Menstrual Disorders

The topic of menstrual disorders (hereafter abbreviated MD) is one I have wanted to write about for many years and many reasons, some of them very personal:

• MD are common and have been around since the dawn of time.
• MD are life altering and disruptive to normal functioning.
• MD are changeable, but many girls/women don’t know this and continue to suffer.
• Many healthcare providers are unaware of all that can be done to help MD.
• The root causes of MD, left unresolved, can be the precursor to other problems.
• MD have plagued me for the majority of my life.

DEFINING MENSTRUAL DISORDERS

First let’s define the topic. MD include a host of issues with all kinds of intimidating names and symptoms such as:

• Amenorrhea – the absence of menstruation
• Dysmenorrhea (primary and secondary) – frequent, severe cramping and pain
• Hypermenorrhea or Menorrhagia – heavy, prolonged bleeding
• Hypomenorrhea – light menstruation
• Oligomenorrhea – infrequent menstruation
• Polymenorrhea – periods at intervals of less than 21 days
• Precocious puberty – beginning to have periods at age 7 or younger
• Premenstrual Syndrome (PMS) – a host of physical and emotional/mental symptoms

Let’s unpack each of these, beginning with amenorrhea. This is the absence of menstruation, which is pretty straightforward and clear (I’ll address the “why’s” in a future post). But many of the other MD definitions beg further clarification. What is considered frequent and severe cramping? What is heavy bleeding versus light? I’ll try to tackle all this below.

Dysmenorrhea – the presence of frequent, severe cramping and pain – is one that merits more discussion. Some would limit this definition to cramps only during menstruation. My perspective is that cramping can occur outside of menstruation, and may still signal a MD. I would also suggest that the pain may not just be cramping in the abdominal region, but can also be lower back pain. What is considered frequent and severe? Good question, and one that is not readily answered. I have heard many females speak of seeking help due to severe menstrual pain, only to have it dismissed by a provider (often but not always male) as normal. Truth is, setting a standard for a “normal amount of pain” is practically impossible, even if you resort to a pain scale. That’s because pain is such a multifaceted and personal event, completely subject to the perception of the person experiencing it. One person’s 8/10 pain may be 2/10 to another. That doesn’t mean they’re a wimp. It just means they perceive it differently. I make it a practice to try to never dismiss someone’s problem just because it’s not my reality.

So here’s what I propose be considered abnormally frequent and severe:

• Pain that is present throughout the majority of the day, and continues for more than 2-3 days.
• Pain that requires frequent, repeated, and high doses of medication.
• Pain that incapacitates the sufferer, causing her to modify or miss work, school, sports, social events, and even normal daily activities.

Certainly my definitions are not absolute, research driven, or above scrutiny. But they are based on my years of personal and professional experience. A one-time occurrence of any or all of these pain elements may not necessarily warrant action. But when they recur with regularity and ferocity it’s time to pay attention. To me this should never be considered “normal,” and should not be dismissed. Before moving on I’ll mention that dysmenorrhea can be categorized as primary or secondary. In the primary type there is no other potential source for the pain and it is attributed solely to the menstrual cycle. Secondary dysmenorrhea arises from a problem or infection in the reproductive organs.

Next let’s look at what is meant by heavy and prolonged bleeding, termed hypermenorrhea or menorrhagia. Most women will lose less than 16 teaspoons of blood (80ml) during their period, with the average being around 6 to 8 teaspoons. Heavy menstrual bleeding is defined as losing 80ml or more in each period. The Mayo Clinic website definition of heavy and prolonged bleeding is a bit easier to grasp:

• Soaking through one or more sanitary pads or tampons every hour for several consecutive hours
• Needing to use double sanitary protection to control your menstrual flow
• Needing to wake up to change sanitary protection during the night
• Bleeding for longer than a week
• Passing blood clots larger than a quarter
• Restricting daily activities due to heavy menstrual flow
• Symptoms of anemia, such as tiredness, fatigue or shortness of breath

Again, the presence of one or more of these without regularity does not necessarily signal MD. But their recurrence and intensity in any combination deserves scrutiny.

Hypomenorrhea or light menstruation is the polar opposite of menorrhagia. By default, it would involve lower than average blood loss of 6-8 teaspoons of blood per period. While this may seem desirable, it can signal a problem which we’ll look at later.

Oligomenorrhea is the tongue twister name for infrequent menstruation. There is variability in the menstrual cycle, which is counted from the first day of one period to the first day of the next. Menstrual flow normally occurs every 21 to 35 days and last 2-7 days. Environmental and personal factors can impact this, such as heavy exercise or the extreme stress as with a death or move. While there is certainly a range of normal, oligomenorrhea is defined as having fewer than 6-8 periods per year.

Polymenorrhea, or frequent menstruation, is the term describing the menstrual period as normal in terms of volume of blood flow, but occurring at intervals of less than 21 days.

Precocious Puberty is an interesting term for a girl (we could say child) who begins to have periods at or before age 7. The average age of onset is 12, but anytime between ages 8-15 is considered normal. For a girl who has not started by age 16, the diagnosis of amenorrhea is applied.

Lastly we come to premenstrual syndrome, or PMS. There is no shortage of PMS jokes, which serve as great comedy club material. PMS is a combination of symptoms that many women get about a week or two before their period, when ovulation typically occurs.  Again, what is “normal” versus “abnormal” for PMS? That is impossible to quantify. According to the U.S. government Office on Women’s Health, over 90% of women report having PMS symptoms which can occur in any combination and intensity:

• Appetite changes or food intolerance
• Back pain
• Bloating, gas
• Breast tenderness and swelling
• Constipation
• Cramping
• Depression, feelings of sadness, or crying spells
• Diarrhea
• Difficulty concentrating or remembering
• Fatigue
• Headache
• Irritability or hostile behavior
• Mood swings
• Nausea and vomiting
• Sleep problems (sleeping too much or too little)
• Tension and/or anxiety

So what’s the point of all this? Kind of depressing if all we do is analyze, commiserate, and carry on. But that’s exactly why I’m writing this: I want to heighten awareness of all that can be done to address MD, and be part of the solution for millions of suffering girls and women everywhere. It’s my goal that maybe as you read this you will recognize your MD or someone else’s, realize there’s hope for change, and be empowered to pursue it.

“It’s my dream to reach a girl suffering with MD when she first manifests the problem, and potentially alter the trajectory of her health and well-being – maybe even her life story – by intervening early and appropriately.” Colleen Whiteford

I’ll share with you an even deeper dream of mine: to reach a girl suffering with MD when she first manifests the problem. It’s sad how often I listen to people’s past medical history – their story – and think to myself, “Gosh, I wish I’d seen you sooner.” And I’m typically thinking years earlier. On the topic of MD it often sounds like this: she’s seeking help for pelvic pain, urinary incontinence, low back pain, IBS, hip pain, dyspareunia (pain with intercourse), neck pain, knee pain, headaches, foot pain – there is no end to this list. As I dig and dig through their history looking for those old-is-gold problems (as discussed in linked post) I often hear about a young girl who currently has or in the past had MD. She suffered from it, struggled through it, and carried on in spite of it. She may have had difficulties with pregnancy, labor, and delivery (or maybe is yet to). Perhaps she had/is having difficulty conceiving. She may have pursued care that involved invasive procedures, surgeries, and medications, or simply had her symptoms dismissed as “normal” and just lived with them. As I listen to these heartbreaking stories year after year I ponder the same gnawing question: what could it have looked like for her if we had intervened when that young girl began manifesting MD? I believe there’s potential to change the trajectory of her health and well-being – maybe even her life story – by intervening early and appropriately.

POSSIBLE CAUSES OF MENSTRUAL DISORDERS

So why do these problems occur? Is it genetics? Hormones? Poor nutrition? Stress? Possibly yes to all, although some of these influences may be more impactful for some individuals than others. Is there anything we can do about it? Absolutely!

In reality, the cause of menstrual disorders (MD) is most likely a combination of factors, as is often the case with many diagnoses. If you go to the most noted authority on the topic (the internet), you get all kinds of proposed causes for MD. (I said most noted, not most accurate.) Certainly some causes may play more heavily into certain diagnoses than others. But there is so much overlap that I decided to not try to correlate them with a specific diagnosis. Here is the list of proposed causes of MD that I have compiled (I may have missed some), in alphabetical order:

• Abdominal scar tissue
• BMI (body mass index)
• Cancer
• Depression/stress/anxiety
• Diabetes
• Eating disorders
• Fascial dysfunction – related to trauma, injury, surgeries, and fractures anywhere
• Genetics
• Heavy exercise
• Hormone/chemical imbalances
• Hypermobility
• Menopause
• Neuro/musculo/skeletal
• Nutrition
• Reproductive system disorders (adenomyosis, cervical stenosis, cysts/PCOS {polycystic ovarian syndrome}, endometriosis, fibroids, polyps)
• Reproductive system infections (STD {sexually transmitted disease}, PID {pelvic inflammatory disease})
• Sexual trauma
• Smoking
• Thyroid

This is where assessment by a qualified medical professional comes into play: sinister possible causes of MD like cancer or infection must be ruled out. Certainly there are cases that require interventions like surgery and medications. But in the absence of red-flag conditions, more often there are multiple lower tier options than surgery or medications which warrant consideration. For instance, many conditions like ENDOMETRIOSIS and PCOS may exist in a completely benign fashion – meaning they do not always cause pain. This is not just my opinion: the research and literature support this. Typically people are surprised to hear this as these conditions are often blamed for a host of issues including MD. The presence of such conditions certainly signals that something is wrong, but the research shows that women can have these issues without pain. So when a woman seeks help for some symptom-producing problem and presents with these conditions, it’s good to appreciate that her symptoms may be coming from something else – especially before proceeding with surgery or medication to cover the symptoms. Something to ponder.

Remember that this listing is of possible and proposed causes, not absolutely confirmed. The broad span of these potential origins for MD could be associated with other diagnoses as well, like IBS, prolapse, hernia, or low back pain. I can’t help but point out that many of these causes listed above could be turned around and explained by their fellow causes; for instance, depression could stem from hormone imbalances. By the same thought process, MD could cause an eating disorder and/or BMI issue as opposed to just being caused by them. Many of the MD are associated with the sad statement so common with multiple medical conditions: “The etiology of this heterogeneous condition remains obscure….” In other words, they really don’t know what causes it. But some very good theories exist as to the cause behind MD, which we’ll look at next. I’ll say here too that some elements, like genetics or past trauma, are not changeable. But I encourage everyone, regardless of the issue, to change what you can and maybe what you can’t change won’t have such a huge impact.

As you might expect, I am biased in my belief that fascial dysfunction can play a huge role in MD. This is based on scientific as well as empirical evidence. First, let’s look at the science. There is a growing body of literature exploring the role of fascia and connective tissues in movement, pain, and disease/dysfunction. The RESOURCES section I have compiled has some articles dealing with this topic, although there are many more than I have loaded. One in particular that I would direct you to is THIS ARTICLE by colleagues in Italy. It outlines two case reports using Fascial Manipulation®, one of them on a young lady with dysmenorrhea who responded very well. I would also direct you to the sections I have on Fascial Manipulation® (FM) and Fascial Manipulation® for Internal Dysfunction (FMID) under the Interventions tab. MD would be grouped into the category of FMID. I have also added a recorded webinar on dysmenorrhea to the Resources section. In summary, MD often occurs in response to the faulty fascial environment in which the reproductive organs are trying to function. The organs are frequently not the problem, which could explain why so often the tests examining the organ (uterus, ovaries) are negative. We’re always glad when it’s not cancer, but then what is it? Fascial dysfunction is a very viable consideration supported by science.

In addition to the science, my own empirical evidence – what I experience every day in clinical practice – also supports fascial dysfunction as a plausible explanation for MD. It makes my heart sing to have a female of any age return to me in follow up after treatment and tell me that her last period was much less painful, involved less bleeding, required no pain medication, and did not put her on the couch for three days missing work, sports, and life. I have experienced these results repeatedly over the years – often enough to prompt me to submit a proposal to speak on this topic at a national physical therapy conference, which was accepted (American Physical Therapy Association Combined Sections Meeting February 2022, San Antonio TX, presentation title: “Dysmenorrhea: Managing the Monster.” You can view an edited version of this talk HERE, given for the Fascial Manipulation Association). Writing this series on MD here on my site is part of my preparation (okay so I’m double dipping). In hindsight I wish I would have made the presentation title broader to reflect the full spectrum of MD, but the talk will be all inclusive because the treatment for dysmenorrhea is really no different than the treatment for menorrhagia in the FM method. It approaches the body globally, regardless of diagnosis, taking into account all the past and co-existing problems a person has to determine the best treatment plan. From my perspective this is essential for addressing the root cause of a problem and moving beyond just treating symptoms.

TREATMENT OPTIONS FOR MENSTRUAL DISORDERS

As with the possible origins of MD being multi-causal, so should the treatment approach. Sources cite multiple intervention options, which I’ve listed below in alphabetical order. While FM is my fundamental approach, I also utilize other compatible interventions (noted below in italics). This isn’t to imply the other interventions are inferior; some are currently outside of my scope of practice or I don’t use them much:

• Acupuncture
• Birth control
• Cupping
• Dry needling
• Education
• Exercise
• Fascial Manipulation
• Joint mobilization
• Lifestyle changes
• Massage
• Medication
• Nutrition
• Surgery

I have many of the above interventions I utilize explored on this website, and encourage you to explore them. Cupping can impact the autonomic nervous system, which is the driving force behind all involuntary functions of our body, such as the menstrual cycle. Dry needling can be very effective in changing the physiology of the connective tissues and restoring an environment more conducive to homeostatis. This is true whether one believes they are targeting a myofascial trigger point, fascial densification, muscle knot, or whatever. Sites needled might be in or around the pelvic segment, but could also be into the lower limb which is often involved, for instance in the case of an old ankle sprain. Dry needling powerfully impacts the body at the local, segmental, and systemic levels. Education (lots of sources under the resources tab) is a huge part of what I utilize, hence this website. I believe the more people understand about their body and their problems, the more hopeful, confident, and successful they will be toward recovery. Education on such items as percussion/vibration tools and cupping equip and enable people to participate in their program as well as future management and prevention. Educating people as to activities of daily living and needed Lifestyle Changes that may be crucial to modify for recovery is also essential. Exercise has its place for supporting changes made in treatment and combating the negative effects of what we do all day, such as prolonged sitting. This is where a regular exercise program (yoga, Pilates, running, biking) can also be very helpful. None of these interventions by itself is the answer, and not all of these interventions is what every person needs. It takes a customized approach addressing the specific needs of the individual.

MY STORY OF MENSTRUAL DISORDER

I wouldn’t feel like I have done this topic justice if I didn’t share my own story, for multiple reasons. First, I know what havoc menstrual disorders (MD) can exert because I have lived with them much of my life. I’m not just writing about a topic I’ve researched, I HAVE LIVED THIS! Second, maybe by me sharing some of my struggle I can embolden someone else to act in a positive way to help theirs. And third and foremost, I want a Mom, Grand-mom, sister, co-worker, BFF, cousin, father, brother, boyfriend, husband or whoever reads this to recognize someone they know and love who is struggling in the same manner as I have and encourage them to seek help. No one has to live with this.

Some of you may be uncomfortable with me sharing so much information, and I get it. You don’t have to read on! As you’ll see there was a day I wouldn’t even share this with my own Mother. But understand that my blatant honesty here is because I am passionate about not only witnessing change in a problem that has been perpetuated too long, but to perhaps being part of what ignites such change.

My struggles began from the get go, as they say. I started my periods when I was roughly 11 years old, which is pretty normal. What wasn’t normal was the pain I had (dysmenorrhea), as well as the heavy bleeding (hypermenorrhea or menorrhagia). I didn’t let on about it because I was so timid and shy (isn’t it shocking how people change? Ha!). I was just too embarrassed to talk about any aspect of the whole construct to anyone. I remember I didn’t even tell my Mom I had started – I was that private. But the severity of my cycle made it hard to keep to myself. Of course it’s impossible to keep such things from a Mom, especially when she does the laundry. It was a regular event for me to soil my pajamas and bed sheets with shocking amounts of blood because no matter how much I got up and how many pads I wore it was never enough. If it happened that a sleepover at a friend’s house came up while I was on my period I simply wouldn’t go. Trips or special event that I couldn’t evade I had to pack an arsenal of supplies and barely slept for fear of messing up the bed or sleeping bag. Years later I learned to fortify the bed with extra folded sheets, towels, anything in an attempt to not soil everything and so I could get some sleep.

The same scenario happened with my clothes. After many times of soiling my outfit at school and wanting to crawl in a hole and die from embarrassment, I finally learned to always wear dark colored clothes and carry spare undergarments and an arsenal of pads with me. Fortunately my school uniform was a dark plaid. Back in those days (~ 1973) there weren’t as may convenient options as there are now, and it wasn’t easy to hide what you were carrying or wearing. Not only did I bleed heavy, but it was also irregular and very unpredictable which caught me by surprise and unprepared at times – not a nice situation as you might imagine. I felt like my life was lived around my period. Symptoms began the week before my period, reached a crescendo the week of, and then still continued the week after. I would have a week of freedom for one week of the month. If you do the math, that’s more days with symptoms than without – a chunk of my life.

There’s no telling how much aspirin I ingested to help with the pain. I knew it was bad for me in such quantity but I couldn’t function otherwise. When Motrin finally become available over the counter in 1984 I thought I’d died and gone to heaven. Unfortunately it has its own issues, but at the time it seemed miraculous. I never went to a physician or other practitioner as it just didn’t seem like an option. Back in those days the only thing I remember going to the doctor for was strep throat. My Mom was a nurse and dealt with most of our ailments. I figured this was just how it was and what everyone else dealt with.

Writing this post is resurfacing all kinds of memories. One is of my Mom giving me a book called “Are You There, God? It’s Me, Margaret,” by Judy Blume. I’m guessing I was about age 11 or 12, so this would have been around 1973-ish. I always loved reading and to get a book from Mom was not unusual. I have no idea why she chose this book for me or how much she knew about the story line, much less my struggles. Maybe she envisioned this particular one would help me in my circumstances. The fact that she gifted it to me gives me hope, in retrospect, that she knew more of what was going on than I might have realized at the time. The main character, Margaret, was a girl my age who struggled with puberty among other issues. Contrary to the book, I couldn’t relate in any way to all the celebration surrounding Margaret getting her period. If I remember right her parents took her to dinner to commemorate the happy milestone. My reality was altogether different, and I didn’t experience any element to celebrate. I associated this time in my life with pain, embarrassment, and concealing. Interestingly, I only recently learned that this book was pretty controversial and eventually banned from multiple libraries in the 1980’s. I’ll have to ask my Mom if she even knew that when she gave it to me, or maybe the controversy came after she gave it to me. Too funny. Glad she was a trailblazer and counter-cultural!

Another memory I recall was in 1974 at my oldest sister Rene’s wedding to Ted, the first wedding in our family. I was 12 years old at the time, and struggling very much with puberty and menstruation. I remember the dress I wore to the wedding was full length and, of course, homemade. I can’t recall who sewed it – I may have. I do remember the material was white double knit polyester with small embroidered yellow flowers scattered all over it. The big day arrived, and we drove at least an hour to the chapel in Detroit where my sister went to college. I don’t remember exactly how long it was before the wedding, but suffice it to say not much time was left when I discovered I had started my period and I was completely unprepared. I went to my poor Mom, who had enough on her hands already. I recall we walked forever throughout the halls of the Marygrove college trying to find some sanitary products – her in her heels, long dress, and corsage and me in my white dress – bad color choice. We finally found a nun who rescued me with her stash, and Mom was incredibly grateful and relieved. Me too, but I worried the rest of the day in that dress.

The years went by and my problems didn’t seem to abate. I became a running fanatic as it helped my symptoms some. I eventually began yearly gynecology appointments, and at some point it was suggested to me that I try birth control measures to see if hormone regulation would help. Right or wrong, my Catholic upbringing had so instilled in me that birth control was wrong that for years I declined it. I finally conceded, basically worn down by my relentless issues. I tried multiple prescriptions, moving from one product to the next in search of what worked best. While there was some improvement, none of them really made the difference I was hoping for and I continued to ingest Motrin. In the meantime I was happily married to my dream guy, Bill, and life rolled along despite my issues. There were many meals my husband ate alone while I laid on the couch, too nauseated and cramped to even consider joining him. I joke that it was my strategy for staying thin. I appreciate him hanging with me all these years. Thank you and God bless you, Bill!

The end of it all came in a time and manner I did not anticipate – nothing new for my history with menstruation. Around 2013 we were flying home from a trip to Alaska to visit family stationed there. This trip is no small ordeal from Virginia, as it entails multiple legs and a very long day of travel even with the best itinerary. I had meticulously planned and scheduled to make it as painless as possible. So I was pretty aggravated with getting on the plane for the longest leg (~ 7 hours) to find that they had flipped our seats and scrambled us so that Bill was sitting in a window seat which he hates, while I was deposited several rows in front and on the other side from him in the middle seat – the seat I absolutely detest! In a take-it-or-leave-it scenario which does not endear me to airlines, we boarded and got underway. Trying to be a good sport I made conversation with the man on each side of me. About an hour into the flight I felt an overwhelming sense of discomfort, followed by profuse sweating then extreme nausea. I have never been a person subject to air sickness but I was looking for a barf bag, confounded by what was happening to me. The next thing I knew I felt this gush come from me – I mean my crotch. I worked up my courage to put my hand down onto the side of my leg and pull it up, only to realize that I had just completely soaked the seat I was to sit in for the next 6 hours with blood. Wonderful.

I will spare you the details of all that happened from there. When I got home the first thing I did was schedule a gynecological appointment which led to a uterine ablation. I remember the day of the procedure and into the days following the song “Goodbye to You” kept running through my head, I have no idea where this came from but it summed up my situation: I desperately hoped I was kissing my problems goodbye. The procedure absolutely helped with the heavy bleeding, and somewhat diminished the cramping and pain. Eventually menopause set in and further abated most of my remaining MD symptoms, although my other fascial problems that I believe caused the MD persisted. But at least I had some reprieve from the MD, after ~ 40 years of living with it.

So why did I have so much trouble? Why is it so rough for some of us and not others? That’s the million dollar question, but I believe for me it comes back to multiple factors such as hypermobility, hormones, and past traumas and injuries causing fascial dysfunction. I can’t unequivocally connect an instigating event in my life with my MD. This is not unlike a lot of other folks with problems that are “idiopathic,” or the cause is unknown. But the body always has a reason behind every malady – we just may not recognize it or connect it to a cause. I like to point out that we begin falling down from the moment we first stand up. We marvel at the resilience of a little girl who, swinging by her arms from one monkey bar to the next, misses and lands full force on her belly. Yes, that was me and I was pretty small, one of the random memories I have no idea why I recall. It was at St. Anne church where my Mom was doing something and my siblings and I were playing outside while we waited. I hit the ground hard and it was a while before I could breathe, much less stand up. I have no idea what happened after that, but I will say this: it was a trauma to an important area of my body, and maybe had something to do with my troubles later – no way to know.

I hope me sharing my story triggers something in someone somewhere that triggers a girl or woman to reach out for help – the sooner the better. There is MUCH that can be done to help diminish/resolve these problems: Fascial Manipulation, dry needling, education, exercise, cupping, lifestyle changes, and more. Unfortunately a lot of people just never hear about these options. Hence the impetus for this website. I really suspect that left unresolved MD can be the first symptom of fascial dysfunction that later plays into difficulties with pregnancy/labor/delivery, urinary incontinence, pelvic organ prolapse, diastasis rectus abdominus, endometriosos, and much more. I wish I would have had these options available to me years ago, but I do now and use them to address my other remaining issues with good results. Don’t go down this path! Learn from my experience, and please don’t suffer with MD when you can change it!

References:

International Association for the Study of Pain. Primary dysmenorrhea: an urgent mandate. PAIN: CLINICAL UPDATES. October 2013, Vol XXI, No. 3.

Margueritte et al. The underestimated prevalence of neglected chronic pelvic
pain in women, a nationwide cross-sectional study in France. J Clin Med, 2021, 10, 2481. https://doi.org/10.3390/jcm10112481.

Osayande A, Mehulic S. Diagnosis and initial management of dysmenorrhea. American Family Physician, March 1, 2014, Volume 89, Number 5.

Tatyana et al. Dysmenorrhea and impact on quality of life. Journal of Current Medical Research and Opinion 1:3 April (2018)

Zafar et al. Pattern and prevalence of menstrual disorders in adolescents. IJPSR, 2018; Vol. 9(5): 2088-2099. DOI: 10.13040/IJPSR.0975-8232.9(5).2088-99.