Does your menstrual cycle affect your life?

I have been reading a new book that is out in Autumn called Red Moon Gang: An Inclusive Guide to Periods, by Tara Costello, a London-based writer who specialises in covering menstruation which will be published by Prestel. Reading the book has made me want to ask you some questions about your menstrual cycle. The next few weeks Institute for Women’s Health hot topics (#ifwhhottopics) will be on the menstrual cycle and periods.

This week I want to ask you – does your menstrual cycle affect your life? Do you have to take time out when you have your period?

Mood swings can be a major part of our menstrual cycle, as our hormones go up and down. In 2018 I was interviewed for an article that was published in the Mail Online which discusses how women should be aware of the changes that may happen to them during their cycle and go with the flow (sorry about the pun!). I said ‘After ovulation, oestrogen and progesterone levels change; oestrogen starts to drop and progesterone rises. Some women are very sensitive to these changes, especially the increased levels of progesterone. We think progesterone and oestrogen may also decrease the levels of serotonin in your brain. Serotonin impacts every part of your body; it is often referred to as the “happy” hormone, as it is linked to mood, wellbeing and feelings of happiness. The main thing is that you recognise what’s happening and then do what works for you. Just don’t be passive. We still don’t have a full enough understanding about why it is hormones affect women so profoundly in the first place — which makes it all the more important for you to monitor your own hormonal journey.’

Besides our fluctuating hormones which can affect our mood throughout our cycle, there are  three main issues with having a period: premenstrual syndrome, painful periods and heavy periods.

Premenstrual tension or syndrome

About 95% of women experience physical and emotional symptoms called premenstrual tension (PMT) or premenstrual syndrome (PMS). PMS can start anywhere from a few days to two weeks before a period is due. The symptoms usually resolve when the period begins. The physical symptoms include breast tenderness, bloating, lethargy, weight gain, nausea, constipation, diarrhoea, insomnia, backache, joint ache, and acne. The emotional symptoms include mood swings, anger, aggression, depression, irritability, crying, anxiety, clumsiness, loss of libido, cravings for sweet and salty food, poor concentration, and forgetfulness. The symptoms of PMS are similar to other disorders such as chronic fatigue syndrome, depression and the menopause (see Chapter 8). So, when making a diagnosis, it is important to determine if these symptoms are linked to the menstrual cycle.

We are unsure exactly what causes PMS, but it is probably due to changes in hormone levels which occur between the time of ovulation (about 2 weeks before the period starts) and the next period (see above). After ovulation, oestrogen and progesterone levels change; oestrogen starts to drop and progesterone rises. Some women are very sensitive to these changes, especially the increased levels of progesterone. It is thought that progesterone and oestrogen may decrease the levels of serotonin in the brain. Serotonin impacts every part of the body; it is often referred to as the mood hormone, as it is linked to wellbeing and happiness. It plays a key role in mood, appetite and sleeping – all of which are affected by PMS.

Not all women get PMS, but there is a genetic link (more likely to get it if female family members have it) and it is affected by lifestyle. Lifestyle factors that may contribute to PMS are being overweight, lack of exercise, stress and diet (too much salt, sugar, alcohol and caffeine). There is less PMS after having had a child, but it can get worse with age. Women with a history of depression or other mood disorders are at increased risk. Asthma, irritable bowel syndrome, allergies, depression, seizure disorders or migraines, may get worse. There is no PMS when pregnant or after the menopause.

Since PMS can start up to 2 weeks before a period, this means some women spend half of their fertile life suffering from PMS, which can have a hugely negative impact on their lives during those years. In 5% of women, PMS is so severe that they cannot lead a normal life and this is termed premenstrual dysphoric disorder (PMDD). The symptoms of PMDD are more severe than PMS and can include suicidal thoughts and panic attacks.

If suffering from PMS, there are ways to try and reduce the symptoms.  Tracking the cycle, either by writing it down or using an app (see below), may help identify when PMS is imminent.

It is important to have a good diet including five a day of fruit and vegetables, high fibre, complex carbohydrates, and also keep hydrated (which will reduce the chance of headaches). B vitamins (especially B6) are thought to be important, but studies show that taking supplements with B vitamins does not work. B vitamins are found in foods that are high in thiamine, such as pork and Brazil nuts, and also in foods that are high in riboflavin, such as eggs and dairy products. It is also important to have enough calcium and magnesium in the diet. Keeping blood sugar levels steady will help reduce mood swings, so avoid eating a diet high in sugar, which causes food cravings. It is important to reduce caffeine and alcohol intake as these can disrupt mood and energy levels and result in a poor sleep pattern. Being overweight is related to increased PMS.

Exercising can really help PMS. To reap the benefits, women need to be active all the time, ideally with 30 minutes of exercise a day (see Chapter 1).

It is important to get enough sleep. If there are sleep problems around the time of the period, eating well and exercising should help – but also try to reducing stress levels with massage, relaxation techniques, meditation, listening to music, reading and yoga.

Giving up smoking may reduce PMS.

Aspirin, paracetamol and ibuprofen may help with some of the physical symptoms of PMS. As with all drugs, taking them should be discussed with a doctor or pharmacist.

For some women, preventing ovulation and the rise in progesterone might reduce PMS. Therefore, the oral contraceptive pill, oestrogen patches or oestrogen implants may help. Most contraceptive pills contain progestogen, which has a similar action to progesterone on PMS. The newer contraceptive pills may work best because they contain a different type of progestogen to the older versions, but further studies are needed to see if they have a beneficial effect on PMS. It should be noted that the pill has side effects in some women such as breast pain, depression and blood clots.

If prescribed oestrogen patches or implants, a low dose of progestogen will also be given as using oestrogen on its own can increase the risk of womb cancer. This progestogen may be given via the Mirena® coil (intra-uterine device), which is inserted into the womb where it steadily releases a small amount of progestogen.

Some women may benefit from cognitive behavioural therapy (CBT) which explores ways of coping with PMS. CBT may produce beneficial effects on anxiety, depression, and daily activities, but the scientific evidence is not conclusive.

Use of herbs such as evening primrose oil, chasteberry (Agnus castus) and black cohosh has been suggested for treatment of PMS, but there has been very little research on whether these herbs actually work. Health care providers should be told about any complementary or integrative health approaches that are used. This will help ensure coordinated and safe care. Evening primrose oil is thought to be effective for menstrual cramps, period pain, acne, anxiety, mood swings, headaches, irregular periods and heavy menstrual periods. Evening primrose oil contains about 70% linoleic acid and 10% gamma-linoleic acid, both of which are essential fatty acids. The oil may help those who have a diet deficient in gamma-linoleic acid, but a doctor should be consulted first as these products may interfere with other medications. I am not a fan of vitamin supplements, as I think it is more important to make sure we eat a healthy diet, with a low intake of processed foods (see Chapter 1) but there are supplements that are marketed at reducing PMS that contain a mixture of herbs, vitamins and minerals. There is no scientific evidence that these work and they could cause harm, it is important to seek advice from a doctor or nutritionist before taking them.

Since in some cases PMS might be due to defects in serotonin levels, treatment can involve antidepressant drugs such as selective serotonin reuptake inhibitors (SSRIs), that increase serotonin levels. These may be taken daily to relieve tiredness, food cravings and insomnia, but they can have negative effects such as nausea, insomnia, headache and loss of libido, which might outweigh the benefits.

Keeping a diary of or using a menstrual cycle app may help identify when the symptoms occur (see below). Try out different methods to try and reduce PMS and see what works. The menstrual cycle information may help the doctor identify which treatment is needed such as the contraceptive pill or patch. In the UK, only about 20% of women visit the doctor to discuss PMS.

Painful periods

As if PMS is not enough to deal with, unfortunately pain during periods (dysmenorrhea) affects 90% of women, with 15% classing the pain as severe. The pain tends to improve with age and after childbirth. Pain is the result of  the body producing prostaglandins, which help the womb to contract to ensure the blood is expelled, and can occur just before and during the period. As the womb contracts, it compresses the blood vessels lining the womb and these can temporarily cut off the blood supply – and hence oxygen supply – to the womb. Women who have higher levels of prostaglandins have more pain. It is mainly pain in the abdomen but can spread to the back and thighs.

Adolescent girls may get more severe period pains. When I was at school, I can remember girls going to hospital with period pains.

Smoking seems to make it worse. Exercise, application of heat, a hot bath, a back and stomach massage, and relaxation may help. Painkillers such as aspirin and ibuprofen can be used, but studies have shown that paracetamol might not be as effective as aspirin or ibuprofen for period pains. As noted in the PMS section, evening primrose oil may help PMS, and it also may help menstrual cramps and period pain.

Some women who experience severe pain choose to use the oral contraceptive pill or an intrauterine device, both of which alters hormone levels and reduces the frequency of painful periods.

Endometriosis is a condition where the cells lining the womb transplant to other parts of the pelvis, such as over the ovaries, the lining of the pelvis, the tubes, the bowel and the bladder (see Chapter 9). It can cause severe pain during periods, and one of the treatments is the contraceptive pill.

Whoopi Goldberg joined forces with Maya Elisabeth (who has a reputation as one of the best creators of medical cannabis products in California) to form the company Whoopi & Maya and they offer marijuana-infused products to reduce and relieve pain and cramps during menstruation. Whoopi & Maya Synergy provides a signature line of medical cannabis products designed specifically for relief from menstrual discomfort, which includes Soak, Savor, Rub and Relax.

Any woman who finds that her periods are affecting her life to the point where she has to have time off work or school, or who finds sex very painful, should see a gynaecologist.

Heavy periods

Some women experience unusually heavy periods (menorrhagia) and this can impact so negatively on a woman’s life that treatment is needed. ‘Flooding’ is the term used to describe the situation whereby normal sanitary protection is not sufficient and double protection and regular changing is required. If periods are very heavy and affecting quality of life, or even causing anaemia (low iron levels), please see a doctor for help to treat this.

There are non-hormonal tablets that which help reduce blood loss by about a third (tranexamic/mefenamic acid), but treatment can also be with the contraceptive pill, the Mirena® coil and other surgical treatments. In the UK, the Mirena® coil is the first choice in treating heavy periods, because it reduces blood loss in 9 out of 10 women within a few months of insertion.

If these treatments are tried and they have not helped, a doctor may decide to refer the woman to a gynaecologist for further investigation and specialist treatment. This may involve having an ultrasound scan of the womb and a biopsy to check that the womb lining looks normal. Benign muscle growths of the womb muscle, called fibroids, can cause heavy periods, and removal of these can help (see Chapter 9). Benign growths of the womb lining, called polyps, also cause heavy periods and these can be easily removed using a small camera (hysteroscope) passed through the vagina into the womb, whilst awake or under anaesthetic (see Chapter 9). The womb lining can also be destroyed on purpose to reduce periods, but this only suitable once the family is completed. As a last resort, a woman may be offered a hysterectomy (removal of the womb).

Do any of these issues affect you? Should employers allow women time off if their periods are adversely affecting their health? There would be no questions asked if you took time off because you were unwell for other reasons.

Read More:

Want to learn more about your menstrual cycle – our analysis of 600,000 menstrual cycles.

Period pain – http://www.globalwomenconnected.com/2017/02/cope-period-pain/

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