Periods, PMS & Ovulation
This week we are going to talk about periods! We thought this was important to discuss because there’s a lot we go through and don’t address so we are here to dispel it all for you.
What is your period? It’s also known as menstruation and basically it’s bleeding that occurs on a monthly cycle in women as your body prepares for pregnancy. So your period comes once your body determines that pregnancy will not occur leading to the uterus or as some people know it as the womb to shed its lining thus, giving you your period!
Most people experience their first period between the ages of 11-14 although some people get it as early as 9 and others as late as age 16. Different factors may influence this and some of them are not well understood. You continue to have your period till about your early fifties at which point you undergo menopause. Side note: prior to menopause your periods will become more irregular usually with associated menopausal symptoms that come along to let your body know that you are about to stop having your periods entirely! Most periods typically last between 3-8 days and are regular meaning they occur each month in a predictable pattern.
Now, there are four stages of the menstrual cycle and the typical cycle lasts on average 28 days but can go as long as 35 days which is affected by the proliferative phase. The length of the cycle is counted from the first day of day one of your period to the first day of the next period. It is controlled by hormones obviously that are made either by the pituitary gland or the hypothalamus stimulating the ovaries. Let's start with the first phase:
Phase I is the follicular or proliferative phase (Day 0 - Day 13)
- During this phase your primordial follicles develop into a single mature one, the primary follicle turns into the secondary follicle which contains the oocyte and the secondary follicle turns into a tertiary follicle which turns into the graafian follicle
- At this time you also have a certain type of estrogen release which prepares the uterus for embryo implantation by thickening the endometrium
- The graafian follicle will rupture and release the oocyte during ovulation and the other follicles that we spoke about initially basically die or disintegrate
- So from Day 1 - 5 you have your period, and from days 6 - 14 you have the uterine lining preparing for a possible pregnancy becoming thicker and enriched with blood and nutrients
Phase II is the mid cycle or ovulation phase (Day 14)
- LH surge occurs due to increasing levels of estradiol which triggers ovulation. The graafian follicle ruptures and releases the secondary oocyte which gets picked up by the fallopian tube and is transported down to the uterus. If sperm is present in the fallopian tube between days 14 - 25 fertilization can occur and the fertilized egg would go to the uterus to try to implant into the uterine wall
Phase III is the luteal or secretory phase (Day 15 - Day 28)
- This phase is constant and is always a total of fourteen days
- During this phase you have the post ovulation LH surge that drives the development of something known as the corpus luteum which is made up of the ruptured graafian follicle and makes progesterone and estradiol. The progesterone is responsible for maintaining the endometrium to support the embryo implanting and increasing the body temperature. If the egg was not fertilized between days 25 - 28 or implantation does not occur, hormonal changes signal for the uterus to prepare to shed its lining
Phase IV is the menses or pregnancy phase
- The corpus luteum regresses and instead you get a fibrotic scar (this is due to the loss of progesterone and estradiol). The lining sloughs causing menstrual bleeding or if fertilization occurs, hcg is secreted which rescues the corpus luteum so it continues to make progesterone and estradiol
A more scientific way to think about the above is as follows:
Day 1 - 14 (from day of period to ovulation) the pituitary gland releases FSH which causes several follicles to rise on the surface of the ovary and each fluid filled bump contains an egg, one becomes dominant and within it develops a single mature egg while the others shrink. During this time if more than one follicle matures you can have twins or even more than that. This mature follicle makes estrogen which increases over the follicular phase and peaks in the day or two prior to ovulation. In the second part of this process the endometrium becomes thicker and more enriched with blood in response to the increasing estrogen which stimulates the production of GnRH which in turn stimulates the pituitary to secrete LH
On day 12, LH and FSH surges leads to the release of the egg from the follicle and the LH surge causes a brief increase in testosterone which increases sex drive right at the most fertile time of the cycle! Ironic isn't it?
On day 14, the release of the mature egg occurs after this surge of LH and FSH. The egg goes and tries to get fertilized and if not it disintegrates after about 24 hours. Once the egg is released the follicle seals over and this is called the corpus luteum.
Between days 14 and 28, the luteal phase starts and basically it occurs after the egg is released and LH and FSH decrease. The corpus luteum produces progesterone at this time so if fertilization occurs it continues to produce this hormone which prevents the shedding of the endometrium but if not, the corpus luteum disintegrates which causes the progesterone levels to decrease and signals the endometrial lining to begin shedding
In summary, what happens throughout these phases is you have an ovarian follicle and oocyte development, then the reproductive tract prepares to receive the fertilized ovum, if fertilization does not occur or fails then the endometrial lining sheds hence your period comes.
So what goes along with these periods? Our favorite... symptoms! Just kidding. Women usually feel abdominal or pelvic cramping or pain, lower back pain, bloating, breast soreness, food cravings, mood swings and irritability, headache or fatigue. These symptoms vary from person to person and even from period to period. Usually they occur as early as a week prior to the period and can last throughout the cycle ending by around day three. For example, I experience mood symptoms a week before with associated breast soreness and then heavy cramps during the first two days of my period. Fun fact though, my skin is amazing at the end of my period and the first week thereafter!
There is a subtype known as premenstrual syndrome or PMS. This includes a group of symptoms that start before the period which can be either emotional or physical or both. Some of these women develop premenstrual dysphoric disorder or PMDD which is similar to PMS but can lead to severe depression or anxiety a week or two before your period with symptoms resolving within two to three days of starting your period. The latter is linked to having underlying associated psychiatric conditions and patient's may benefit from treatment. The treatment options include cognitive behavioral therapy aka CBT or pharmacologic management like SSRIs.
Abnormalities to know with respect to the Menstrual cycle:
- Oligomenorrhea: cycle intervals occur at more than 35 days
- Polymenorrhea: cycle intervals occurring at less than 21 days
- Metrorrhagia: cycles occur irregularly and with inter-menstrual bleeding
- Menometrorrhagia - cycles occur irregularly, at more frequent intervals with heavy menstrual bleeding
What can cause irregularities?
- Obviously pregnancy or breastfeeding (delays return of menstruation after pregnancy). But other things include eating disorders, extreme weight loss, excess exercise (all three can disrupt menstruation), PCOS, premature ovarian failure (leading to irregular or missed periods), pelvic inflammatory disease secondary to infection (most commonly, gonorrhea or chlamydia), uterine fibroids (causing heavy and prolonged periods)
Tampons and Pads
- You can use either or depending on your preference. However, there are risks when you don’t change your tampons. Either option you choose still means they should be changed every 4-8 hours but we personally, do it more frequently (say every two to three hours) to decrease risk of infection or a condition known as toxic shock syndrome which can be life-threatening although it has become a lot more rare. If you are very active, tampons are a good alternative and you want to choose the lowest absorbency necessary with respect to your flow. Many women use a combination like pads to sleep in because it’s for a longer period of time and tampons during the day or pads during your heavier time of the week. Newer pads are thinner and highly absorbent so choose what you like.
#1: Flo App
- Remember instead of an app you can use a menstrual diary but in today’s day and age it might be easier to use an app
#2: Exercise with lighter activities during your period
#3: Use a heating pad, I personally love this one and would use a back massager which doubled as a heating pad and put it on my lower back for those initial two days when my cramps are the worst
#4: Drink lots of water, it really does help! or even juice or milk.. you want to have ten 8 ounce glasses of fluid and along with this goes a good diet. I know this one will be hard because this is the time we have cravings and it’s okay to curb into them a little bit. They may alleviate your emotional needs but not your pain! If you have these cravings opt for dark chocolate or herbal teas.
#5: Wear liners in between periods especially during ovulation and right before your period so no accidents occur!
#6: Avoid coffee as it retains water and can make you feel bloated but we can’t live without our morning coffee so this is ultimately up to you.
#7: Get your sleep on … we always stress how we try to get at least 8 hours of sleep every night!
Tests to check when you’re ovulating? These include cervical mucus testing, basal body temperature, and ovulation prediction kits
- Cervical mucus changes over your cycle but when you're fertile it changes to a consistency and structure that lets the sperm travel to the egg (so when you are most fertile it will be clear, you will have a lot of it and consistency will be stretchy). This is also known as the egg white cervical mucus or EWCM. Usually seen between days 13 and 15. Note: when you are not fertile it is more sticky, cloudy and without stretch
- Lowest body temperature is when you are at rest, usually taken after several hours lets say six hours of sleep and recorded once you wake up because once you are up and about your temperature increases a little. So normal temperature is around 36.2 and 36.5 celsius but the day after ovulation it can increase by at least 0.5 and stay at this temperature until menstruation. For this to be accurate you need to take it around the same time everyday and get a thermometer. This will help you track when you ovulate, the regularity of cycles and length. This will take months to ensure there are no variations in your cycle.
- Ovulation prediction kits work by measuring the concentration of LH in your urine. LH is always there in small amounts but increases 24 to 48 hours before ovulation. There are also other kits that measure estradiol.
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