Menstruation and Menstrual Rehab: Difference between revisions

Menstruation, also known as a period is the process of discharging blood and other material from the lining of the uterus at regular intervals of about one lunar month from puberty until the menopause, except during pregnancy. The first period usually begins between ten and sixteen years of age[1][2], a point in time known as menarche.

Each month, one of the ovaries releases an egg — a process called ovulation. At the same time, hormonal changes prepare the uterus for pregnancy. If ovulation takes place and the egg isn’t fertilised, the lining of the uterus sheds through the vagina[3].


Physiology of menstruation[edit | edit source]

With the beginning of puberty the hypothalamus release Gonadotropin-Releasing Hormone (GnRH) this in turn send positive feedback signals to the anterior pituitary to secrete both hormones; the stimulating follicle hormone (FSH) and the luteinizing hormone (LH).

FSH hormone is responsible for stimulation and maturation of the follicle and there will be a secretion of FSH secreted by the granulosa cells of the follicle. When there is arise in estrogen release by developed follicle there will be a negative impulse back to the anterior pituitary gland to decrease LH and FSH. Before ovulation there will be a temporary rise in LH to stimulate the release of one ovum from the developed follicle, and the remnant follicle will shrink and become corpus luteum that will in turn release progesterone- steroid sex hormone- if the ovum does not fertilized the corpus luteum body will deteriorate and a decrease in progesterone and estrogen will happen and shedding of endometrium lining of uterus will happen and bleeding will be there, in turn there will be a rise a gain in LH and FSH for the next cycle[3].

The day count for menstrual cycle begins on the first day of menstruation when blood starts to come out of the vagina. The typical cycle is of 28 days. The cycle may be short as 21 days or long as 40 days.

There are 2 cycles to be understood.

  1. Uterine cycle – Menstrual phase, Proliferative phase and Secretory phase.
  2. Ovarian cycle – Follicular phase, Ovulation, Luteal phase.

Uterine Cycle[edit | edit source]

Menstrual Phase (day 1-5)[edit | edit source]

Menstrual phase begins on the first day of menstruation and lasts till the 5th day of the menstrual cycle. The uterus sheds its inner lining of soft tissue and blood vessels which exits the body from the vagina in the form of menstrual fluid. Blood loss of 10 ml to 80 ml is considered normal. Abdominal cramps can be experienced. These cramps are caused by the contraction of the uterine and the abdominal muscles to expel the menstrual fluid. Shedding of endometrium oestrogen and progesterone are at the lowest levels.

Proliferative Phase (day 6-14)[edit | edit source]


There is maturation of graffian folllicles and secretion of oestrogen by theca interna of graffian follicle. Endometrial cells increase in number. There is increase in thickness of endometrium from 1mm to 4.6mm. Because of secretion of oestrogen, formation of new endometrial layer is initiated.

Secretory Phase (day 15-28)[edit | edit source]

During the secretory phase, progesterone (as well as oestrogen) is secreted by the corpus luteum, which develops from the Graafian follicle. Progesterone secreted by the corpus luteum stimulates the further build-up of the cells in the endometrium of the uterus. It also stimulates the glands in the uterus to secrete substances that maintain the endometrium and keep it from breaking down. Thickness of endometrium further increases and the endometrial cells also increase in number. Smooth muscles show relaxation. Endometrium becomes receptive to implantation and thus supports early pregnancy.


Ovarian Cycle[edit | edit source]

Follicular Phase (day 1-13)[edit | edit source]

This phase also begins on the first day of menstruation, but it lasts till the 13th day of the menstrual cycle. The pituitary gland secretes a hormone that stimulates the egg cells in the ovaries to grow. One of these egg cells matures. While the egg cell matures, its follicle secretes a hormone that stimulates the uterus to develop a lining of blood vessels and soft tissue called endometrium.

Ovulation (day 14)[edit | edit source]

The pituitary gland secretes a hormone and causes the ovary to release the matured egg cell. The released egg cell is swept into the fallopian tube by the cilia of the fimbriae. Under the influence of LH surge the Graafian follicle ruptures and releases ovum.


Luteal Phase (day 15-28)[edit | edit source]

This phase begins on the 15th day and lasts till the end of the cycle. Under the effect of the pituitary hormone, FSH and LH causes development of corpus luteum and increases progesterone levels. The egg cell released during the ovulation phase stays in the fallopian tube for 24 hours. If a sperm cell does not impregnate the egg cell, the egg cell disintegrates and causes the menstrual phase of the next cycle to begin.[7]

Menstrual Health And Hygiene Management[edit | edit source]

Menstrual health management is human right.[10] Women and adolescent girls must use clean menstrual management material to absorb or to collect the blood. soap and water must be used to cleanse and there must be proper facilities to dispose the used menstrual management material. Menstruation is a natural process, but in most parts of the world it is taboo. It has to be properly managed or it can result in health problems.[11]

Different Menstrual Products[edit | edit source]

  • Sanitary napkins: These are menstrual pads available in different size, shape, length and thickness. They may be disposable or reusable. Some have wings that fold at the sides of the underwear.[12]
  • Cloth pads: They are reusable but they absorb the menstrual blood, making them soggy and ineffective for period protection.[13]
  • Tampons: It absorbs blood and vaginal secretions by insertion into the vagina during menstruation. Unlike a pad, it is placed internally, inside the vaginal canal. Once inserted correctly, a tampon is held in place by the vagina. It expands while blood gets absorbed.[14]
  • Menstrual cups: It is ecofriendly, reusable, flexible cone shaped which can be inserted into the vagina. It can collect menstrual fluid. The collected flid can then be disposed and the cup can be reused after cleaning it properly.[15]
  • Menstrual discs: It is round in shape and has flexible ring with a catch that sits at the base of the cervix in a place called the vaginal fornix.[16]
  • Menstrual panty: They look and feel like regular underwear but can collect blood. They are washable and can be reused[17]
Sanitary pad.jpg

Disposal Methods[edit | edit source]

Appropriate disposal of used menstrual material is still lacking in many countries of the world. Most women dispose of their sanitary pads or other menstrual articles into domestic solid wastes or garbage bins that ultimately become a part of solid wastes. Best choice is to use reusable and non-commercial sanitary materials like reusable pads, menstrual cups and thus generate lesser amount of menstrual waste as compared to use of commercial disposable pads. If the product used is reusable, clean it with water, sterilize and store it clean for the next use. If it is disposable, use proper guidelines.[18][19]

  • Premenstrual Syndrome It is a syndrome characterized by an involvement of both physical and psychological symptoms seen among women of reproductive age. Monthly symptoms are both physical and psychological which includes irritability, hot flushes, vertigo, muscle cramps, breast soreness, acne, bloating, headache, anxiety, depression, difficulty concentrating, appetite changes, low energy etc.[20] Sudden fluctuation of hormones are responsible for this. It can sometimes be so severe that they will need to miss work or school.[21]The intensity or severity of symptoms may vary between females.[20]

Period pain.png

  • POLYMENORRHOEA – Frequent menstruation at interval between 2-3 weeks. Blood loss is usually normal.[22]In this condition, ovulation may occur earlier than usual or happen at irregular times during the cycle. Some females may have a shorter luteal phase. [20]
  • OLIGOMENORRHEA- It is a condition characterized by infrequent or very light menstruation with previously normal periods. Causes includes hormonal imbalances, eating disorders such as anorexia nervosa, stress (including physical & psychological), chronic illness etc. [20]
  • AMENORRHEA – It is characterized by a woman of child bearing age fails to menstruate. There are two types of Amenorrhea, i.e Primary Amenorrhea and Secondary Amenorrhea. In primary amenorrhea, there can be delay in puberty and it is usually common in females who are thin or athletic. In secondary amenorrhea, there is an absence of menstrual period for more than 3 cycles. It can be naturally caused by pregnancy, breast feeding and menopause. Other causes include obesity, sudden weight loss, stress, frequent strenous exercise, PCOS or PCOD etc.[23][24][20]
  • Dysmenorrhea – It is characterized by severe pain, cramps during menstrual period. It includes 2 types; primary which means the common menstrual cramps due to uterine muscle contraction and secondary due to underlying pathology like endometriosis, adyneomyosis etc.[25][26]Symptoms can include cramps or pain in the lower abdomen, low back pain or radiating pain down the legs, nausea, vomiting, diarrhea, fatigue, weakness, fainting, headache etc.[20]
  • MENORRHAGIA – Excess or prolonged bleeding at regular interval.[27]It is considered as the most common type of abnormal uterine bleeding. Woman complains of severe bleeding that can disrupt her daily activities, moreover she soak through enough sanitary napkins which requires regular changing every hour. Her menstrual bleeding can lasts longer than 7 days in a duration. [20]
  • METRORRHAGIA – Irregular , heavy and intermenstrual bleeding.[28]Vaginal bleeding occurs at irregular intervals which is not usually associated with menstrual bleeding. It does not represent a normal period. The woman might feel as if like, she is experiencing second period at another time during the month. [20]
  • Polycystic Ovarian Syndrome – It is the hormonal and metabolic disorder. In this type, thee ovaries fail to release egg due to numerous small fluid filled follicles. Causes include excess insulin, heredity, excess androgen. Symptoms include excess weight gain, acne, prone to diabetes etc.[29]
  • POLY CYSTIC OVARIAN DISORDER – symptoms are almost same as PCOS. Ovaries contain immature eggs which turn to cysts due to excess junk food consumption, stress or being overweight.[30]
  • ENDOMETRIOSIS – It is a condition where endometrial tissue is outside the uterus. this leads to adhesion and scar tissue formation causing severe pain and discomfort. common symptoms are dysmenorrhia, pain on urinating and intercourse, excess bleeding etc.[31]


  • PELVIC FLOOR DYSFUNCTION – Chronic and severe menstrual pain may lead to spasm of pelvic floor muscle resulting in hypertonus dysfunction. Pelvic floor muscles may become tight leading to vaginismus, dyspareunia, etc.
  • POST MENOPAUSAL BLEEDING – Bleeding from genital tract after menopause. Causes include malignancy, vaginitis, uterine prolapse etc.[32]

Role of Physiotherapy In Menstrual Rehabilitation[edit | edit source]

The management includes two categories

  • General management
  • Pelvic floor rehab for menstrual disorders : This includes pelvic floor exercises.

General Management[edit | edit source]

This includes dietary management, exercise, modalities, stress management, and yoga.[33]

Dietary Management[edit | edit source]

Avoid a sugary diet, Excess raw meat, fried foods, fast food, soda, alcohol, and caffeinated drinks. Food to be taken include green leafy vegetables, oats, avocado, broccoli, olives, walnuts, almonds, beans and lentils, and legumes. Berries, Naturally processed food like milk, butter, and curds also can be taken. Fish oils, salmon, and tuna have great health benefits and are good to take during menstruation.

Exercises And Modalities[edit | edit source]

Aerobics[34] and resisted exercise play major role here to reduce pain[35], discomfort.[36]

Modalities : TENS, Hot pack, Acupuncture, Acupressure ,Taping.[37][38]

Stress Management[edit | edit source]

Managing stress and anxiety is very important as it can cause negative effects on menstruation. Breathing exercises and relaxation techniques can help in a great way to reduce stress and anxiety. Meditation also plays an important role to manage stress. Meditation is often defined as thinking continuously about one object of thought. It is important to develop some hobbies which will help to divert your mind. Having a bath with Luke warm water and Epsom salt also contributed to reducing stress levels.[39][40]

Yoga[edit | edit source]

Different yoga poses like Bhujangasana, Malasana, Usthrasana, Baddha konasana and Dhanurasana help to ease pain and discomfort during menstruation.[41](see Yoga And Mindfulness For Pelvic Health)


Pelvic Floor Rehabilitation[edit | edit source]

Rehabilitation depends on the findings of pelvic floor muscle grade. Individuals with PCOS, and endometriosis may have tightness of pelvic floor while lactating, or individuals with low oestrogen may have weakness of pelvic floor muscles. It involves treating various menstrual irregularities.[43][44] Rehabilitation includes various pelvic floor exercises.[45] Pelvic floor muscles are skeletal muscles. They can be trained, retrained, strengthened by repeating the same exercise overtime.

Rehabilitation includes:

  • Mirror biofeedback where mirror can be used to visualize pelvic contractions and relaxations.[46]
  • Use of vaginal dilators: After menopause, vagina becomes drier, less elastic, narrower, and shorter. Vaginal dilators can be used to stretch the vagina.[47]
  • Kegel exercise: It means to find right pelvic floor muscles and make them work. Most of them contract abdominals, buttock, or inner thigh muscles and don’t reap the benefits of the exercises.[48]
  • IFT, US.
  • NMR: Aids rehabilitation of shortened muscles and tendons. [49]
  • Soft tissue mobilisation: Use of hands-on techniques on your muscles, ligaments and fascia with the goal of breaking adhesions and optimizing your muscle function.
  • Lower limb stretches.
  • Identifying and activating the right muscles.
  • Relaxing tight and overactive muscles
  • Controlling and doing the right exercise at the right time
  • Learning to coordinate the pelvic floor muscles with the diaphragm, the deep abdominals and the other core muscles.
  • Controlling abdominal pressure and avoid damaging the pelvic area with high impact activities, wrong abdominals exercises or coughing.
  • Integrating functional exercises according to your daily activities and sports.[50]
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