The Gynae Geek

Periods are one of society’s biggest taboos. Over half of the population has had or will have one at some point during their lifetime. Yet we barely talk about them.

I’ve noticed an interesting three-way split in the way women feel about periods. In the first group are women who are ambivalent; they don’t mind either way whether they come or not. The second group hate them and would do anything to make them go away (‘Give me anything you’ve got to make them stop!’). The third group love them and are horrified at the thought of not having their period every month – some, because they see it as a sign that their bodies are working, and many because they feel like it’s ‘cleaning their body from the inside’ (although I’m always quite keen to point out that having a period doesn’t clean your body of germs or toxins; in fact, I think period blood often has a ‘dirty’ connotation, which is probably one of the reasons we’re so reluctant to address the issue).

There are some types of contraception – for example, the hormonal coil – that will stop your periods (see Chapter 7), and if that happens it’s not a bad thing. It doesn’t mean your uterus will become ‘unclean’. The medication is simply preventing the lining from building up, so there’s nothing to shed. I once offered the hormonal coil to a lady whose periods were so heavy that she’d had several blood transfusions. However, for her the possibility of having no period at all was unacceptable and she declined, explaining that she ‘wouldn’t feel like a woman any more’. I really like the fact that some women appreciate their period as a sign that their body is working. This is so true, and I always tell my patients that their period is a reflection of what’s been going on in their bodies for the last month, even slightly longer.

The next three chapters will cover the basics of periods, the menstrual cycle and what can, and commonly does go wrong.

CHAPTER 3

Periods – the basics

Me: How long is your menstrual cycle?

Patient: Three to four days.

Many people think that the length of a cycle is how long you bleed for, but this is a common misconception. Your cycle is actually the number of days from the start of one period until the start of the next.

Education about periods is pretty mediocre at best. In fact, at my school it was so dire that I genuinely thought a period was the contents of an egg cracking and being released through the vagina, which often makes me laugh when I think of the irony that I now spend my life explaining periods to others. But rest assured, I’ve done my fair share of reading since then.

In this chapter I want to start with the absolute basics, so do bear with me if you’re a period pro, although I hope there will be something to be gained for you geeks too.

If you fall into the ‘I’m-in-need-of-period-101’ group, you are not alone. A recent survey by ActionAid UK revealed that one in four women in the UK does not understand her periods, and that 20 per cent feel embarrassed to talk to their friends about them. If we can’t talk about periods, we will never work out what is normal or abnormal. And this results in so many women suffering unnecessarily because they don’t realise that there are things that can be done to help the problems they experience on a monthly basis.

What is a period?

A period is what happens when the lining of the uterus (the endometrium) falls away. Even though most of us are not trying to get pregnant the majority of the time, the entire reason for having a menstrual cycle is to prepare your uterus for a fertilised egg to implant. When this doesn’t happen, your uterus chucks out the lining it had prepared. But in order to actually have a period there is a lot of work going on behind the scenes throughout the menstrual cycle.

‘Day 1’ is the first day of your period. If you have a textbook twenty-eight-day cycle, Day 28 is therefore the last day before your next period. We are, however, humans, of course, and not everyone goes by the book, with only about 15 per cent of women actually having a twenty-eight day cycle,1 and anything between twenty-one and thirty-five days being considered a ‘normal’ cycle length.

The menstrual cycle: more than just a bit of bleeding

Let me take you through the different stages of your cycle.

Follicular phase: fifty shades of period blood

It all starts on ‘Day 1’ – this is the first day of your period – and the bleeding usually lasts for three to eight days (on average five). Bleeding is classically heaviest on Day 2.

The blood during your period can come in a huge range of shades and hues. It won’t look the same as the blood you see when you cut your finger, because it’s not just plain blood. It’s mixed with mucus and cells from the inside of the uterus and the reason there is blood in the first place is because the juicy lining that’s built up over the month contains an intricate network of blood vessels that were meant to feed that elusive pregnancy it was planning on accommodating. The colour also depends on the time taken for the blood to come out. Just as an apple goes brown when it is cut and left exposed to the air, so blood starts to darken and, ultimately, go brown or almost black if it’s left to hang around for long enough.

It’s not uncommon for a period to start as spotting. This means light bleeding that’s not really enough to need a pad. It can be pinkish, which is usually due to the lining starting to fall away, or various shades of brown, which means it’s coming out very slowly or could even be old blood from your last period. Don’t be overwhelmed by this; it’s normal. New red bleeding tends to be thinner and often a bit watery because it’s the freshest. It can get a bit thicker and more crimson in colour because it has had a bit of a wait before show itself. Then normally it becomes quite light and turns brown to black before it stops completely. A wide range of colours is completely normal and to be expected.

The blood that’s being shed will clot in the uterus, so your body has to make anticoagulants – chemicals to break them down – in order to re-liquify the blood, so it can flow out. Many women tell me that ‘pieces of liver are coming out’. Admittedly, clots may look pretty sinister, but it’s not always something to worry about. If the amount of blood present exceeds the speed at which your body can make these anticoagulants you may experience clots, which can escape through your cervix, which softens slightly to allow the blood to escape. Clots tend to be small, usually no bigger than the size of a fifty-pence coin. However, larger clots, and lots of them, are a sign that there’s heavy bleeding going on, so it’s worth visiting your GP to check it’s not causing anaemia, to consider treatment and whether there’s an underlying reason, many of which are covered in Chapter 5.

While you’ve been busy concentrating on the outward manifestations of your period, you may not have realised that your brain has been busy making hormones: GnRH (gonadotrophin-releasing hormone), LH (luteinising hormone) and FSH (follicle-stimulating hormone). GnRH is produced first by the hypothalamus and then signals to the anterior pituitary to release LH and FSH, which then stimulate the ovary to prepare an egg for release (ovulation) and to produce oestrogen, which starts to rebuild the endometrium, in preparation for the hope of a pregnancy during this new cycle. Eventually, there is a massive surge in LH release, which triggers ovulation. LH is what you are trying to detect with the ovulation sticks that you can buy if you’re trying to get pregnant and want to work out when you’re ovulating. A patient once proudly told me that she usually ovulates about three times per month because her ovulation sticks told her so. You cannot ovulate more than once during a single menstrual cycle, although you can release more than one egg, which is how you get non-identical twins. This is one of the quirks of ovulation sticks; they tell you when you have had an LH surge, which can happen several times in one cycle, but they don’t confirm you popped out an egg.

Luteal phase: eggs and shells

Eggs live in sacs called ‘follicles’ which undergo several months of maturation before they can get to the stage of being released. Ovulation marks the start of the luteal phase and is like a Hollywood audition; at the start of your cycle there may be ten eager, willing candidates, but as time goes on, only one is selected to go forward and become the ‘dominant follicle’, which grows and grows, forming a cyst which pops on about Day 12–16 of the cycle, throwing it on to the main stage in the hope of being fertilised. It’s not unusual to get a bit of pain at this point. Ovulation itself is an inflammatory process and the ovary producing the ‘star egg of the show’ can get slightly enlarged which itself causes pain; then, when the cyst bursts, it leaks a little bit of fluid into your pelvis which can be uncomfortable. This ovulation pain (also called ‘mittelschmerz’, German for ‘middle pain’) can be sharp or like toothache, really low down near your hip bone on one side, but it usually lasts only twelve to twenty-four hours. Many women are quite anxious about this kind of pain and are horrified by the idea of a cyst bursting in their tummies. But it’s a positive sign that their bodies are working the way they should, which reassures most people. There may also be a little bit of bleeding at this time; ovulation bleeding only happens in about 3 per cent of cycles,2 but it’s certainly nothing abnormal that you need to worry about. It happens due to a momentary drop in oestrogen.

After the egg is released, a shell of the original follicle, called the ‘corpus luteum’ is left behind in the ovary, which starts to release progesterone – the pro-pregnancy hormone. One of its main roles is to ensure the lining is fully preened and plumped up for the arrival of a fertilised egg. Progesterone levels are at their highest seven days after ovulation, and if fertilisation has not occurred, the corpus luteum eventually throws its hands up in the air and says, ‘I can’t do this any more. I’m bored of pumping out all this progesterone to no avail. I’m out of here!’ It then slowly starts to degrade, and this causes a drop in both oestrogen and progesterone, which means the growth of the endometrium is no longer supported, so it begins to fall away. This is your period and the cycle starts again.

Variations in cycle length

It’s normal for there to be some variation in the length of your menstrual cycle on a month-to-month basis.

A lot of mums of teenage girls contact me online, worried that there is something wrong with their daughters because they are only having periods every two or three months. But this is quite common when your periods start because the hormone cycles are still synchronising, and also coming up to the menopause when you have fewer eggs left, meaning you’re less likely to ovulate as easily. Cycles are typically shortest and most regular in your twenties and thirties. Any variation in the length of the cycle at any age will be due to changes in the follicular phase because the length of the luteal phase is pretty standard being dictated by the lifespan of the corpus luteum.3 (See Chapter 4 for other factors affecting cycle length besides age.)

Menstrual cups, tampons, pads … ?

There are an overwhelming number of ‘menstrual-hygiene’ products on the market; I’m not hugely keen on the term because I think it perpetuates the myth of periods being ‘dirty’.

Menstrual cups, tampons, pads … I’m constantly asked which are ‘the best’, and, to be honest, from a health point of view there is no shining star – so I’d advise you to use whichever makes you feel most comfortable.

Menstrual cups

There may be a few furrowed brows at the mention of ‘menstrual cups’. If you are wondering, they are small and egg-cup-shaped and made of a soft silicone, which you insert into your vagina, where they sit collecting blood as it comes out of the cervix. There’s only one small study that has ever compared tampons and cups head to head and actually found greater satisfaction with cups compared to tampons, but it didn’t find any difference in terms of infections4 and there don’t appear to be any clear health benefits. The main advantage is that they are probably better for the environment and will definitely save you money in the long run. But don’t feel you have to use them. I don’t recommend them for the squeamish, as you have to be quite cool about putting your fingers into your vagina to insert them (they don’t come with an applicator like tampons), and it takes a bit of patience to learn how to remove them. After writing an Instagram post on menstrual cups I received a flurry of messages from women sharing the horror stories and proud moments of their first time. The most common initial problem seems to be difficulty removing it. Do not underestimate the strength of the vacuum that a menstrual cup can make with the cervix. However, you’ll quickly learn how to break the vacuum and remove it like a pro.

I’m frequently asked if it’s OK to use them with a contraceptive coil. Different manufacturers have different ideas on this, some saying it’s OK, others saying it should be avoided. This is because theoretically you could dislodge your coil with the aforementioned vacuum effect – something that has, in fact, been confirmed by several women who have contacted me via social media saying they managed to suction out their coil: ‘Anita, I’ve saved my coil, can you put it back in?’ was one SOS message I recently received from a friend. But while I’m all for recycling, you can’t reuse a coil, so I promptly replied, ‘Sorry, darling, you need a fresh one!’ If you do choose to use a cup with a coil, I would advise checking the strings at the end of your period. If you feel they are lower than normal, you can feel the rod of the coil or you can’t feel any strings at all, I would use condoms until you’ve had it checked by a doctor to ensure it’s still in the right place to give you full contraceptive protection.

Tampons

Just as menstrual cups may not be for everyone, the same goes for tampons. Some women just don’t feel comfortable putting something inside themselves. Others find it too painful. This may be due to tight pelvic-floor muscles or not being relaxed enough or, in my experience, endometriosis, probably due to inflammation and scarring in the pelvis. One study suggested that tampon use is protective against endometriosis,5 but I think this finding is skewed by the fact that a lot of patients with endometriosis don’t use tampons because it’s too uncomfortable to put them in or because their period is so heavy that a tampon isn’t going to cut it.

Toxic-shock syndrome

Toxic-shock syndrome (TSS) is caused by bacteria and has nothing to do with any kind of chemical that is in the tampon itself. Staphylococcus aureus is a type of bacteria commonly found on the skin, and a particular form can produce a toxin called TSST-1. On entering the bloodstream, this can cause a massive inflammatory reaction, usually characterised by a really high fever, vomiting, skin rashes and aching muscles. But, unhelpfully, it doesn’t always lead to any symptoms ‘down there’ which would make it easier to identify the cause. It can be life-threatening and requires urgent medical attention. It’s also incredibly rare, with only about forty cases per year in the UK, around half of which are thought to be related to tampon use (the other half are seen in children, men and older women, and are typically associated with skin burns and infections).

The ways that tampon use can potentially increase the risk of TSS include:

 collecting blood and increasing vaginal pH to create a breeding ground for bacteria

 causing tiny little micro-tears in the vaginal wall on insertion and removal, which allow bacteria to enter the bloodstream (it has been suggested that menstrual cups are safer in this regard, although I disagree; there has been a reported case of TSS with menstrual-cup use,6 probably because it too can cause vaginal abrasions and potentially create the right bacterial breeding ground.

On balance, I don’t think there’s any reason for the social media-based frenzy related to tampons, or enough evidence for changing your practices, especially because TSS is so rare.

Pads

Let’s not forget pads now. They might not be the sexy option these days, but they’re still incredibly useful, especially for light days, and a godsend to the many women who don’t like tampons or cups. To be clear, you don’t need the scented ones, which some women find cause irritation to the delicate vulval tissue. Reusable pads, as well as periods pants, with an inbuilt absorbable pad, are also increasingly popular. These are better for the environment, and there’s no difference between them and disposable pads from a health perspective.

THINGS YOU’VE ALWAYS WANTED TO KNOW, BUT WERE TOO AFRAID TO ASK

Should I track my menstrual cycle?

I’m a massive fan of cycle tracking and usually recommend the Clue app (see Resources). It stops you being caught short without pads or tampons and can be really useful in helping you to recognise patterns in symptoms that you might get at particular times of the month. I breathe a sigh of relief when a patient gets her phone out to tell me all about her periods because it makes things so much easier to pinpoint; and if you haven’t been doing it, we will often give you a menstrual-cycle tracking chart to fill in for the next few months.

I started tracking my period as a way of reassuring myself that the pain in my side every month was ovulation pain and not some dreadful case of appendicitis; all doctors are hypochondriacs to some extent. I did my medical-school elective on a tiny island in Fiji, where I had what I now realise was terrible ovulation pain, but at the time I was panicking and planning how I would get airlifted out to get my appendix removed because I didn’t want to undergo surgery in our operating theatre, which was essentially a shed with a bright light. It was the worst twelve hours of my life! (And I’ve also seen the occasional woman arrive at A&E with the same fear.)

What is a fake period?

I’ve heard people referring to periods on the Pill as ‘fake periods’, which can cause a bit of anxiety. What they mean is that the bleeding is due to the hormones in the Pill, unlike a ‘true period’, in which the bleeding is caused by your body making the necessary hormones. When you stop taking your Pill it mimics the last few days in your cycle where the corpus luteum is dying away, so the levels of synthetic hormones from the Pill are dropping, which causes the lining to fall away.

I’m often asked: ‘If it’s a fake period, does that mean I could still be pregnant?’ And the answer is, ‘No’. If you have a bleed on the Pill when you have your week-long break, then you are not pregnant.

Are organic tampons better?

Many concerned women have contacted me asking if they’re harming themselves by using conventional tampons, which, if you believe the hype, contain bleach plus cancer- and endometriosis-causing toxins. These claims are entirely unfounded, as very sophisticated lab techniques have failed to pick up any of these compounds in non-organic tampons.7 Dioxins are a type of toxin that seem to get the most attention, but you actually ingest way more of these through your diet than you ever could through a humble tampon.8 At present there is no scientific evidence to show organic tampons are better for health or any less likely to be associated with TSS. But they’re definitely more expensive.

Some people have said they find organic tampons less irritating, and while there’s no specific mechanism for why that might be the case, if you do find you’re not satisfied with your current brand, you have nothing to lose by changing to an organic brand to see if it makes a difference. But my medical (and non-medical) opinion is: if it ain’t broke, don’t try to fix it.

Can I stop my period if I’m going on holiday?

Yes, and there are two ways to do so.

If you’re on the combined oral contraceptive pill (COCP) The COCP is the type you take for twenty-one days and then have a break for seven days, during which you would have your period. If you want to stop your period, it’s OK to take up to three packs in a row without a break. You won’t have a bleed because you maintain a constant hormone level, although some people will find they get some cramping and spotting, especially towards the end of the third pack.

If you’re not on the COCP In this case, your GP can prescribe Norethisterone, a synthetic progestogen tablet that you take three times per day, starting about ten days before your period is due and continuing for the duration of your trip/the time for which you want to stop your period. Your period will usually start about two days after stopping the tablets. Again, they can cause cramping and spotting and your period might be heavier than normal.