducing PMS symptoms. Vitamin B6 in doses of 50mg daily may be helpful. Food sources of B6 include meats, oily fish, poultry, whole grains, dried fortified cereals, soybeans, avocados, baked potatoes with skins, watermelon, plantains, bananas, peanuts and brewer's yeast. Vitamin B1 (thiamin) may also help menstrual pain. Thiamin is found in pork, dried B-fortified cereals, oatmeal and sunflower seeds. Vitamin E is also being studied. Caution should be used because excess doses of vitamin B6 and E can be harmful.

Aerobic exercise such as walking may help. Get plenty of sleep - 8 hours a night is ideal. Keep to a regular schedule of meals, bedtime and exercise. Try to restructure your priorities so that you plan ahead for pleasurable activities during your premenstrual phase and try to avoid stressful events at that time.

Anti-inflammatory drugs such as over the counter ibuprofen and naproxen can help most premenstrual cramping and headaches. If you get severe cramps, you may need to start the anti-inflammatory 1 to 2 days before you expect cramps to begin.

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What are drug treatments for premenstrual syndrome?

If your symptoms of PMS are not reduced with lifestyle modifications, consult you health care provider. Certain antidepressants called SSRIs (selective serotonin -reuptake inhibitors) help with depression, fatigue and relationship problems during the premenstrual time period. Anti-anxiety medications are sometimes prescribed. For very severe symptoms, A gonadotropin-releasing hormone agonist (GnRH) is sometimes prescribed. These medications suppress ovulation and hormonal fluctuations that produce PMS. For some individuals, oral contraceptives may help prevent PMS symptoms. Occasionally diuretics, which increase urination, are prescribed to reduce bloating, food craving and breast tenderness. All the above medications can have serious side effects and should be prescribed only under a health provider' care and management.

What causes cramps?

Pain from menstrual cramps is a result of contractions of your uterus, which are caused by prostaglandins. Prostaglandins circulate in your bloodstream and they can cause diarrhea because they also speed up contractions in your intestines. If your cramps are especially painful and persistent, you should consult your health care provider. Also, try some of the remedies mentioned above.

What is Premenstrual Dysphoric Disorder (PMDD)?

Three to eight percent of women suffer from a very severe form of premenstrual syndrome known as Premenstrual dysphoric disorder that seriously impacts their daily life. PMDD is a severe, disabling form of PMS. In PMDD, the main symptoms are mood disorders such as depression, anxiety, tension, and persistent anger or irritability. These severe symptoms lead to problems with relationships and carrying out normal activities. Women with PMDD usually also have physical symptoms, such as headache, joint and muscle pain, lack of energy, bloating and breast tenderness. You must have at least five of the typical symptoms to be diagnosed with PMDD. The symptoms must occur during the two weeks before your period and go away when bleeding begins. Research has shown that SSRIs can help many women with PMDD. Commonly prescribed medications to treat PMDD include, Zoloft and Sarafem.

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What does it mean if I stopped getting my period?

Some women who experience a loss of menstruation for a period of three months or more, may have amenorrhea. Amenorrhea has been classified as being either primary or secondary. Primary amenorhhea is typically diagnosed if you are over the age of 18 and have yet to start menstruating. Secondary amenorrhea takes place if you've previously had your period and then lost it. Click here to find out more about amenorrhea.

What does it mean if I experience really painful periods?

If you experience severe menstrual cramps and pain along with your periods, you could have dysmenorrhea. Dysmenorrhea can also be classified as either primary or secondary. Primary dysmenorrhea takes place when you experience severe menstrual cramps caused by abnormal or rigorous uterine contractions as a result of a chemical imbalance in the body (particularly prostaglandin and arachidonic acid - both chemicals which control the contractions of the uterus).

Secondary dysmenorrhea is caused by other medical conditions, most often endometriosis (a condition in which tissue that looks and acts like endometrial tissue becomes implanted outside the uterus, usually on other reproductive organs inside the pelvis or in the abdominal cavity . This can often result in internal bleeding, and pelvic pain. Other possible causes of secondary dysmenorrhea include pelvic inflammatory disease (PID), uterine fibroids, infection, tumors, or polyps in the pelvic cavity, or abnormal pregnancies such as miscarriages, ectopic pregnancies.

What are common symptoms of dysmenorrhea?

Symptoms can vary from woman to woman but common symptoms of dysmenorrhea may include:

  • cramping in the lower abdomen
  • pain in the lower abdomen
  • low back pain
  • pain radiating down the legs
  • nausea
  • vomiting
  • diarrhea
  • fatigue
  • weakness
  • fainting
  • headaches

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How is dysmenorrhea diagnosed?

Diagnosis begins with a trained physician, typically your gynecologist who will evaluate your medical history and perform a complete physical examination including a pelvic examination. A diagnosis of dysmenorrhea can only be certain when your gynecologist rules out other menstrual disorders, medical conditions, or medications that may be causing or aggravating the condition. In addition to this there are diagnostic procedures to detect if you have dysmenorrhea. An ultrasound can be used through a technique called sonography which includes using high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function, and to assess blood flow through various vessels. A magnetic resonance imaging (MRI) could also be used to detecet dysmenorrhea. An MRI is a diagnostic procedure that uses a combination of large magnets, radio-frequencies, and a computer to produce detailed images of organs and structures within the body. In some cases your gynecologist could opt to do a laparoscopy which is a minor surgical procedure in which a laparoscope, a thin tube with a lens and a light, is inserted into an incision in the abdominal wall. Using the laparoscope to see into the pelvic and abdomen area, your gynecologist can often detect abnormal growths. Also, a hysteroscopy could be performed. A hysteroscopy is a visual examination of the canal of the cervix and the interior of the uterus using a viewing instrument (hysteroscope) which is inserted through the vagina.

How is dysmenorrhea treated?

Treatment for dysmenorrhea will vary from person to person. Factors such as the extent of your condition, your age, and your preference will need to be taken into consideration. Dysmenorrhea can be treated with pharmacology products. Nonsteroidal anti-inflammatory drugs (NSAIDS) can be used to suppress prostaglandin synthesis, thereby reducing pain symptoms. If periods are regular, NSAID treatment will be more effective if started one day before menstruation begins. Drugs that are commonly used include ibuprofen and naproxen. Oral contraceptives can also be used to reduce dysmenorrhea. Low dose combination birth control pills reduce dysmenorrhea by inhibiting ovulation.

There are also other ways to treat dysmenorrhea without the use of medicine. For example, exercise can be used to relieve pain associated with dysmenorrhea. Acupuncture and acupressure have also been shown to reduce pain. In you have moderate to severe dysmenorrhea, your medical provider could recommend that you try a low-fat diet. This could lead to significant reductions in menstrual pain duration, pain intensity, and duration of premenstrual symptoms related to concentration, behavioral change, and water retention.

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What if I experience heavy periods or long periods?

Heavy periods or long periods are referred to as menorrhagia. During menorrhagia there is excessively heavy or prolonged uterine bleeding, which may be caused by medical problems or hormone imbalances.

In a normal menstrual cycle, there is a balance between estrogen and progesterone, two hormones in the body. These hormones regulate the buildup of the endometrium (uterine lining of blood and tissue), which is shed each month during menstruation. Menorrhagia can occur because of an imbalance between estrogen and progesterone. As a result of the imbalance, the endometrium keeps building up. When it is eventually shed, there is heavy bleeding.

Menorrhagia is commonly treated using oral contraceptives which can lead to lighter flows that occur more regularly. If you smoke, then your provider may recommend that you try injectable forms of progestin to regulate and lighten your cycle. An example of this could include Depo-Provera.

Can I make an appointment at Health Services?

If you are a Brown student and you are have concerns about menstruation, you can make a confidential appointment at Health Services by calling 401.863-3953.  Health Services provides a range of services including general health care, STI testing, and emergency medical care. You can request a medical provider by gender or by name. We are located at 13 Brown Street on the corner of Brown and Charlesfield Streets.

Links You Can Use

CDC Women's Health
Information about menstrual disorders.

The Diva Cup
Information about alternatives to sanitary napkins and tampons.

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Disclaimer: BWell Health Promiotion is part of Health Services at Brown University. Health Promotion maintains this site as a resource for Brown students. This site is not intended to replace consultation with your medical providers. No site can replace real conversation. Health Promotion offers no endorsement of and assumes no liability for the currency, accuracy, or availability of the information on the sites we link to or the care provided by the resources listed. Health Services staff are available to treat and give medical advice to Brown University students only. If you are not a Brown student, but are in need of medical assistance please call your own health care provider or in case of an emergency, dial 911. Please contact us if you have comments, questions or suggestions.