The menstrual cycle is a truly gender-specific process that has a profound effect on women’s lives. When viewed in the general context of biological rhythms, the menstrual cycle requires a complex sequence of physiological events coordinated by the hypothalamus in conjunction with the pituitary glands, ovaries, and uterus, along with the adrenal and thyroid systems, and that adapts to environmental phenomena. Derived from the Latin mensis (month), the menstrual cycle is marked by the shedding of the
uterine lining—menstruation, or a menstrual “period.” We start menstruating at 11–12 years of age (menarche) and have our last menstruation at about 51 years(menopause). With a few interruptions, such as pregnancy or taking the Pill, women will have about 400 periods during their lifetime.
Menstrual period and menstrual cycle are not one and the same: menstrual period refers to the days that a woman bleeds. An average length of a period is 5 days; about half of all women bleed for 3–4 days and another 35% bleed for 5–6 days (Voda, Morgan, Root, & Smith, 1991). The term menstrual cycle (or menstrual cycle interval) refers to the span of time from the start of one period to the start of the next. The length of a menstrual cycle can range from 21 to 35 days, with 29 days as the average.
The basic facts about the cyclical changes in hormonal levels and in the reproductive organs are well-known and appear in many medical and nursing textbooks (Fogel & Woods, 1995; Speroff, Glass, &Kase, 1999). The neuroendocrine mechanisms which control the reproductive cycle are by no means completely understood. Most interest has focused on the ovarian hormones estrogen and progesterone, and on their influence on the release of follicle stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland at the base of the brain. Not only a physiologic process, menstruation is associated with feminine role development and feelings of health and well-being, and it is embedded in the sociocultural context of women’s experience. Nursing scholarship and science focused on menstrual-cycle phenomena can be traced to the care our profession provided to women and their children beginning with Lillian Wald’s work among the poor women of New York, Margaret Sanger’s efforts to help women control their fertility, and Mary Breckenridge’s efforts to provide maternity care in the rural Kentucky Hills.
Since the late 1970s, nursing research has contributed in unique ways to understanding menstrual cycle events—menarche, menstruation, and menopause—as normative experiences and symptoms related to the menstrual cycle and menopause as illness experiences. In contrast, during the same period, biomedical research has focused on understanding the problems related to menstruation and menopause as disease or risk factors for disease with little attention to the interaction of psychosocial, behavioral, cultural, or health factors. Nursing science and scholarship have contributed new conceptual models, advanced research methods, and new interventions that link therapeutics with advocacy. Nurse investigators have explored phenomena such as beliefs and attitudes among menarche al girls, menstrual cycle characteristics and premenstrual changes among adult women, experiences typical of menopausal transition among midlife women, as well as examining the menstrual cycle experiences in populations seldom studied, such as disabled women, athletes, shift workers, toxic exposures in oncology nurses, diabetic women, and beyond those of gynecology clinic populations to the broader spectrum of healthy community samples. They have contributed to work complementing biomedical research in describing physiologic patterns across the menstrual cycle, developing diagnostic categories and criteria for phenomena such as dysmenorrhea, premenstrual syndrome, pre-menstrual dysphoric disorder, and therapies for problems related to menstruation and menopause.
Nurses with a concern for women’s health have historically included feminist approaches in their clinical practice as well as their research. Angela McBride (McBride & McBride, 1981) was one of the first nurse scholars to embrace feminist theory as a research paradigm, calling for a reframing of gynecological disease within the greater context of a woman’s everyday life. The early nursing literature related to the menstrual cycle reflects a definition of health grounded in everyday life (gynecology) and not just clinical definitions of health such as risk fac-tors and diseases (gynecology) (McBride, 1993). Nurses have focused their study on biopsychosocial response patterns, normative or developmental transitions, functional status, role performance, adaptation to environmental demands, and high-level wellness (Woods, 1988). Nursing research has helped to focus women’s development and normative transitions (menarche and menopause) as normal rather than deficiency conditions that need medical treatment (Andrist &Mac Pherson, 2002). Feminist methods of inquiry have been expanded by nurse researchers to provide information “for” women rather than merely “about” women. For example, nurse investigators’ use of methods such as researcher-in-relation, reflexivity, and social transformation to understand women’s perimenstrual and menopausal symptom experiences provides the basis for women-centered therapeutics.
In the past decade, multidisciplinary efforts have increased our power to institute change in women’s health status through cross-disciplinary research, building on the wisdom of early pioneers. For example, the Society for Menstrual Cycle Research (SMCR), a multidisciplinary organization with strong nursing leadership, has been the vanguard of the movement away from a reductionist perspective to a more comprehensive approach to the study of women’s health (SMCR web site). Since 1977, the Society’s published research conference proceedings have provided an invaluable chronology of research on the menstrual cycle and advanced thinking across several disciplines: nursing, psychology, sociology, epidemiology, anthropology, biostatistics, physiology, medicine, and literature (SMCR web site). Instead of a circumscribed phenomenon peculiar to sex hormones, the Society defined the menstrual cycle in the context of other biorhythms of human variability or a sociocultural network of meanings, and of a new understanding of how the endocrine system interacts with other functions.
Nursing research has been at the forefront in the study of normative experiences of menstrual cycle events. Menarche presents nurses with a unique opportunity to address health promotion issues, particularly those related to reproductive and sexual health of school age girls. In a review of nursing research contributions to menstrual cycle research (Woods, Mitchell, & Taylor, 1999), investigators addressed images of menstruation presented to menarcheal girls, menstrual attitudes, symptoms, and the relationship of recalled menarcheal experiences and attitudes to adult women’s subsequent experiences of symptoms. Since the last Encyclopedia of Nursing Research review by Reame, Medline and CINAHL searches yielded 34 published papers related to menstrual function and alterations related to daily activities, menstrual attitudes and knowledge, and preparation for menarche across multiple cultures. In contrast to the last review, the cultural and ethnic context is addressed by nurse researchers more than by other disciplines. These studies of menarcheal experiences and programs for menarcheal preparation in 12 cultures, including African-American girls, provides an expansive understanding of the developmental opportunity presented by menarche. More recently, nurses have been at the forefront of translating research to practice in the development of menstrual health advocacy groups (Red Web Foundation) and internet-based education (www.redspot.org).
Early efforts to understand the normative experience of menstruation and menstrual symptoms as illness experiences have included studies of healthy community-based populations of women. From these studies, we have been able to estimate the normative experiences of women and identify some that are idiosyncratic.
The Tremin Trust Database, first administered by Ann Voda at the University of Utah and now at Pennsylvania State University, represents a national resource of information about women’s menstrual cycles that includes data from over 5,000 women spanning four generations (Voda, 1991). From the Tremin Trust Database it is possible to follow women from menarche through menopause and in some instances to do so for three generations.
This database has provided important information about menstrual cyclicity across the reproductive years, length of cycles and bleeding episodes, regularity, and estimates of menopause. Since the early 1980s, nurse researchers have expanded the scope of explanatory models and methods for menstrual cycle research. Woods and colleagues have systematically examined how symptoms synchronized to the menstrual cycle are influenced by the context of social class, education, race, marital status, self-esteem, occupation, and menstrual attitudes (Woods, Most, & Longenecker, 1985). They have documented the dynamic nature of symptom formation across and within individuals in response to their changing social environments (Taylor, Woods, Lentz, & Mitchell, 1991). A by-product of nursing studies has been the development of improved designs and methods for the biobehavioral assessment of menstrual cycle phenomena (Woods, Most, & Dery, 1982; Shaver & Woods, 1986; Taylor, D., 1990; Mitchell, Lentz, & Woods, 1991; Reame, Kelch, Beitins, Yu, Zawacki, & Padmanabhan, 1996; Woods, Mitchell, &Lentz, 1999; Mitchell, Woods, & Mariella, 2000; Woods, Mitchell, & Mariella, 2002). Such methods have included the measurement of menstrual flow absorbency, assessment of perimenstrual symptom patterns and cluster types, statistical methods for handling the detection of LH pulsatile secretion, and comparison of daily menstrual symptoms across cycles of the same individual. The Washington Women’s Daily Health Diary includes a menstrual symptom severity list of positive and negative experiences. It has been used by several nurse researchers to define a variety of menstrual cycle symptom patterns, including menarcheal and menopausal experiences. Nursing research on menopause, like that on the menstrual cycle, has emphasized studies of normative experiences. A review of the literature contains rich descriptions of symptoms associated with menopause, including studies of hot flashes, sleep problems, and depression (Woods, Mitchell, & Taylor, 1999). In addition, nurses have focused on the meanings of menopause, women’s attitudes toward the experience, and the social context in which it occurs and how the social context modifies the experience. In a recent review of nursing research on the menopausal transition, Andrist and MacPherson (2002) demonstrated that nursing research has helped to refocus women’s development and developmental transitions as normal rather than deficiency conditions that need medical treatment. Nursing scholars have also focused on the experience of menopause across cultures (George, 1996; Punyahotra &Street,1998; Meleis & Park, 1999; Berg & Taylor,1999), studies of decision processes women use in arriving at a commitment to use (or notuse) hormone therapy (Rothert &O’Connor,2002), and more recently on nonhormonal symptom management strategies (Cohen, Rousseau, & Carey, 2003).Nursing research results reflect a wide range of studies with women seeking care in clinical settings as well as community-based populations of women. Comorbidity in these samples remains a challenge, as does accounting for the influences of oral contraceptives, other drugs, psychiatric history, age, ovulatory status, and characteristics of the menstrual cycle. Encouraging is the promotion of the menstrual cycle as the “fifth vital sign” to be incorporated into all women’s health assessment.
There is only beginning work focusing on biological changes surrounding menarche and in relation to symptoms. More studies of menarcheal preparation are needed to provide young girls with optimum preparation for healthy experiences of menstruation and their sexuality. The type of information girls need, beyond how to cope with the hygienic challenge of menstruating, is yet to be defined. Psychoeducational interventions for school-age girls provided by school nurses is
an area for continuing study.
What is needed for future menopause-related research are studies of health education interventions, such as those designed to reduce women’s uncertainty about the experience. In addition, primary care models of therapeutics for menopause are needed.There is an acute need to find nonpharmacological and culturally-appropriate options for symptom management for symptoms such as hot flashes and sleep disturbances