Normal (pre)menstrual changes

What's normal?

What are normal changes?

Menstrual physiology

Menstrual physiology

Changes versus symptoms

Changes versus symptoms

Tips and tricks

Tips and tricks

Normal changes

Normal (pre)menstrual changes...

Are not an 'illness' and do not usually require treatment or support from a doctor.

They are caused by the normal and healthy biological changes involved in maintaining the female reproductive system. Ovulation, the thickening of the womb lining, and menstruation (the period) are all inflammatory events, which lead to these cyclical 'side effects' (see physiology section below) [1].

Ultimately, the menstrual cycle helps to ensure the continuation of the human species and also prevent dangerous pregnancies that could otherwise prove fatal [2]. While menstrual blood loss is costly in terms of the reduction in iron stores, it is less costly than the loss of a female adult of reproductive age to the community/ species!

What's normal? Quick links...

Cycle length
Blood loss
Mood changes
Period pain

What are normal changes?

These changes are variable between individuals and typically go up and down at different times in the cycle [3]. Contrary to popular belief, therefore, there are many positive as well as negative cyclical changes...

[Click on individual changes to find more specific tips and tricks]
  1. Mild abdominal (period) pain
  2. Mild digestive changes
  3. Mild muscle/ joint pain
  4. Appetite
  5. Sociability
  6. Weight/ water retention
  7. Skin quality
  8. Sleep quality
  9. Energy levels
  10. Tearfulness (e.g. due to joy, empathy or emotional distress)
  11. Mood (positive and negative e.g. feeling joyful, or a bit irritable- especially if hungry, tired, or in pain)
  12. Body temperature
  13. Sensitivity to light, sound, odour
  14. Mild dizziness/ low blood sugar feeling
  15. Concentration levels
  16. Creativity
  17. Blood loss of less than 80ml (approx. 160ml total fluid) per period
Most cyclical changes go up and down...
Most cyclical changes go up and down...

Menstrual physiology...

Watch this space for more info about menstrual physiology... coming soonish in 2021!

Image source: Menstrual Matters. Data sources [4]
Image source: Menstrual Matters. Data sources [4]

Changes versus symptoms...

If you experience these changes but they are typically mild and do not really disrupt your daily activities, it is best to describe them as 'normal (pre)menstrual changes' (rather than 'symptoms' or 'PMS').

This is because, over the past century, the menstrual cycle itself has become positioned as an illness (through a process known as medicalisation), even though it is a normal, healthy, and vital human phenomenon [5]. The medicalisation of the menstrual cycle contributes to gender myths that position 'women' as morally, intellectually, physically, and, therefore, politically inferior to 'men' [6].

If your experiences are more regularly disruptive, and sometimes severe, you may have what we call '(Pre)Menstrual Inflammation' or PMI. These experiences can be called 'symptoms' but they should respond well to anti-inflammatory dietary, lifestyle or medication approaches.

If you regularly experience moderate to severe cyclical symptoms, but they do not respond to anti-inflammatory approaches, you most likely have an underlying health condition.

Tips and tricks...

If you would like to reduce your (pre)menstrual changes, especially in relation to period pain and blood loss, anti-inflammatory approaches can work well [7];

1. Taking anti-inflammatory medications such as Ibuprofen, or Naproxen, 2-4 days (400-1200mg per day) before you expect your period, will substantially reduce blood loss and cramping [8].

2. Taking high strength Omega 3 oils every day can also make a big difference [9].

3. Taking hormonal (contraceptive) medications, which typically alleviate all (pre)menstrual symptoms [10]. You may need to try a few different types before you find the one that works best for you- each person responds differently!

4. If you prefer not to take medications (and/ or dietary supplements), the good news is that menstrual health responds very well to some simple lifestyle changes.

By following these four steps, many people will notice a significant improvement in their health and wellbeing. Better still, even if these approaches do not completely prevent all of your symptoms, they will definitely help, and won't make things any worse, since they are all health-promoting interventions.

4 steps to health

1. Diet- what you eat can affect your menstrual health considerably.
Please see this blog post for more information, and to see the clinical research behind these 8 general recommendations:

1. Eat lots of fresh fruit and vegetables
2. Eat lots of fibre (and drink water with it!)
3. Eat oily foods (mainly unsaturated fats)
4. Reduce meat and dairy products
5. Avoid sugary foods and drinks
6. Avoid caffeine
7. Avoid alcohol
8. Take nutritional supplements, if needed (e.g. Omega oils, calcium, iron, magnesium, vitamins, or zinc)

Note: An 'anti-inflammatory' diet is recommended for the management of several chronic health conditions, including those that are known to be triggered, or worsened, at certain points in the menstrual cycle.

Exercise

2. Exercise- Don't panic! You do not have to run a marathon, or take up competitive sports (unless you want to?) What's most important is that you regularly spend time moving your body, developing your strength, and getting slightly out of breath. The key to success is finding an activity that you enjoy doing, perhaps with others, to provide the motivation to keep going.

The NHS recommends that adults spend [11];

- at least 2.5 hours of moderate aerobic activity such as cycling or fast walking every week, and

strength exercises on two or more days a week that work all the major muscles (legs, hips, back, abdomen, chest, shoulders and arms).

Obviously, there are many reasons why moderate exercise is good for your health, but in terms of menstrual health it can improve self-esteem and low mood, and metabolic conditions such as PCOS (Polycystic Ovary Syndrome) or amenorrhea (a lack of regular periods).

Self-esteem

3. Improve self-esteem- in a sexist (patriarchal) society it is very easy to develop negative feelings towards the menstrual cycle, or female body. The pressure we feel to hide our periods can make them appear disruptive to work, socialising, exercise, care for others, or other enjoyable activities. This can lower mood and self-esteem, and increase anxiety levels.

Getting to know and trust your body, especially the taboo bits (i.e. the vulva and vagina) can boost self-esteem. Making peace with your body can make a surprisingly big difference in improving menstrual health and well-being.

Happily, improving self-esteem is a relatively easy thing to do!

It involves noticing any negative internal thoughts, and analysing them to prove to yourself that they are not actually true, or reflective of who you really are (i.e. a human being of equal worth to all other human beings). Some people might benefit from the support of a professional counsellor, but a good (and cheap) starting point is this amazing booklet from the Oxford Cognitive Therapy Centre.

Learning more about the menstrual cycle, using a menstrual cup, and tracking changes over time, can also help boost self-esteem. For example, a menstrual cup encourages the user to get to know (and like!) their reproductive anatomy better, and to observe menstrual fluid up close. Cycle tracking helps you to know what is normal for you, and so feel more in control of health and well-being.

De-stress

4. Reduce stress - Although we have become used to differentiating between ‘mental' and ‘physical' health, this is an artificial separation, especially when thinking about menstrual health.

For example, it is known that the menstrual cycle interacts with the HPA (Hypothalamic–Pituitary–Adrenal) axis, better known as the ‘stress axis’ [12]. If you experience an increase in stress, you will feel anxious- your ‘fight or flight’ response is triggered. This is what we have evolved to do, regardless of the fact that this response might have been triggered by healthy changes in the menstrual cycle, rather than a scary, dangerous, or otherwise stressful situation.

Interestingly, research shows that cyclical changes are strongly affected by external (stress) factors, as well as physiological changes [13]. For example, irritability, is nearly always in response to an experience of 'injustice'  or 'frustration' of some sort- e.g. shouting at the kids whilst trying to get them ready for school, if your partner does not equally share in this responsibility. In fact, being single, or having a supportive partner can significantly improve menstrual health, by simply reducing the sense of 'injustice' regarding personal responsibilities during the premenstrual/ menstrual phase [14]!

A top tip is to ask your partner to cook dinner, or to be in charge of childcare just before and/ or during your period...

Another is to set a regular sleep pattern- use an alarm for when you should start to get ready for bed, switch off any screen devices, and try and wake up at a similar time each day. This will help regulate your body clock, which is also involved in the stress/ inflammation responses and the menstrual cycle!

By tracking changes over time, and getting to know when you are likely to feel more anxious, or sensitive to stress,  you can feel more in control, and ‘resist’ those first fluttery feelings in the pit of your stomach.

Take note of any triggering experiences- this will help you to identify the cause(s) of your stress e.g. work, home, or finances etc. Relaxation techniques or mindfulness practice can help to calm your breathing, and body, to break out of a downward spiral of emotional distress.

Then talk to the people in your life about the triggers that contribute to stress. Perhaps they could help in some way e.g. provide childcare support, help you to manage debt, or simply allow you some more space (e.g. at certain times in your cycle)?

Page last reviewed: Dec 2020

References...

[1] Bertone-Johnson ER, Ronnenberg AG, Houghton SC, Nobles C, Zagarins SE, Takashima-Uebelhoer BB, Faraj JL, Whitcomb BW. Association of inflammation markers with menstrual symptom severity and premenstrual syndrome in young women. Hum Reprod. 2014 Sep;29(9):1987-94. doi: 10.1093/humrep/deu170. Epub 2014 Jul 17. PMID: 25035435.

[2] Critchley HOD, Babayev E, Bulun SE, Clark S, Garcia-Grau I, Gregersen PK, Kilcoyne A, Kim JJ, Lavender M, Marsh EE, Matteson KA, Maybin JA, Metz CN, Moreno I, Silk K, Sommer M, Simon C, Tariyal R, Taylor HS, Wagner GP, Griffith LG. Menstruation: science and society. Am J Obstet Gynecol. 2020 Nov;223(5):624-664. doi: 10.1016/j.ajog.2020.06.004. Epub 2020 Jul 21. PMID: 32707266; PMCID: PMC7661839.

[3] Kues JN, Janda C, Krzikalla C, Andersson G, Weise C. The effect of manipulated information about premenstrual changes on the report of positive and negative premenstrual changes. Women Health. 2018 Jan;58(1):16-37. doi: 10.1080/03630242.2016.1263274. Epub 2016 Nov 28. PMID: 27892822.

[4] This diagram was developed by MM but using the data from:

  • Salamonsen LA, Woolley DE. Menstruation: induction by matrix metalloproteinases and inflammatory cells. J. Reprod. Immunol. 44(1–2), 1–27 (1999).
  • Angeli, A., Lainé, F., Lavenu, A. et al. Joint Model of Iron and Hepcidin During the Menstrual Cycle in Healthy Women. AAPS J 18, 490–504 (2016). https://doi.org/10.1208/s12248-016-9875-4
  • Yeung EH, Zhang C, Mumford SL, Ye A, Trevisan M, Chen L, Browne RW, Wactawski-Wende J, Schisterman EF. Longitudinal study of insulin resistance and sex hormones over the menstrual cycle: the BioCycle Study. J Clin Endocrinol Metab. 2010 Dec;95(12):5435-42. doi: 10.1210/jc.2010-0702. Epub 2010 Sep 15. PMID: 20843950; PMCID: PMC2999972.
  • E. Montero-Lopez, A. Santos-Ruiz, M.C. Garcia-Rios, M. Rodriguez-Blazquez, H.L. Rogers, M.I. Peralta-RamirezThe relationship between the menstrual cycle and cortisol secretion: daily and stress-invoked cortisol patterns Int. J. Psychophysiol., 131 (2018), pp. 67-72
  • White, C. P., Hitchcock, C. L., Vigna, Y. M., & Prior, J. C. (2011). Fluid Retention over the Menstrual Cycle: 1-Year Data from the Prospective Ovulation Cohort. Obstetrics and gynecology international2011, 138451. https://doi.org/10.1155/2011/138451
  • Emera, D., Romero, R., & Wagner, G. (2012). The evolution of menstruation: a new model for genetic assimilation: explaining molecular origins of maternal responses to fetal invasiveness. BioEssays : news and reviews in molecular, cellular and developmental biology34(1), 26–35. https://doi.org/10.1002/bies.201100099
[5] Chapter 4- 'The menstrual cycle; attitudes and behavioural concomitants' by Chrisler, J & Gorman, JA. in Ussher, J.M., Chrisler, J.C., & Perz, J. (Eds.). (2019). Routledge International Handbook of Women’s Sexual and Reproductive Health (1st ed.). Routledge. https://doi.org/10.4324/9781351035620

[6] King S. (2020) Premenstrual Syndrome (PMS) and the Myth of the Irrational Female. In: Bobel C., Winkler I.T., Fahs B., Hasson K.A., Kissling E.A., Roberts TA. (eds) The Palgrave Handbook of Critical Menstruation Studies. Palgrave Macmillan, Singapore. https://doi.org/10.1007/978-981-15-0614-7_23

[7] Vélez Toral M, Godoy-Izquierdo D, Padial García A, Lara Moreno R, Mendoza Ladrón de Guevara N, Salamanca Ballesteros A, de Teresa Galván C, Godoy García JF. (2014) 'Psychosocial interventions in perimenopausal and postmenopausal women: a systematic review of randomised and non-randomised trials and non-controlled studies'. Maturitas. 2014 Feb;77(2):93-110. doi:0.1016/j.maturitas.2013.10.020. PubMed PMID: 24289897.

[8] Feng X, Wang X. Comparison of the efficacy and safety of non-steroidal anti-inflammatory drugs for patients with primary dysmenorrhea: A network meta-analysis. Mol Pain. 2018 Jan-Dec;14:1744806918770320. doi: 10.1177/1744806918770320. Epub 2018 Mar 27. PMID: 29587566; PMCID: PMC5987898.

[9] Behboudi-Gandevani S, Hariri FZ, Moghaddam-Banaem L. The effect of omega 3 fatty acid supplementation on premenstrual syndrome and health-related quality of life: a randomized clinical trial. J Psychosom Obstet Gynaecol. 2018 Dec;39(4):266-272. doi: 10.1080/0167482X.2017.1348496. Epub 2017 Jul 14. PMID: 28707491.

[10] Jarosz AC, Jamnik J, El-Sohemy A. Hormonal contraceptive use and prevalence of premenstrual symptoms in a multiethnic Canadian population. BMC Womens Health. 2017 Sep 26;17(1):87. doi: 10.1186/s12905-017-0450-7. PMID: 28950854; PMCID: PMC5615478.

[11] NHS. (2011) Physical Activity Factsheet. [ONLINE] Available at: http://www.nhs.uk/Livewell/fitness/Documents/adults-19-64-years.pdf. [Accessed 22 March 2017].

[12] Goel N, Workman JL, Lee TT, Innala L, Viau V. (2014) 'Sex differences in the HPA axis'. Comparative Physiology 4(3):1121-55. doi:10.1002/cphy.c130054. Review. PubMed PMID: 24944032.

[13] Kirschbaum C, Kudielka BM, Gaab J, Schommer NC, Hellhammer DH. (1999) 'Impact of gender, menstrual cycle phase, and oral contraceptives on the activity of the hypothalamus-pituitary-adrenal axis'. Psychosomatic Medicine 61(2):154-62. PubMed PMID: 10204967.

[14] Ussher, JM, Perz, J & Mooney-Somers, J (2007) 'The Experience and Positioning of Affect in the Context of Intersubjectivity: The Case of Premenstrual Syndrome'. International Journal of Critical Psychology (now Subjectivity), 21: 144-165