In 2015, the American Association of Obstetrics and Gynecology (ACOG) published a position paper with far-reaching implications for the practice of medicine. The American Pediatric Association supported the position paper. The paper had the potential to change the medical attitude towards menstruation and the menstrual cycle.
For the first time in its history, ACOG, which represents some 60,000 U.S. gynecologists, put forth the radical idea that menstruation should be treated as an essential part of individual health and that it is the responsibility of physicians to prepare each pre-adolescent and their parents for the onset of menses and to regularly assess various aspects of the menstrual cycle among those who already have their periods.
The document defines menstruation as the fifth vital sign – a vital sign comparable to the other four vital signs: heart rate, body temperature, respiration rate and blood pressure. If one of these signs malfunctions, then overall health is compromised, not only fertility. The absence of a regular, natural and normal menstrual cycle, necessitates inquiry. The document presents a protocol for both family physicians and gynecologists. It recommends that at each clinic visit, the practitioner ask about regular/irregular bleeding, the length of the menstrual cycle (between 21-35 days is considered normal), the amount of bleeding and the number of days of staining. In addition, attention should be paid to the physical and emotional aspects of the menstrual experience, such as pain, patterns of staining, mood changes, and more. The physician should also be informed about unexplained bleeding, as this might be an indication of a serious problem.
Acknowledging the essential role of the menstrual cycle and the hormones which not only control the cycle but impact the functioning of many organs in the body, is no trivial matter. In fact, the importance of a healthy menstrual cycle was demonstrated in a recent article published in the British Medical Journal. A long-term study ( Sept. 2020), that has been following a cohort of 80,000 nurses in the U.S. for 24 years now, found that natural and regular menstrual cycles actually affect life expectancy, and that abnormal, irregular cycles, especially from a young age, are associated with premature mortality! Who knew?
The understanding that there is a direct relationship between regular menstruation and overall health (not just fertility), is an idea that still wanes on the fringe margins of conventional medical consciousness. There is a huge gap between the values and attitudes that gynecologists hold about menstruation and what they should know and preach. Medical understanding and practice needs to extend beyond a limited, superficial mindset of “cycles are related to fertility, pregnancy and reproduction” or “periods are a nuisance for many and cause all kinds of problems which can be solved with hormonal birth control (HBC).” Ignorance about the cycle plagues our culture as a whole, perpetuated by centuries of taboos and stigmas about menstruation, biological determinism of the “weaker sex,” and the historical legacy of misogyny, shame, silence and embarrassment. Western medicine needs to step up and talk the talk (beyond position papers) and shift its focus from seeing the menstrual cycle less as a cause of (potential) pathology and more as an asset, as a fifth “vital sign” of health.
Significant numbers of adolescents and older females suffer from menstrual irregularities related to endometriosis, PCO/S, and nutritional deficiencies, to name a few. How can it be that in the modern age, physicians do not communicate the true message that the absence of regular ovulation and cycles is an indication of a (health) problem? And that these health problems cannot be cured by HBC?
Why do physicians not see their role as one of helping their patients understand the most basic facts about the menstrual cycle? Instead of hearing or dismissing a patient who says “I get my period twice a month (something which is physiologically impossible), why keep her in the dark? Why not explain the difference between a real period, breakthrough bleeding, and bleeding which occurs during the week of a Pill break. Patients want information and honest communication from their providers.
When society denigrates and dismisses the importance of regular menstrual cycles, then so do physicians. As long as menstruation is perceived as a negative- a hassle and a burden, and a source of pathological distress, then it becomes difficult to recognize the value and the importance of the cycle and hormonal balance as a fifth, vital sign. If our culture, including doctors, does not begin to normalize and affirm the value of the menstrual cycle, more than half of the population is going to pay a painful price.
Pathologizing the menstrual cycle leads to the use and over-use of hormonal medications for treating a huge array of period problems. In fact, prescribing HBC has become the easy default. Notice how the following questions are followed by the same answer:
Does your period hurt? Is it irregular? Do you suffer from acne? Bad PMS? Mood swings? Do you experience heavy or irregular bleeding? Do you not menstruate? Is your period an inconvenience? Do you want more sexual freedom? – IF YES -JUST TAKE HBC!
What is worse than HBC being the default treatment for so many problems is that these medications only treat the symptoms rather than the root of the problems. Hormonal medications do not cure hormonal or period problems; HBC only masks and hides underlying problems, which may never get diagnosed or treated (PCO/S is a classic example) or only discovered years later when repeated attempts to get pregnant fail.
When physicians encourage their patients to give up ovulation as a “quick fix,” prescription for “candy pills,” they are conveying a disturbing message- that the cycle is something marginal, optional and non-essential. If physicians do not value the cycle as something important, then adolescents, their parents and peers won’t either. If physicians do not communicate the science that a regular cycle and balanced hormones are essential for many systems in the body, and not just for fertility and childbirth, then all women are going to pay a price. Menstrual cycle hormones work together with dozens of other hormones, in synchronization, and they have a beneficial effect on heart and arterial health, the breasts, the bones, brain function and cognition, sexuality, mental health, the thyroid, vaginal tissue, and on the urinary, digestive and nervous systems. So while the ACOG “manifesto” gave lip-service to the idea that the menstrual cycle is a barometer of health, doctors continue (mostly out of convenience) to prescribe HBC for an ever-growing list of “issues,” having no qualms about “cancelling” or suppressing the cycle when something goes awry.
It is truly disturbing that physicians and medical organizations do not use their voices and influence as leaders for promoting menstrual health education. When so many factors can jeopardize hormonal balance, fertility and overall health, including environmental, pharmaceutical, cultural, nutritional and even psychological- why don’t physicians speak up? When modern living puts girls and women at risk for many reproductive and hormonal problems (e.g. poor nutrition and food quality, overweight and underweight, artificial hormones in our food supply, smoking, eating disorders and restrictive diets, toxic chemicals in our water, food, air and homes) – physicians should be the first to sound the alarm. They are the ones who see the fall-out, every day in their clinical practice. They should care, more.
One of the reasons that modern medicine does not have the tools for curing and fixing hormonal disturbances is a lack of research and a lack of priority, even though these health issues and threats impact the quality of life of millions. It is hard to track down hard data but if there was, we might be appalled to see one in three or one in four females suffers from some form of period problem. HBC may be a quick fix but its not a long-term solution. The most common period problems which impact fertility and health of nearly a third of all females are associated with poly-cystic ovaries (PCO/S), endometriosis, disordered eating, nutritional imbalances, obesity and endocrine disruption. This is a huge number of people! In medical culture, these problems are typically addressed by prescribing HBC when someone doesn’t want to conceive, and with other hormonal and invasive treatments when pregnancy is the goal. It is time to get beyond this simplistic formula and meet the real and urgent health needs of so many affected by these conditions.
It is time to reframe the subject of menstruation and menstrual cycles, first by ending the mind-set of pathologizing the cycle and second by acknowledging its value and importance to reproductive and overall health. As a society, it is time to wake up and realize that pharmaceutical solutions to common health problems are temporary band-aids, which do more for yielding profits for pharmaceutical companies than they do for yielding health benefits for consumers and patients.
When medical practitioners begin to talk the talk (ACOG statement) and walk the talk, they will contribute so much more to improving the health and quality of life of those they serve. But until then, if you or someone you know suffers from menstrual problems such as heavy or prolonged bleeding, irregular cycles, pain, acne, etc.- know that there are many effective therapeutic approaches in natural medicine, including dietary changes, nutritional supplements, herbs, exercise, Chinese medicine, naturopathy and various body-mind interventions, No one should suffer during their periods. Natural approaches are available and accessible. Hormonal medications are not the only default. The choice is ours. The responsibility is ours. Your health is literally in your hands.
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