Normal Menstrual Flows
About once a month, women of childbearing age normal menstruate for 4-6 days, losing
between 25 and 60 cc of blood. The blood is dark in color and mixed with mucous,
inflammatory exudate, and cellular debris, representing the shed lining of the uterus.
Day #1 of the menstrual cycle is designated as the first day of the menstrual flow. At
approximately Day #14, one or the other ovaries releases an egg (ovulation), an event
which may or may not be perceived by the woman. With ovulation, some women notice brief
abdominal cramping while others do not. Some women notice a small amount of pink vaginal
discharge or spotting, while others do not. Some women notice a significant, brief,
increase in cervical mucous secretions (evidenced in vaginal discharge) but others do not.
Following ovulation, progesterone, the other female hormone (other than estrogen) is
produced in significant quantities. Progesterone has a number of functions, but in the
normal menstrual cycle, continues to be produced by the ovary for 10-12 days. Following
the abrupt fall in progesterone, a new menstrual flow is triggered, starting several days
after the drop in progesterone.
Normal bleeding occurs every 26-35 days, lasts 3-7 days, and usually
does not involve the passage of blood clots.
Abnormal bleeding is any bleeding occurring outside these normal
Menstrual cramps (dysmenorrhea) are among the most common of menstrual cycle symptoms.
They may be mild, moderate or severe, and may not be consistent from one cycle to the
next. They are usually midline and suprapubic. The cramps are waxing and waning in
character but a constant dull ache is also common. The pain may radiate into the back or
upper anterior thighs.
The cramps typically begin a day or two prior to the menstrual flow and are usually
resolved before the menstrual flow has finished, although there is considerable
Simple cramps usually respond well to simple measures. Any of the nonsteroidal
anti-inflammatory agents (Ibuprofen, naproxen, etc.) can be effective, but sufficiently
high doses are most effective. A loading dose of ibuprofen, 800 mg PO can be started a day
prior to the anticipated onset of cramps. This is followed by 600 mg PO every 8 hours for
as long as the cramps persist. If you wait until cramps have already begun to start the
NSAIDs, they will not be as effective, but may still prove useful.
Regular exercise has been demonstrated to reduce the frequency and severity of
menstrual cramps, probably through the release of internal beta-endorphins.
More severe menstrual cramps usually respond very well to BCPs. Possibly through
blocking of ovulation and also perhaps by the reduction in amount and duration of
bleeding, BCPs are a first-line treatment for significant dysmenorrhea. Any of the
low-dose, monophasic BCPs can be employed for this purpose. Significant relief should be
expected after the first BCP-induced flow and additional improvement over the next 6
months may continue.
For those women with severe cramps whose symptoms are not improved with BCPs,
continuous BCPs may provide the solution. In this case, the
BCPs are taken without letup (continuously) and there is no menstrual flow at all. Without
a menstrual flow, menstrual cramps are inhibited. For these women, gynecologic
consultation while in garrison is probably wise to evaluate such patients for the possible
Cyclic breast pain is usually most
prominent in the upper, outer quadrant, and in the areolar areas.
For some women, cyclic breast pain and tenderness (mastodynia or cyclic mastalgia)
accompanies the later portions of the menstrual cycle. Typically for several days
preceding the menstrual flow, the breasts of these women enlarge, become lumpy, tender to
touch, and produce a generalized aching. The nipples may become extremely sensitive and
very uncomfortable. This condition is sometimes called fibrocystic breast disease,
fibrocystic breast changes, or cyclic mastalgia.
Very mild cases of mastodynia can be treated with mild analgesics and reassurance. The
more severe forms respond well to a number of medication; The simplest of these is BCPs.
After starting low-dose, monophasic BCPs, the cyclic breast pain is usually immediately
improved to some extent. In the months and years to come, the breasts usually become
progressively less lumpy, less tender and less uncomfortable. BCPs are a very effective
long-term treatment for this problem.
Also effective is the use of Danazol. Unfortunately, Danazol (800 mg/day) is expensive,
not often available in operational settings, and has many significant side effects
(unwanted hair growth, deepening of the voice, weight gain, clitoral hypertrophy, and
others), which limit its' usefulness.
If these medications are unavailable, probably any medication which disrupts ovulation,
such as Lupron, or DEPO-PROVERA, will be reasonably effective in stopping the cyclic
breast pain that is so annoying to some women.
Midcycle pain ("mittelschmerz") is the pain that can accompany ovulation.
Typically occurring on about Day #14, the pain is unilateral, may occur on either side,
and lasts for a few hours to a day or two.
It is not known why this ovulatory pain is so disabling to some women, is minor in
other women, and not even felt by still other women.
The treatment of mild cases is usually reassurance and oral analgesics during the pain.
For more significant symptoms, BCPs generally work very well at inhibiting ovulation and
preventing the pain. Other alternatives include any medication which would interfere with
ovulation, such as DEPO-PROVERA, or Lupron. The latter two, while effective, often have so
many other side effects that the treatment is worse than the problem.
Acne is caused by a combination of hereditary predisposition (genetic factors) and
stimulation of skin glands by male hormones. Both men and women produce both male and
female hormones, but men mainly produce male hormones and women mainly produce female
In the second half of the menstrual cycle, particularly as menstruation is approaching,
there is a fall in the amount of estrogen (female hormone), although the small amount of
male hormone remains more or less constant. This results in a relative increase
in the influence of the small amount male hormone present. In the susceptible woman, this
will lead to increased acne just before the menstrual flow.
BCPs are usually effective in treating this. In fact, BCPs are usually helpful in
treating acne in general, primarily because of the suppression of ovarian function. Since
the ovaries produce about a third of all male hormone in women, this drop in male hormone
levels is often sufficient to lead to improvement in acne.
Occasionally, (uncommonly) the BCPs aggravate the acne, and in these cases, the BCPs
should be switched or stopped altogether. While some evidence suggests that Ortho-Cyclen
and Demulen 1/35 may be more effective against acne than the other BCPs, good results can
likely be obtained from any of them.
Headaches may accompany the menstrual cycle and present in a number of ways.
Menstrual migraine headaches are common and temporarily disabling. They usually occur
just before the onset of a menstrual flow or during the first day. They are triggered, in
susceptible individuals, by the sudden drop in hormones accompanying the premenstrual
phase. Good success in treating menstrual migraines can usually be achieved through the
use of BCPs:
In some cases, low-dose monophasic BCPs are effective at suppressing the menstrual
In some cases, the 7 days "off" BCPs each month is too long and the
accompanying hormone changes trigger the headaches. These women do well for a few days
during their "off" week, but then develop headaches at the end of the week. For
these women, shortening the "off week" to only 3 days will frequently provide
them relief from their menstrual migraines. There is still a change in hormones, but about
the time the menstrual migraine is going to begin, the reinstitution of the BCPs prevents
the migraines from starting.
In some cases, it will be necessary to go to continuous BCPs to achieve good migraine
In some cases, BCPs are not effective in controlling the menstrual migraines and other
treatments must be used.
Sinus headaches may be more pronounced during the days leading up to the menstrual
cycle, due to changes in hormone levels and their impact on sinus mucosa and fluid
retention. These headaches have their focus of pain in the paranasal sinuses which become
sensitive to direct digital pressure, and also by the indirect pressure of putting the
head down between the knees. In addition to the usual methods of treating sinus headaches
(analgesics, decongestants, antihistamines, antibiotics, as appropriate), cyclic symptoms
can often be controlled by BCP suppression of ovulation.
Tension or stress headaches may also worsen or improve, depending on the menstrual
cycle. In these cases, hormone changes or fluid retention may play a role in the
development of such headaches in susceptible individuals. BCPs can often improve these
headaches, although occasionally, the BCPs may aggravate them. A therapeutic trial of BCPs
is often undertaken.
The fluid retention just prior to menses usually amounts to a pound or less of
extracellular fluid collected in the dependent extremities and to a lesser degree in the
Mild to moderate degrees of fluid retention are usually tolerated with reassurance
while more dramatic forms are often treated. BCPs, by blocking ovulation and the
accompanying hormonal changes are very effective at blocking the fluid retention elements
Alternatively, any diuretic can be used and generally has very dramatic, though very
temporary effects. Used every other day for a few days, diuretics in reasonable doses will
generally keep fluid retention to a minimum, but with some risk of salt imbalance. Used
more frequently or for longer periods of time, the risks of electrolyte imbalance
increase. In operational settings, the risks of diuretic therapy very often are greater
than any potential benefits in other than very extreme cases.
Progesterone has a quieting effect on smooth muscle contractility. Largely for this
reason, gastrointestinal function usually slows to some degree during the second half of
the menstrual cycle.
While most women do not notice the change, a few will notice bowel sluggishness,
constipation, increased gas production and abdominal dissension. While this is not
dangerous, it can be annoying. When combined with the natural tendency in many deployed
settings to intentionally dehydrate (avoiding the problem of urination), constipation can
become a quite significant problem.
BCPs can block this change in gastrointestinal function by virtue of the inhibition of
ovulation and the hormone changes that go along with ovulation. Increasing dietary fiber
and fluid intake can also be helpful. In extreme cases in operational settings, bulk
laxatives or bowel stimulants may prove necessary.
Depression and Irritability
It is not known why some women, as they approach their menstrual flow, experience these
mood changes. For most women, these symptoms are either very mild or absent, while others
have moderate or severe symptoms. For them, the symptoms may begin around the time of
ovulation and persist until the menstrual flow has begun. For others, the mood changes are
limited to a day or two preceding the menstrual flow.
About 80% of women with moderate to severe premenstrual mood changes will obtain
significant relief from BCPs. The blocking of ovulation seems to be the key element as
very low dose pills or progestin-only pills do not seem to have the same effect.
If BCPs are not available or the patient is not a good BCP candidate, any medication
which blocks ovulation will likely have the same effect. Unfortunately, some of these
medications (Lupron, DEPO PROVERA, Danazol) have depression and irritability as potential
side-effects, so the patient must be closely watched.
Anti-depressant medications (Prozac, etc.) are also about 80% effective in improving
the mood changes associated with the premenstrual syndrome. These are not, however, the
same 80% who benefit from BCPs, so for BCP failures, a therapeutic trial of antidepressant
medication may be considered. Whether such a trial is appropriate in an operational
setting should be individually determined.