Menstration and Menstrual Problems

Teenage Section

Menstruation is the periodic red discharge (usually at monthly intervals) from the uterus of a mixture of blood, tissue fluids, and tiny pieces of the lining of the uterus (the endometrium). The amount of blood and tissue fluids in the menstrual discharge varies, but the exact quantities of each cannot be determined by looking at the discharge. Usually a woman menstruates (i.e. has a period) every 26 to 30 days, but it is normal for menstruation to occur at intervals from 22 to 35 days.

Sometimes a woman consults a doctor because she is worried about her periods. The doctor asks questions to try to find out what is worrying her. One of the questions the doctor asks is: ‘How often does your period occur?

This might confuse the woman if she wonders whether the question means how many days are there between periods, or how many days are there from the beginning of one period to the beginning of the next. In fact, the doctor, is asking ‘How many days is it from day 1 of your previous period to day 1 of your next period?’ so that she or he can calculate the length of the menstrual cycle.

Additionally the doctor might also ask how many days the period lasts and to enquire about the amount of the menstrual discharge. A heavy menstrual discharge, which appears as heavy bleeding, is a common concern in the teenage years. In the first two or three years after periods start, they often occur at longer intervals than later and might occur at irregular intervals. (The reason for this is that the teenage woman is not yet ovulating regularly, and so consequently the hormonal control of the endometrium is not precise). By the age of 16, most teenagers have regular periods, and they remain regular (unless a pregnancy occurs) until the woman is older than 40 and is approaching the age when women cease to menstruate, in other words, have reached the menopause.

As mentioned above, it is sometimes difficult for a woman to estimate how much blood is lost in the menstrual discharge, as the quantity of blood in the discharge varies, the balance consisting of tissue fluid. In other words, the menstrual discharge might be profuse, but the blood loss is still in the normal range.

Most women lose an average of 30 ml of blood during a period, but it is normal to lose as little as 3 ml or as much as 80 ml. A blood loss of more than 80 ml is excessive and, if the total menstrual discharge is also excessive, might be associated with episodes of ‘flooding’, when the menstrual discharge seems to pour out of a woman’s vagina. If the blood lost in the discharge is considerable and continues for some months, the woman might become anaemic. For this reason, if your periods are very heavy, it is advisable to visit a doctor.

To try to find out how much blood you are losing, the doctor might ask how often you need to change your pad or tampon on days of heavy bleeding. Not more than every two to three hours is normal.

The first menstrual period
In the past 200 years the age at which a woman has her first period (menarche) has been decreasing. Two hundred years ago, an average woman first menstruated when she was sixteen and a half years.

A hundred years ago, the average age of first menstruation was fifteen and a half years. Today an average woman first menstruates when she is between twelve and thirteen years old. ‘Average’ means that some women menstruate earlier and some later. It is normal for a girl to first menstruate as early as 9 years old or as late as 16. The downward trend in the age of menarche seems to have leveled in the past thirty years.

Why do women start menstruating earlier today than they did a hundred years ago? Why do ballet dancers first menstruate later than other girls? Why do some athletes stop menstruating when they are in heavy training?

These questions are not easily answerable. Usualy a girl does not begin to menstruate until she reaches a certain weight, or until the amount of fat in her body is proportionate to her weight. When she reaches this critical level she starts to menstruate, provided that she has secreted enough oestrogen for a number of months for her uterus to be of the required size.

Two hundred years ago, because of frequent illness during childhood and poorer nutrition, girls did not have the critical amount of fat in their bodies to permit menstruation until they were aged 16 or 17. Today, childhood illnesses have been largely eliminated and girls are better nourished, so menarche occurs earlier.

That doesn’t explain why ballet dancers start menstruating later, or why female athletes might stop menstruating. Intensive, frequent exercising seems to be the reason. The exercising leads to a decrease in the woman’s body fat, and her periods either do not start or cease.

Gymnasts sometimes try to slow puberty not only by exercising but also by restricting their food intake to maintain low body fat, because inadequate nutrition delays skeletal maturation and height.

Feelings about the first period
Many girls do not know enough about what they should expect when they have their first menstrual cycle. This is because many mothers do not tell their daughters much, and in many schools sex education (or personal development) lessons do not start until high school. Due to this lack of knowledge, many young women feel embarrassed, scared, upset, or angry. Others might have more positive feelings being excited, happy, or proud when they first menstruated. Before their first period, girls who were able to talk with their mothers, or whose mothers were able to talk to them, felt that they would feel ‘grown – up’ and be able to have children. However, after menarche many of these girls felt differently and were embarrassed and secretive when they menstruated.

We asked more than a thousand teenage women what their expectations of menstruation had been before they started menstruating. Half of the young women said that menstruation had been worse than they had expected it would be. Half regarded menstruation as something that happened and that should not be discussed openly, and they did not think they had information to prepare them for menstruation. In fact, nearly all of the teenage women surveyed would have liked to know more about menstruation before they reached puberty. Some of the their comments included:

• Some mothers are too shy to talk.
• Some mothers hope someone else will do it.
• Most information is learnt in the school locker room.
• Some mothers only tell their daughters the basics:
  ‘You’re a woman now’, meaning just that the young woman can become pregnant.
• Some daughters are embarrassed by the topic.
  Some of the teenage women were quite critical:
• ‘My mum gave me all the wrong information. She said “ A bag fills up with blood and bursts when it gets full’ – I think she believes this’.
• ‘My mother told me nothing. She only told me not to use tampons’.
• ‘Mum gave me a book about how rabbits and banana files reproduce. It included a brief paragraph about menstruation.
• ‘She told me enough not to be terrified at what was happening, but not as much as I know now – and that’s not much’.
• ‘She explained it was bleeding at a certain time of the month. It came from an ovarian egg not being fertilized. It might be uncomfortable’.
• On the other hand, some teenage women appreciated what they were told.
• ‘They came on my thirteenth birthday. (How lucky!) My mother said it was a gift from God. She was pleased.
• ‘My mother and I can talk about everything. So I asked her questions and she answered them all. I felt good about it when it came.
• ‘She told me about it and that it was natural and there was nothing to hide.’

Teenage women’s experience of menstruation

The ritual of the first period
In our society, menarche is perceived as a private affair, perhaps to be shared with the teenage woman’s mother, but no one else. In some other cultures a woman’s first period is a time for ritual and celebration.

In many societies the young woman is segregated with an older woman to attend to her. The young woman has to observe various taboos, which might extend to her eating and drinking habits. She might be given special tasks or have pain inflicted on her. She might undergo special rituals, which are meant to guarantee her a good sexual response and that she will conceive easily and have a quick and easy childbirth.

In some cultures the period of segregation is also a period of learning, the young woman receiving instruction in sexual and domestic matters from her more experienced attendant. In south India in certain cases, a ritual takes place to celebrate the young woman’s first period. She sits on a mat of banana leaves, eats raw egg prepared with sugar, and is washed with buffalo milk. When the ceremony is over, the family has a feast, celebrating that the girl is now a mature woman.

Perhaps we should also have a celebration to mark a girl’s first menstrual period, so that menstruation is regarded as a normal event, not a time for secrecy and embarrassment.

Menstrual Myths
During a normal menstrual period the blood does not clot, and this is a cause of fear in some cultures; menstrual blood is different from other blood, as the latter always clots. People know that unless bleeding after an injury or a wound was stopped, the person died. They also knew that bleeding only followed an accident, an injury, or a wound. But women’s menstrual blood came from a hidden place, it didn’t clot, it ceased as suddenly as it started, and it recurred at reasonably predictable intervals. No wonder that the people believed that menstrual blood was magical and menstruating women were special.

The magical view of menstrual blood has a long history. Eighteen hundred years ago, Pliny, a woman, wrote a book, Natural History, in which she said that if a menstruating woman passed a vineyard, the vines would wither, the grass would die, the birds would fall, and the wine would become sour. Another writer said that if a dog tasted menstrual blood it would go mad. Another wrote that if a man had sexual intercourse with a menstruating woman, he would die, so poisonous was her menstrual flow. On the other hand, in other societies menstrual blood was thought to have beneficial properties. A woman could bewitch a man if she smeared some menstrual blood on him when he was not looking. In sixteenth century Europe it was believed that clothes stained with menstrual blood, washed in fresh milk, and hung on a hedge helped an infertile woman to conceive a child.

The peculiar nature of menstrual blood provoked these myths and led to the belief that menstruating women were special and probably dangerous, not only to themselves but also to men. This is the reason why in many societies, as widely different as those of Papua New Guinea and the modern Hindus, menstruating women are either segregated from men or, if living in a family, are restricted in what they may do when menstruating. In rural India, Hindu women may not cook food or work in the fields when menstruating. In Bali, a menstruating woman is not allowed to enter a temple.

Even in western societies, myths about menstruation persist, and some of these are listed below. Some men (and some women) in western cultures still believe that menstruation is a symbol of the inferiority of women and that it demonstrates their weaker physical nature. This myth ensures that women only undertake domestic and child – rearing duties. This belief is particularly found in societies in which women talk only to each other about menstruation and where it is thought improper for men to hear about ‘women’s problems’.

Myths about menstruation

• Women cannot be trusted in important position because they become irrational in the week before and during menstruation.
• Menstruation cleans the body of dirty blood.
• A woman should douche when menstruation finishes.
• Intercourse should be avoided during menstruation as the man’s penis might introduce infection or damage women’s fragile tissues, and the menstrual blood might damage his penis.
• Menstruation is weakening, so a woman should not play active sports during a period.
• A woman should not get cold or wash her hair during menstruation as the blood might not flow easily and this could lead to disease.

Why menstrual blood does not clot
Myths about menstruation have a common theme; women’s menstrual blood is magical in some way because it does not clot. This, too is a myth. Menstrual blood, like any other blood, does clot. When it is shed inside the uterus it clots quickly, and then an enzyme in the uterus breaks down the clot so that it becomes, and stays, liquid. This is helpful to women, as the liquid menstrual discharge passes through the cervix more easily than it would if it were in clots. When the blood and tissue lost from the lining of the uterus is excessive, there is not enough of the enzyme to break down all the clots inside the uterus, and the woman might find that she has clots in the menstrual discharge. A few women appear to make tiny clots in the blood when it is in the vagina, but these are not true clots. They are collections of red blood cells in a meshwork of endometrial tissue.

Attitudes to menstruation
Women have several reasons for wanting to menstruate. In the early 1980s, the World Health Organization asked women in ten countries about their attitudes to menstruation. These countries were Egypt, England, India, Indonesia, Jamaica, Korea, Mexico, Pakistan, the Philippines, and Yugoslavia. In all countries a large number of women, ranging from 45 percent in England to 95 percent in Egypt and India, believed that menstruation was necessary for a woman to be a woman – to confirm her femininity. The belief was so strong that, in all the countries, more than half the women (53 percent in England; 90 percent in India) would not use a contraceptive that prevented menstruation from occurring. Another reason why many of the women wanted to menstruate regularly was to prove that during a specific month they were not pregnant. Rather fewer than half of the women believed that menstruation removed ‘waste products’ from the body; in other words, it was dirty. Another belief that the women reported was that hair should not be washed during menstruation (more than 60 percent of Indonesia and Filipino women, to 5 percent of English women). Another belief held by more than 90 percent of women, except the English women (54 percent), was that sexual intercourse should be avoided during menstruation.

When the age of all these women interviewed was checked, 85 percent were older than 24, and 38 percent were older than 35. This might have affected the attitudes expressed. By contrast, in a study made in 1984 of adolescent women in Australia, seven out of every ten teenagers considered menstruation a nuisance or an inconvenience. When asked whether they would prefer not to menstruate if it were safe and reversible, eight out of ten said they would prefer not to. Thirty percent of the teenage women said that if they didn’t menstruate they would be free of the heaviness and tiredness they felt in the days before their period. On the other hand, many of the women felt that having regular periods indicated that their body was working properly, and a few were reassured that they were not pregnant.

Teenage Australian women’s feelings about menstruation

As mentioned earlier, in the past many women in many different cultures thought that menstruation was necessary in order to rid the body of toxic substances. If these substances were not able to escape, the woman would become unwell sick, or sterile. Some of the teenage women surveyed felt that they ought to menstruate ‘to get rid of wastes’ from their body and that ‘the bad blood must get out’. These beliefs are clearly false. Some teenagers hold other erroneous beliefs. For example, 37 percent believed that when menstruating they should avoid getting cold or going out of doors if it was cold. But only 5 percent believed that they should not wash their hair (this was a common belief when their mothers were teenagers).

In general, young Australian women have a very practical attitude to menstruation, and only a few hold negative views that menstruation is dirty, revolting or disgusting. Many young Australian women believe that more information about menstruation should be available and that menstruation should be discussed openly so that myths about menstruation and the belief that it is dirty can be eliminated.

Strange words for menstruation
The mysterious nature of menstrual blood and of menstruation led to the use of a variety of strange euphemisms or slang words to describe menstruation. Instead of calling menstruation a ‘period’ or a ‘menstrual period’ many women say that they have rags, the flowers, the curse, the visitors, or a visit from a friend. The ‘friend’ might be given a name – such as George, Henry, and Charlie (oddly, most are masculine names). American women use the phrases ‘files the Baker flag’ ‘ rides the rag’ or ‘ falls off the roof’ to describe menstruation. European women more often see menstruation as the sickness, the monthlies the term or the courses, the time of your grief or ‘them’ or ‘those’.

These words indicate that menstruation is something very private that should not be talked about openly. It is understandable that women regard menstruation as a private matter, since its absence announces a probable pregnancy and its presence indicates non – pregnancy.

Menstrual protection:
By ‘menstrual protection’ we mean those articles used to absorb menstrual discharge. Until the last sixty years women used rags, which were then thrown away or washed for use in the next menstrual period. In the developed countries most women now use pads or tampons, although some women of certain ethnic groups continue to use rags.

Almost all women use pads for their first few periods. This is sensible, as it helps a woman to learn about her own pattern of menstrual bleeding. She finds out on what days the heaviest bleeding is likely to occur, how often she has to change her menstrual protection on ‘heavy days’ and ‘light days’ and any changes in rate of flow that might appear to occur at night or when exercising. For these reasons, pads offer an advantage over tampons in the first few months or years after menarche, but there is no reason why a woman as young as 12 or 13 should not use tampons, even for her first period. Some young women normally use pads but change to tampons when they want to go swimming.

Many young women still do not know about tampons until after they have had their daughters about tampons because they find it difficult or embarrassing to explain to their daughters how to use them, or they believe that tampons should not be used until the daughter is older as they have to be inserted into the vagina. Some mother might also assume that their daughters have learned about tampons at school or from magazines. Often teenagers learn about tampons from older sisters or friends.

As the teenager grows older she might make the decision to continue using pads, as she finds them comfortable and convenient, or she might decide to change to tampons, because of the convenience that they offer.