By Dr. Aishah Fadhila Adamu
Many people may already know that women bleed 3-7 days roughly every month but fewer people, including women, know that the amount of blood women lose during those 3-7 days is averagely 30mls (about 2 tablespoons). Have you ever bothered about what could be going on behind the scenes…why women menstruate not just once in a lifetime but every month…how it happens?
To better understand the menstrual cycle, we need to see how the world behind the scenes looks like. Here is a picture of the female reproductive organ.
- The vagina: Canal between the uterus and the outside.
- The uterus: Pear-shaped organ where the baby grows during pregnancy. It is separated from the vagina by a narrow canal called the cervix.
- Ovaries: They are small oval-shaped glands located on the sides of the uterus. Eggs form inside the ovaries. These eggs are fertilized by sperm to form a baby.
- Fallopian tubes: Narrow canals connected to the upper part of the uterus. Through them, the eggs travel from the ovaries to the uterus. Inside the fallopian tubes, the egg meets the sperm (fertilization). Then, the fertilized egg travels through the tubes to the uterus where it sticks to the uterine wall and starts growing into a baby.
A menstrual cycle consists of natural changes that occur in the structures above every month in preparation for pregnancy. The cycle is the result of a hormonal
interplay between the brain, the ovaries, and the uterus. The are four major (but not the only) hormones regulating the cycle; Oestrogen, Progesterone, Follicle Stimulating Hormone, and Luteinizing hormone. What do these four hormones do?
Oestrogen is produced by the ovaries in females but smaller amounts are also produced in the adrenal glands and fat tissue. It is responsible for the physical changes that occur during puberty, breast development, increase bone formation, and causes the uterus to thicken with blood (the blood that is shed during menstruation) in preparation for a pregnancy.
Progesterone is produced mainly by the ovaries and adrenal glands. During pregnancy, it is produced by the placenta to support the pregnancy and prevent miscarriage.
Follicle Stimulating Hormone (FSH) is released from the pituitary gland in the brain. Its main role is to stimulate the ovarian follicles (the follicles containing the eggs) to mature and get ready to release the egg from the ovaries.
Luteinizing hormone (LH) is released from the pituitary gland in the brain and causes the mature follicles to rupture and release an egg. This rupture and release, is called OVULATION!
FSH and LH are called gonadotropins
THE MENSTURAL CYCLE.
Newborn girls have about 1-2 million eggs, but by puberty the eggs die off leaving about 300,000 – 400,000 eggs. Of this, only about 500 eggs will be released during the lifetime of a women (one every month). The remaining eggs continue to die off until there are no more eggs (a period known as MENOPAUSE!). Each of these egg cells exists within a fluid filled sac called an ovarian follicle.
The menstrual cycle begins during puberty, when the hypothalamus (in the brain) releases gonadotropin-releasing hormone. This hormone causes gonadotrophins (LH, FSH) to be released by the pituitary (in the brain) which in turn act on the ovaries leading to the first egg being released. If there is no pregnancy, the girl experiences her first menses called MENARCHE! The first cycle is set in motion!
One full cycle includes the time from the first day of one period (day 1 of bleeding) to the first day of bleeding of the next. Typically, a cycle ranges somewhere between 21 and 35 days with an average length of 28 days.
There are two ways to get to understand the menstrual cycle. First, through what’s happening with the ovaries (the ovarian cycle). Second, through what’s happening in the uterus (uterine cycle). These cycles are not separate but they overlap and influence one another.
The ovarian cycle has three phases: follicular, ovulatory and luteal. The uterine cycle
also has three phases: menstrual, proliferative, and secretory.
Let’s use a 28-day cycle to understand how menstruation occurs in a young girl who is yet to experience her MENARCHE.
OVARIAN CYCLE
Follicular phase: FSH released by the brain stimulate the ovary and cause about 10-20 follicles to start maturing. The maturing follicles produce oestrogen. Oestrogen causes the inner lining of the uterus to thicken with blood in preparation to receive a fertilized egg. One of the follicles matures faster than the others and is called the “dominant follicle” while the others slowly die off. This occurs from day 1 to 13. Oestrogen levels reach it highest around day 12/13 prompting the brain that the dominant follicle is ready to be released. Mucus produced by the cervix and vaginal discharge are minimal at the beginning of this phase.
Ovulatory phase: The brain then releases a lot of Luteinizing hormone (LH). This surge in LH causes the mature dominant follicle to rupture and release the egg inside it. This rupture and releases in known as ovulation and usually happens around day 14 (remember we are using a 28-day cycle). It is important to note that, the follicular phase is variable in length but ovulation usually happens 14 days before the beginning of the next period and is fixed. Don’t get confused. It means that, if you have, say, a 28-day cycle, there are some months that your cycle may be 26, 27, 28, 29 or even 30 but the average of all of your days is 28. The difference is the variable nature of the follicular phase. Thus, in the month you had a 26-day cycle, your follicular phase lasted 12 days, for the 27-day cycle, the follicular phase lasted 13 days and so on and ovulation occurred when it was left with exactly 14 days for the cycle to be completed.
An ovulating person’s “fertile window” is considered to be the day of ovulation, the 5 days preceding it, and a few (1-2) days after. This is because sperm can live for 5 days once they’re in the reproductive tract. The remaining days of the cycle are safe days where you will not get pregnant from unprotected sex. Cervical mucus is clear and thin, during this time in the cycle in order to help sperm move freely to fertilize an egg. Some people experience ovulatory pain as pain in one or the other side of the lower abdomen where the ovaries are. However, it lasts a few hours and is nothing dangerous.
The egg begins it journey towards the uterus through the fallopian tube where fertilization occurs. The egg has a lifespan of roughly 24 hours (1 day) then it dies off.
Luteal phase: During this phase, the remnants of the follicle from which the mature egg burst out (now called the yellow body of the ovary or corpus luteum) releases a large quantity of progesterone and some oestrogen. The two hormones help thicken the lining of the endometrium and maintain its thickness. The progesterone stops the production of FSH temporarily and signals breast tissue to prepare to produce milk. This is why some people feel their breasts become bigger/rounder and painful during this part of the cycle and before menstruation occurs.
If the egg that was released comes into contact with sperm and gets fertilized, it will get to the uterus, embed itself into the blood-filled uterine lining and begin to grow into a baby. The yellow body will continue to secrete progesterone to prevent miscarriage until the placenta is formed and takes over the production of progesterone.
However, if fertilization does not occur, the yellow body degrades and progesterone levels decrease, leaving the uterine lining unstable. The lining then breaks down and the blood flows out through the vaginal canal as MENSTRUATION! Averagely, the blood flows for 3-7 days and is about 30mls (2 tablespoons).
The picture above shows the follicular phase, ovulation (rupturing follicle) and the luteal phase in the ovary.
UTERINE CYCLE
Let’s look at the Uterine Cycle and how it overlaps with the ovarian cycle.
Proliferative phase (follicular phase of the ovarian cycle): This phase coincides with the follicular phase of the ovarian cycle. This is where oestrogen produced by the follicles caused the cells of the endometrium to start multiplying (proliferating) and the blood lining to start forming.
Secretory phase (luteal phase of the ovarian cycle): This phase coincides with the luteal phase of the ovarian cycle. Here, the uterine lining continues to thicken to prepare for a pregnancy and secretes proteins to support and nourish the incoming fertilized egg.
Menstrual phase: The beginning of this phase coincides with the beginning of the follicular phase of the ovarian cycle. This is because, as the previous egg dies off and the uterine lining is shedding off as menstruation, new follicles start growing, beginning the next cycle.
Therefore, when the cycle is set in motion at puberty, it continues until all the follicles in the ovary get depleted and the cycle stops (MENOPUASE) and one of the major signs that the cycle has stopped is the cessation of the monthly blood flow. Also, because a cycle is 21-35 days long, menstruation tends to occur once every month in most people.
The cycle is depicted in the picture above.
COMMON ISSUES ACCOMPANYING THE MENSTRUAL CYCLE
- Premenstrual syndrome (PMS)
Some psychological and physical changes may occur towards the end of the luteal phase. These changes occur due to the sudden drop in progesterone and oestrogen levels as the yellow body dies off. However, they disappear a few days after menstruation once hormones are back to their elevated levels
These include:
Physical changes:
o Breast tenderness and swelling
o Diarrhoea or constipation
o Bloating and gas
o Cramps
o Headaches or backaches
o Fluid retention
o Fatigue and vertigo
o Inability to tolerate noise or bright lights
o Acne
Psychological changes:
o Aggressive behaviour and irritability
o Trouble sleeping (too much or too little)
o Changes in appetite
o Difficulty concentrating and remembering
o Stress and anxiety
o Mood swings
o Depression or sadness
o Reduced libido
- Dysmenorrhea (painful periods)
It is the most common menstruation problem. The pain varies from one woman to the other. There are two types of dysmenorrhea:
– Primary dysmenorrhea: It is a very common condition that occurs because of the contraction in uterine muscles. It typically occurs during adolescence and fades away with age. You are more likely to suffer from primary dysmenorrhea if you:
o Started menstruating before the age of 11
o Have heavy and long periods
o Smoke
– Secondary dysmenorrhea: It is the pain resulting from physical problems. The pain becomes worse with age and lasts longer than the pain of primary dysmenorrhea. The most common health issues that may cause it are:
o Endometriosis: This is when tissues of the uterine lining grow outside the uterus where it doesn’t belong. These tissues also undergo the uterine cycle and cause considerable pain to victims every cycle.
o Uterine fibroids: Non-cancerous overgrowth of cells of the uterus. They are a common cause of painful menses, heavy menstrual flow and infertility.
o Ovarian cysts: Do you remember that when 10-20 follicles start growing during the follicular phase, only one matures while the others degenerate? Sometimes, some do not degenerate immediately and remain in the ovary as fluid filled sacs and degenerate over several weeks. Although they are harmless and resolve over time they cause pain sometimes.
- Irregular periods
During the first 2-3 years after menarche, periods are usually irregular as the body tries to adjust to the hormonal changes it is experiencing. Similarly, towards menopause, periods are irregular as the follicles are depleted until it finally stops when there are no more follicles. Irregularity can affect the amount of blood flow, the number of flow days or the cycle length.
Outside these times, irregularities usually occur due to the following reasons:
o Eating disorders
o Thyroid disorders
o Polycystic ovary syndrome
o Premature ovarian failure: Follicles getting finished faster than the usual age.
o Pelvic inflammatory disease: Infection of the reproductive system usually from untreated sexually transmitted infections.
o Stress
o Irregular blood sugar levels (diabetes)
o Obesity
- Bleeding outside the menstrual period
This may occur due to the following causes:
o Hormonal changes during puberty or before menopause
o Endometriosis
o Ovarian cysts
o Malignant tumors (cancerous), such as: Uterine, ovarian or cervical cancer.
KNOW YOURSELF!
One of the best ways to understand your cycle is to track it over time. There are many ways to do this. You can mark your period on a calendar, a menstrual chart or use a menstrual and fertility tracker app.
Once you start to get to know your cycle, there are some messages to pay attention to. If you notice any of the signs/symptoms below, it is time to see a doctor.
- Bleeding that lasts longer than 7 days
- A cycle longer than 35 days or shorter than 21 days
- Bleeding that is heavier or lighter than usual (some variation may be normal)
- Missing more than 3 periods in a row
- Severe cramps with your period that cause you to miss out on things you’d normally do
- Bleeding in between periods or after sex
Take Home Points:
The menstrual cycle tells us a lot about how health and fertile we are.
One of the best ways to understand your cycle is to track it over time, using a calendar,
menstrual chart, or app.
Menstrual blood, like any blood product is infectious and can be a vehicle for transmitting diseases; hence, sexual intercourse during menses is discouraged.
During menses, the reproductive system is susceptible to diseases as the uterine lining comes off and uterine blood vessels gets exposed. Menstrual hygiene is, therefore, a paramount part of menses.
References:
Menstruation. (n.d.). Retrieved from
https://www.plannedparenthood.org/learn/health-and-wellness/menstruation
Stages in the Menstrual Cycle. (2014, April 1). Retrieved from
https://www.ourbodiesourselves.org/health-info/stages-in-the-menstrual-cycle/
Your Menstrual Cycle. (n.d.). Retrieved from
https://www.womenshealth.gov/menstrual-cycle/your-menstrual-cycle
Dr. Aishah Fadhila Adamu can be reached via ; 2017aadamu@uhas.edu.gh
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