MENSTRUAL HYGIENE

INTRODUCTION

Adolescence is a tough time for many teens; these young people face many pressures.
Menstruation is a vital sign of good reproductive health in females. Girls typically start to
menstruate during puberty or adolescence, typically between the ages of 11 to 19.
Adolescent girls constitute a vulnerable group, particularly in India where female child
is neglected one. Menstruation is still regarded as something unclean or dirty in Indian
society. The reaction to menstruation depends upon awareness and knowledge about the
subject.

The manner in which a girl learns about menstruation and its associated changes may
have an impact on her response to the event of menarche. If girls and women are to live
healthy productive life then menstrual hygiene is a priority.

ANATOMY OF THE FEMALE REPRODUCTIVE SYSTEM:

 External Genitalia (Vulva, Pudendum)

 The vulva includes mons pubis, labia majora, labia minora, clitoris, vestibule and
conventionally the perineum. These are all visible on external examination.
 It is, therefore, bounded anteriorly by the mons veneris, laterally by the labia majora and
posteriorly by the perineum.

 Mons veneris (mons pubis)

 It is the pad of subcutaneous adipose connective tissue lying in front of the pubis and, in
the adult female, is covered by hair.

 Labia Majora
 The vulva is bounded on each side by the elevation of skin and subcutaneous tissue,
which form the labia majora.
 They are continuous where they join medially to form the posterior commissure in front
of the anus.
 The inner surface of the labia majora are hairless. The labia majora are covered with
squamous epithelium and contain sebaceous glands, sweat glands and hair follicles.
 The labia majora are homologous with the scrotum in the male.

 Labia Minora
 Labia minora are two thick folds of skin, devoid of fat, on either side just within the
labia majora.
 Anteriorly, they each other in front and behind the clitoris to form the prepuce and
frenulum, respectively. The lower portion of the labia minora fuses across the midline
to form a fold of skin known as fourchette.
 The labia minora do not contain hair follicle. The folds contain connective tissues,
numerous sebaceous glands, erectile muscle fibers and numerous vessels and nerve
endings.
 It is homologous to the ventral aspect of the penis.

 Clitoris
 Clitoris is a small cylindrical erectile body, measuring about 2.5 cm situated in the
most anterior part of the vulva.
 It consists of glans, a body and two crura. The glans is covered by squamous
epithelium and is richly supplied with nerves.
 Clitoris is analogue to the penis in the male, but it differs basically in being entirely
separate from the urethra.

 Vestibule
 Vestibule is a
triangular space
 bounded anteriorly by the clitoris, posteriorly by the fourchette and on either side by
labium minus.
 There are four openings into the vestibule:
1. Urethral opening : The opening is situated in the midline, just in front of the vaginal
orifice about 1–1.5 cm below the pubic arch. The paraurethral ducts open either on the
posterior wall of the urethral orifice or directly into the vestibule.
2. Vaginal orifice and hymen : The vaginal orifice lies in the posterior end of the
vestibule and is of varying size and shape. It is incompletely closed by a septum of
mucous membrane, called hymen.

 Bartholin’s Gland
 The Bartholin’s glands are situated in the superficial perineal pouch, close to the
posterior end of the vestibular bulb. They are pea-sized, of about 0.5 cm and yellowish-
white in color.
 Each gland has got a duct which measures about 2 cm and opens into the vestibule,
outside the hymen at the junction of the anterior two-third and posterior one-third in the
groove between the hymen and the labium minus.
 The duct is lined by columnar epithelium but near its opening by stratified
squamous epithelium. The Bartholin’s gland corresponds to the bulbourethral
gland of male.

 Blood supply of the vulva

 Arteries: (a) Branches of internal pudendal artery— the chief being labial, transverse
perineal, artery to the vestibular bulb and deep and dorsal arteries to the clitoris.
(b) Branches of femoral artery—superficial and deep pudendal.

 Veins: The veins form plexuses and drain into— (a) internal pudendal vein, (b) vesical
or vaginal venous plexus, and (c) long saphenous vein. Varicosities during pregnancy are
 not uncommon and may rupture spontaneously causing visible bleeding or hematoma
formation.

 Nerve supply of the vulva

 The supply is through bilateral spinal somatic nerves. Anterosuperior part is supplied by
the cutaneous branches from the ilioinguinal and genital branch of genitofemoral nerve
(L1 and L2) and the posteroinferior part by the pudendal branches from the posterior
cutaneous nerve of thigh (S2,3,4).
 Between these two groups, the vulva is supplied by the labial and perineal branches of
the pudendal nerve (S2,3,4).

 Internal Genital Organs

The internal genital organs in female include vagina, uterus, fallopian tubes, and the ovaries.
These organs are placed internally and require special instruments for inspection.

 Vagina
 The vagina is a membranous sheath
communicating the uterine cavity with the
exterior at the vulva.
 It constitutes the excretory channel for the
uterine secretion and menstrual blood. It is
the organ of copulation and forms the birth
canal of parturition.
 The canal is directed upwards and
backwards forming an angle of 45° with
the horizontal in erect posture.
 The diameter of the canal is about 2.5 cm,
being widest in the upper part and
narrowest at its introitus. It has got enough power of distensibility as evident during
childbirth.
 The pH is acidic and varies during different phases of life and menstrual cycle.
  The uterus
 The uterus is a hollow pyriform muscular organ situated in the pelvis between the
bladder in front and the rectum behind .
 Position: Its normal position is one of the anteversion and anteflexion.
 Measurements and parts: The uterus measures about 8 cm long, 5 cm wide at the
fundus and its walls are about 1.25 cm thick. Its weight varies from 50–80 g. It has got
the following parts:
• Body or corpus • Isthmus • Cervix

 Body or corpus: The body is further divided into fundus—the part which lies above the
openings of the uterine tubes. The body properly is triangular and lies between the
openings of the tubes and the isthmus.
 Isthmus: The isthmus is a constricted part measuring about 0.5 cm situated between the
body and the cervix
 Cervix: The cervix is the lowermost part of the uterus. It extends from the histological
internal os and ends at external os which opens into the vagina. It is almost cylindrical in
shape and measures about 2.5 cm in length and diameter. The physical and chemical
properties of the cervical secretion change with menstrual cycles and with pregnancy. The
cervical glands secrete an alkaline mucus with pH 7.8.

 Fallopian tube (uterine tube) The uterine tubes are paired structures, measuring about
10 cm (4"). Each tube has got two openings, one communicating with the lateral angle
of the uterine cavity, called uterine opening and measures 1 mm in diameter, the other is
on the lateral end of the tube, called pelvic opening or abdominal ostium and measures
about 2mm in diameter.
 Parts: There are four parts, from medial to lateral, they are—
(1) intramural or interstitial lying in the uterine wall and measures 1.25 cm (1/2") in length
and 1 mm in diameter;
(2) isthmus almost straight and measures about 2.5 cm (1") in length and 2.5 mm in
diameter;
(3) ampulla—tortuous part and measures about 5 cm (2") in length which ends in wide;
(4) infundibulum measuring about 1.25 cm (1/2") long with a maximum diameter of 6 mm.
 The ovary
 The ovaries are paired sex glands or gonads in female which are concerned with:
i. Germ cell maturation, storage and its release.
ii. Steroidogenesis.
 Each gland is oval in shape and pinkish grey in color .
 It measures about 3 cm in length, 2 cm in breadth and 1 cm in thickness.
 Each ovary presents two ends—tubal and uterine, two borders—mesovarium and free
posterior and two surfaces—medial and lateral.

 Structures: The ovary is covered by a single layer of cubical cell known as germinal
epithelium. The substance of the gland consists of outer cortex and inner medulla.
1. Cortex: It consists of stromal cells which are thickened beneath the germinal
epithelium to form tunica albuginea. During reproductive period (i.e.from puberty to
menopause), the cortex is studded with numerous follicular structures, called the
functional units of the ovary in various phases of their development. These are
related to sex hormone production and ovulation. The structures include primordial
follicles, maturing follicles, Graafian follicles and corpus luteum.

2. Medulla: It consists of loose connective tissues, few unstriped muscles, blood

vessels and nerves.
 PUBERTY
 The journey of growing up from a little
girl to a young woman is very exciting.
 Pituitary gland is a pea shaped gland in
the brain that releases hormones when
it’s time to grow.
 Hormones are chemical which can cause
different parts of the body to grow and
develop because of which there are
many physical and emotional changes.
 Many changes in the body is called puberty.

 Definition:
 Puberty is the period in life during which the reproductive organs reach maturity and
child changes to become an adult.
 Puberty in girls is the period, which links childhood to adulthood. It is the period of
gradual development of secondary sexual characters.
 There are profound biological, morphological, and psychological changes that lead to full
sexual maturity and eventually fertility.

 Pubertal Changes in Boys :

Gain height, hair growth in underarms and around genitals and Deeping of voice.

Puberty changes in girls:

 Growth: increase in height and weight.

 Widening of hips (pelvis)
 Deposition of fat and development of body
curves.
 Appearance of breast buds.
 Increase in size of breasts.
 Appearance of hair in groin and armpits.
 Enlargement in size of genitals
 White discharge from vagina.
 Beginning of menstrual periods
 MENSTRUAL CYCLE

 This is a series of events, occurring regularly in females every 26 to 30 days throughout

the childbearing period between menarche and menopause.
 The cycle consists of a series of changes taking place concurrently in the ovaries and
uterine lining, stimulated by changes in blood concentrations of hormones.
 Hormones secreted during the cycle are regulated by negative feedback mechanisms.
The hypothalamus secretes luteinising hormone releasing hormone (LHRH), which
stimulates the anterior pituitary to secrete :
 follicle stimulating hormone (FSH), which promotes the maturation of ovarian follicles
and the secretion of oestrogen, leading to ovulation. FSH is therefore predominantly
active in the first half of the cycle. Its secretion is suppressed once ovulation has taken
place, to prevent other follicles maturing during the current cycle.
 luteinising hormone (LH), which triggers ovulation, stimulates the development of the
corpus luteum and
the secretion of progesterone.
 The hypothalamus responds to changes in the blood levels of oestrogen and
progesterone. It is stimulated by high levels of oestrogen alone (as happens in the first
half of the cycle) but suppressed by oestrogen and progesterone together (as happens in
the second half of the cycle).
 The average length of the cycle is about 28 days. By convention the days of the cycle
are numbered from the beginning of the menstrual phase, which usually lasts about 4
 days. This is followed by the proliferative phase (approximately 10 days), then by the
secretory phase (about 14 days).

 Menstrual phase
 When the ovum is not fertilised, the corpus
luteum starts to degenerate. (In the event of
pregnancy, the corpus luteum is supported
by human chorionic gonadotrophin [hCG]
secreted by the developing embryo.)
 Progesterone and oestrogen levels therefore
fall, and the functional layer of the
endometrium, which is dependent on high
levels of these ovarian hormones, is shed in
menstruation.
 The menstrual flow consists of the
secretions from endometrial glands,
endometrial cells, blood from the
degenerating capillaries and the unfertilized ovum.
 During the menstrual phase, levels of oestrogen and progesterone are very low because
the corpus luteum that had been active during the second half of the previous cycle has
degenerated.
 This means the hypothalamus and anterior pituitary can resume their cyclical activity,
and levels of FSH begin to rise, initiating a new cycle.

 Proliferative phase
 At this stage an ovarian follicle, stimulated by FSH, is growing towards maturity and is
producing oestrogen, which stimulates proliferation of the functional layer of the
endometrium in preparation for the reception of a fertilised ovum.
 The endometrium thickens, becoming very vascular and rich in mucus-secreting
glands.
  Rising levels of oestrogen are responsible for triggering a surge of LH approximately
mid-cycle. This LH surge triggers ovulation, marking the end of the proliferative
phase.

 Secretory phase
 After ovulation, LH from the anterior pituitary stimulates development of the corpus
luteum from the ruptured follicle, which produces progesterone, some oestrogen, and
inhibin.
 Under the influence of progesterone, the endometrium becomes oedematous and the
secretory glands produce increased amounts of watery mucus. This assists the passage
of the spermatozoa through the uterus to the uterine tubes where the ovum is usually
fertilised.
 There is a similar increase in secretion of watery mucus by the glands of the uterine
tubes and by cervical glands that lubricate the vagina. The ovum may survive in a
fertilisable form for a very short time after ovulation, probably as little as 8 hours.
 The spermatozoa, deposited in the vagina during intercourse, may be capable of
fertilising the ovum for only about 24 hours although they can survive for several days.
This means that the period in each cycle during which fertilisation can occur is
relatively short.
 Observable changes in the woman’s body occur around the time of ovulation. Cervical
mucus, normally thick and dry, becomes thin, elastic and watery, and body
temperature rises by about 1°C immediately following ovulation. Some women
experience abdominal discomfort in the middle of the cycle, thought to correspond to
rupture of the follicle and release of its contents into the abdominal cavity.
 After ovulation, the combination of progesterone, oestrogen and inhibin from the
corpus luteum suppresses the hypothalamus and anterior pituitary, so FSH and LH
levels fall.
 Low FSH levels in the second half of the cycle prevent further follicular development
in case a pregnancy results from the current cycle. If the ovum is not fertilised, falling
LH levels leads to degeneration and death of the corpus luteum, which is dependent on
LH for survival.
 The resultant steady decline in circulating oestrogen, progesterone and inhibin leads to
degeneration of the uterine lining and menstruation, with the initiation of a new cycle.
 MENOPAUSE

 The menopause (climacteric) usually occurs between the ages of 45 and 55 years,
marking the end of the childbearing period.
 It may occur suddenly or over a period of years, sometimes as long as 10 years, and is
caused by a progressive reduction in oestrogen levels, as the number of functional
follicles in the ovaries declines with age.
 The ovaries gradually become less responsive to FSH and LH, and ovulation and the
menstrual cycle become irregular, eventually ceasing. Several other phenomena may
occur at the same time, including:
 short-term unpredictable vasodilation with flushing, sweating and palpitations,
causing discomfort and disturbance of the normal sleep pattern
 shrinkage of the breasts
 axillary and pubic hair become sparse
 atrophy of the sex organs
 episodes of uncharacteristic behaviour, e.g. irritability, mood changes
 gradual thinning of the skin
 loss of bone mass predisposing to osteoporosis
 slow increase in blood cholesterol levels that increase the risk of cardiovascular
disease in postmenopausal women to that in males of the same age.
 Similar changes occur after bilateral irradiation or surgical removal of the ovaries.

 MENSTRUAL IRREGULARITIES

INTRODUCTION:
Menstruation is the periodic discharge of blood, mucus, and epithelial cells from the uterus.
In normal healthy women, menarche occurs between the ages 10 and 16 years, mean age of
menarche being around 12.5 years. It usually occurs at monthly intervals throughout the
reproductive period, of life with an average rhythm of 28-30 days, inclusive of 4–6 days of
bleeding (except pregnancy lactation).

It is the end point in a series of events which begin in the cerebral cortex and
hypothalamus and ends at the uterus in the hypothalamic–pituitary–ovarian– uterine axis.
Any break in this axis creates menstrual problems. Excessive or inappropriately timed
menstruation and amenorrhoea are the most common complaints for which women seek
advice from medical healthcare providers.

Menstrual irregularities are common abnormalities of a woman's menstrual cycle.

Menstrual irregularities include a variety of conditions in which menstruation is irregular,
heavy, painful, or does not occur at all. Menstrual irregularities occur in 9% to 14% of
women of childbearing age.

DEFINITIONS OF MENSTRUAL CYCLE IRREGULARITIES :

1. Amenorrhoea: It indicates the absence of menstruation. It is a symptom and not a

disease entity.
2. Oligomenorrhoea : It denotes infrequent, irregularly timed episodes of bleeding usually
occurring at intervals of more than 35 days.
3. Polymenorrhoea: It denotes frequent episodes of menstruation, usually occurring at
intervals of 21 days or less.
4. Menorrhagia : It denotes regularly timed episodes of bleeding that are excessive in
amount (>80 mL) and/or duration of flow (>5 days).
5. Metrorrhagia: It refers to irregularly timed episodes of bleeding superimposed on
normal cyclical bleeding.
6. Menometrorrhagia: It means excessive, prolonged bleeding that occurs at irregularly
timed and frequent intervals.
7. Hypomenorrhoea : It refers to regularly timed but scanty episodes of bleeding.
8. Intermenstrual : It bleeding refers to bleeding (usually not excessive) that occurs
between otherwise normal menstrual cycles.
9. Precocious: It menstruation denotes the occurrence of menstruation before the age of 10
years.
10. Postcoital bleeding : It denotes vaginal bleeding after sexual intercourse.

1. AMENORRHOEA : Amenorrhea is the absence or lack of menstruation during the

reproductive years. Normal causes of amenorrhea include pregnancy, lactation and
menopause. Other causes can be pathologic and may include stress, excessive exercise, eating
disorders, weight loss, a low body mass index(BMI) or other potentially life threatening
disorders.
It is of two types, primary and secondary.

(a)Primary Amenorrhoea:
Primary Amenorrhoea is the absence of menarche until age 16 years or the absence of the
development of secondary sex characteristics and menarche till age of 14 years.
 Causes:
 Congenital obstructive defects such as imperforate hymen, vaginal septum, vaginal atresia
and non canalization of cervix in presence of functioning uterus leads to collection of
menstrual blood inside the genital tract i.e cryptomenorrhea. The young girl presents with
amenorrhoea cyclical abdominal pain, abdominal lump and at times retention of urine.
 Congenital absence or gross hypoplastic non-functioning uterus. The vagina too is absent.
 Congenital ovarian failure, or streak ovaries seen in Turner syndrome. Chromosomal
abnormalities account for 20% of cases of primary amenorrhoea.
 Adrenal gland. Addison’s disease.
 Thyroid gland. Cretinism and childhood myxoedema.
 Diabetes. Adolescence diabetes is associated with primary amenorrhea in 50% cases.
 Nutritional. Very poor nutrition occasionally causes primary amenorrhea.
 Hypothalmic disorders. Organic disorders such as tumours, encephalitis, fracture base of
the skull may cause primary amenorrhea.

 Symptoms:
 Failure to experience menarche when there has been development of secondary sex
characteristics.
 No menarche and absence of development of secondary sex characteristics as in Turner’s
syndrome.

Assessment:
A medical assessments should include:
 History of etiologic factors
 Physical examination for:
 Nutritional status
 Weights, height and vital signs
 Signs of eating disorder (hypothermia, bradycardia, hypertension, and reduced
subcutaneous fat)
 Androgen excess e.g. facial hair and acne
 Delayed puberty: absence of facial hair and axillary hair
 Laboratory tests for:
 U/S
 Thyroid function test
 Prolactine levels
 If high level FSH: indicate ovarian failure
 If high level of LH: indicate gonadal dysfunction
 Leprascopy

 Management:
Therapeutic interventions depend on the cause of amenorrhea:
 Estrogen replacement therapy (ERT) to stimulate development of secondary sex
characteristics and to prevent osteoporosis.
 Cryptomenorrhoea needs incision of the hymen. The vaginal septum needs excision and
drainage and later artificial vagina.
 Hormonal therapy for uterine hypoplasia.
 Improved nutrition.
 Treatment of the cause. Hypopituitarism and hypothalamic disorder may require GnRH,
FSH and LH.
(b) Secondary Amenorrhea:
It is the absence of menstruation for at least 6 months or for three cycles after menarche.

 Causes:
 Physiologic response to pregnancy, lactation or anovulation.
 Hypothyroidism or hyperthyroidism.
 Adrenal disease
 Chronic renal disease.
 Polycystic ovary syndrome
 Chronic hepatic disease.
 Anorexia nervosa
 Malnutrition
 Vigorous athletic training.

 Investigations:
 Thyroid function test
 Blood glucose level
 Laparoscopy to check ovarian pathology
 Ultrasound to check polycystic ovary syndrome.

 Management:
 Cyclic progesterone therapy if the cause is anovulation.
 Oral contraceptives for women who desire contraception.
 Bromocriptine if there is hyperprolactinemia.
 Gonadotropin- releasing hormone (GnRH), when the cause is hypothalamic failure.
 Thyroid hormone replacement for hypothyroidism
 Calcium and estrogen to prevent development of osteoporosis.

2. MENORRHAGIA:
 Definition: Menorrhagia is an abnormally heavy and prolonged menstrual period at
regular intervals. Normal menstrual cycle is 25-35 days in duration with bleeding lasting
an average of 5 days and a total blood flow between 25-80 ml .A blood loss greater than
80ml or lasting longer than 7 days constitutes menorrhagia (also called hypermenorrhea).

 Causes:
Usually no causative abnormality can be identified and treatment is directed to the
symptom rather than a specific mechanism. An overview of causes includes the
following:

Uterine :

 Endometrial polyp
 Submucosal fibroid
 Endometrial hyperplasia
 Endometrial adenomyosis

Ovarian
 Ovulatory DUB
 Anovulatory DUB
 Polycystic ovary syndrome

Others
 Hematological causes
 Leukemia
 Hypothyroidism, hyperthyroidism

 Diagnosis :
 Pelvic and rectal examination
 Pap smear
 Pelvic ultrasound scan is the first line diagnostic study for identifying structural
abnormalities.
 Endometrial biopsy to exclude atypical hyperplasia or endometrial cancer
 Hysteroscopy

 Treatment
When underlying cause can be identified, treatment may be directed at this. Clearly heavy
periods at menarche and menopause may settle spontaneously.

 Medications
 Iron supplements to counter anemia
 Non-steroidal anti-inflammatory drugs to reduce blood loss.
 Hormonal treatment for DUB:
- Oral contraceptives, usually combined estrogen, progesterone pills for few months
-Progesterone only pills or injection Depo- Provera
- Progesterone releasing intrauterine system (IUS)
 Other options:
- Antifibrinolytics: Gonadotropin-releasing hormone agonists

 Surgery:
Surgery treatment is rarely done to:
 Endometrial ablation
 Dilation and curettage
 Hysteroscopic myomectomy to remove fibroids

3. POLYMENORRHEA: Polymenorrhea or epimenorrhea is defined as cyclic bleeding

where the cycle is reduced to an arbitrary limit of less than 21 days and remain constant at
that rate.

 Causes:
 Dysfunctional uterine bleeding
 Common in adolescence, preceding menopause and following delivery, abortion,
hyperstimulation of ovaries by the pituitary hormone may be the causative factor.
 Ovarian hyperemia
 Seen in PID or ovarian endometriosis.

 Treatment:
 Hormone Therapy
Estrogen and progestogen are generally prescribed either separately or as combined oral
pills. The preparations of progestogen used are norethisterone acetate and
medroxyprogesterone acetate. Progestin alone therapy is highly effective in an ovular
DUB, while combined preparations of progestogen and estrogen are effective in ovular
type.Norethisterone preparations (5 mg tablets) are used three times a day till bleeding
stops, which is usually 3-7 days. Low dose combined oral pills (estrogen and
progestogen) used as cyclic therapy from 5 th to 25th day for three cycles in ovular
bleeding.

4. METRORRHAGIA :

Metrorrhagia is defined as irregular, acyclic bleeding from the uterus. It is mostly related to
surface lesions in the uterus. When the bleeding is so irregular and excessive that the
menstruation cannot be identified, it is called menometrorrhagia.

 Causes:
Acyclic Bleeding:
 Dysfunctional uterine bleeding (during adolescence, following childbirth or abortion and
preceding menopause)
 Submucous fibroid
 Uterine polyp
 Endometrial or cervical cancer

Contact Bleeding:

 Carcinoma cervix
 Mucous polyp of cervix
 Infections : Chlamydial or tubercular cervicitis.
 Cervical endometriosis.
 Intermenstrual Bleeding :
 Ovular Bleeding
 Breakthrough bleeding in pill users
 Intrauterine contraceptive device in utero.

5. OLIGOMENORRHEA:

Oligomenorrhea is defined as bleeding occurring more than 35 days apart and which
remains constant at that frequency.

 Causes:
 Age related : During adolescence and preceding menopause
 Obesity
 Vigorous exercise
 Endocrine disorders : Polycystic ovary syndrome (PCOS), hypoprolactinemia,
hyperthyroidism.
 Androgen producing tumors : Ovarian, adrenal
 Tuberculous endometritis

 Treatment:
Treatment according to the cause identified.

6. HYPOMENORRHEA

Hypomenorrhea is defined as menstrual bleeding that is unduly scanty and lasts for less than
2 days.

 Causes:
 Uterine synechiae
 Endometrial tuberculosis
 Use of oral contraceptives
 Thyroid dysfunction
 Malnutrition
 Premenopausal period

 Treatment : directed to specific cause.

7. DYSMENORRHOEA
 Many girls experience pain or cramps
discomfort associated with menstruation is
called dysmenorrhoea .

 Management of common problems associated with dysmenorrhoea:

 Anxiety about unexpected onset of periods Knowing when your period will arrive
will enable you to be prepared so it’s not a surprise. Keep a calendar and mark the
first day of your period. A normal period cycle is 28-33 days, but in your first few
years, it is normal for the menstrual cycle to be more unpredictable. Be prepared for
it. Keep a sanitary napkin with you in your bag especially around the time when your
periods are due.
 Stomach ache Hot fomentation can be used if the pain is unbearable. Take rest. Try
meditation, yoga and breathing exercises.
 Cramps Some girls have cramps during their periods. Cramps are actually uterus’
contractions. The uterus, which is like a pear-shaped muscle, helps get rid of the
endometrium, or lining of the uterus. These contractions that sometimes feel like
cramps are the body’s way of shedding, or getting rid the lining of the uterus,
through the vagina, and out of the body, as the lining is no longer needed that cycle.
 Excess flow and fatigue Follow a balanced nutritious diet, drink plenty of water.
Have bath with lukewarm water
 Itching in the genitals Wash and keep your genitals clean. Change the sanitary
napkin or cloth 5-6 times a day.
  Irritation and blisters in the thighs Apply coconut oil or spray talcum powder. Use
cotton inner garments of correct size.
 Blood flows in clots Mild exercise will regulate the flow.
 Feeling fat Just before and during the period, the body may tend to retain water. This
added fluid might make you feel fat or make your breasts feel tender. Actually, it is
normal to gain a couple of kgs during this time of the month – and lose them right
after your period. If one feels bloated, she may feel better wearing loose comfortable
clothing. immediately before and during the period less amount of salt to be
consumed because salt intake increases water retention.
 Vaginal discharge Vaginal discharge may be thin and clear, thick and mucous-like,
or long and stringy. A discharge that appears cloudy white and/or yellowish when
dry on clothing is normal. The discharge will usually change appearance at different
times during the menstrual cycle, and for a variety of other reasons, including
emotional or sexual arousal, pregnancy and use of oral contraceptive pills.
The following can be a sign of abnormal discharge and could indicate a health
problem:
 Discharge accompanied by itching, rash or soreness.
 Persistent increased discharge
 White, lumpy discharge (like curds)
 Grey/white or yellow/green discharge accompanying a bad smell

Sometimes emotional changes are experienced like short temper, aggression, anger,
anxiety or panic, confusion, lack of concentration, irritability, nervous tension, fatigue,
or depression around the time of her period. Not everyone has these feelings – some do
not feel anything.

WHEN IS IT IMPORTANT TO SEE THE DOCTOR?

 When the period continues beyond seven days

 When one is unable to deal with the pain with the help of home remedies
 Bleeding in between two periods
 Excessive bleeding (the girls has to change the cloth/pad after every one-two hours)
 No sign of menstruation for more than three months post menarche
 Irregular periods after one has already had regular periods earlier
 If the girl is not getting her periods after 2-3 years of breast development or even once she
has reached the age of 15-16 years
 Abnormal white vaginal discharge

NURSES ROLE IN MANAGEMENT OF MENSTRUAL IRREGULARITIES:

 counsel and educate patients
 address the diverse causes of irregular menstrual disorders, the relationship to sexual
identity, possible infertility
 inform the woman about the purpose of each diagnostic test
 sensitive listening, interviewing, and presenting treatment options
 Nutritional counseling
 Emphasize healthy life style
 Amenorrhea: Teaching guidelines for maintaining a healthy lifestyle
 Balance energy expenditure with energy intake
 Modify diet to maintain ideal weight
 Avoid excessive use of alcohol and mood-altering or sedative drugs
 Avoid cigarette smoking
 Identify areas emotional stress and seek assistance to resolve them
 Balance work, recreation, and rest
 Maintain a positive outlook regarding the diagnosis and prognosis
 Participate in ongoing care to monitor replacement therapy or associated conditions.
 Maintain bone density through:
 calcium intake( 1,200-1.5 mg or more daily)
 weight-bearing exercise(30 minutes or more daily)
 hormone replacement therapy

 MENSTRUAL HYGIENE
 Although menstruation is a natural process, it is linked with several misconceptions
and practices, which sometimes result into adverse health outcomes.
  Hygiene-related practices of women during menstruation are of considerable
importance, as it has a health impact in terms of increased vulnerability to reproductive
tract infections (RTI). The interplay of socio-economic status, menstrual hygiene
practices and RTI are noticeable.
 Today millions of women are sufferers of RTI and its complications and often the
infection is transmitted to the offspring of the pregnant mother.
 Women having better knowledge regarding menstrual hygiene and safe practices are
less vulnerable to RTI and its consequences. Therefore, increased knowledge about
menstruation right from childhood may escalate safe practices and may help in
mitigating the suffering of millions of women.
 Menstrual Hygiene is defined as 'Women and adolescent girls using a
clean menstrual management material to absorb or collect blood that can be changed
in privacy as often as necessary for the duration of the menstruation period.

 Sanitary napkin: Using and disposal

 These are disposable and should be discarded after being used once. These are designed
to fit the panty area close to the body. Some sanitary napkins/pads are made with
removable strips of paper that reveal adhesive tape that is made to stick to the panties.
Other pads have wrap-around “wings” that wrap under your panties to keep it from
moving. Some may prefer the belt model where the napkin is held using the belt. Pads
have a plastic lining to minimize the spill of blood. Sanitary napkins manufactured by
multinational companies like Stayfree, Carefree, Whisper, Kotex are available in the
market.
 In the recent times, SHGs have also started manufacturing sterile, low cost sanitary
napkins which can be purchased locally even at the village level. Women SHG
members themselves sell these products and so adolescents and rural girls may feel
comfortable purchasing them. Some schools have installed sanitary napkin dispensers
for easy access.
 Points to keep in mind while choosing a napkin
- Quality of the napkin
-Cost
- Pattern of flow
- Number of menstruation days
 Selecting a napkin depends on individual needs and convenience. One may want to try a
few brands and types and choose the one that most suits you.

 Menstrual flow differs from individual to individual. For some, the flow is heavy only
on the first day, for others it’s for 2 to 3 days. Similarly for some the flow is heavier
during the day and for some in the night. Some napkins may absorb blood well and
prevent leakage, but cause irritation and itching in the thighs and genitals. If that’s the
case, one may want to change the napkin till she find a comfortable one. If the problem
persists, consult a physician.

 The frequency of changing the napkins depends on the flow. If the flow is high, you
can change it once in 3 hours, otherwise you can keep it on for up to 5-6 hours. It’s
quite common for girls to not change the napkins frequently in order to save money.
However, keeping a napkin on for a long time may cause infection or at least irritation.
Each time you urinate and wash your genitals with water, the napkin absorbs the water
and eventually it loses its shape. This may lead to overflow, discomfort and bad odour.
Change the napkins regularly to keep yourself dry and comfortable.

 Safe disposal of used napkins: The manner in which one dispose the napkins depends
on the facilities available. She needs to do any of the below:
- For disposal one can create a sanitary pit in the backyard. Dig a pit in the backyard,
keep dropping the newspaper wrapped used napkins in the pit. Cover the pit to stop
animals from pulling it outside. Keep dropping ash after use. Once the pit is filled up,
close the pit completely and u se another pit.
-One can wrap the napkin in an old newspaper/waste paper and drop it in the dust bin. If
there are no bins, then drop it in the general waste bin.
-Some toilets have incinerators that will burn the napkins.
-Wash your hands with water after disposing sanitary napkins.
-Never flush a sanitary napkin in the toilet to prevent clogging of drainage system and
flooding of toilets.

 Hygiene practices during menstruation:

 Dealing with menstruation hygienically is essential. Unhygienic management can result
in reproductive tract infections and urinary tract infections.
 Bath at least once daily.
 Ensure that undergarments and sweat drenched clothes are changed regularly.
 Cotton panties are preferable to synthetic ones as the latter hold in moisture and
heat making it a breeding ground for bacteria.
 Change napkins and cloth periodically at least 3 to 4 times per day (preferable,
after every 4-6 hours). Most importantly, once wet, the napkin/cloth should be
changed immediately.
 Cloths should not be shared with others.
 Wash the genital area after each use of the toilet, also after urination.
 Keep the area between the legs dry otherwise soreness and chaffing may
develop.
 Some amount of body odour is natural but regular bathing, washing and
changing of cloths/napkins will ensure that it is not noticeable.
 During menstruation, the outer genitals should be washed from time-to-time to
remove any blood that is left.
 Girls should wash their hands every time they change the napkin.
 If the underwear is soiled, it must be changed. Otherwise this makes bacteria to
grow and cause infection.
 Use of toilets is very essential.
 If a girl’s panties or clothes get stained with blood, she can soak them in cool,
mildly salty water before washing. Hot water will cause the blood to set and
remain as a permanent stain

IMPORTANCE OF BALANCED DIET FOR GROWTH AND DEVELOPMENT

 A balanced diet is essential for proper

growth, development and functioning of the
body and this remains true even during the
years of menstruation.
  A balanced diet containing lots of fresh fruits and vegetables should be taken.
Consuming a diet rich in Iron is extremely important. Iron is required by the body to
make haemoglobin, an important component of blood.
 During the years of menstruation, body's requirement for iron increases as it needs to
create more blood to make up for the loss of blood during menstruation. A deficiency
of iron in the body can cause anaemia. Some of the food products rich in iron are: lean
red meat, dark poultry, lentils, spinach, almonds and iron fortified cereals. Citrus
fruits or vegetables should be consumed before taking iron rich food

IMPORTANCE OF EXERCISE AND RELAXATION TECHNIQUES

PMS can cause tension, anxiety, and irritability, Use the measures such as meditation, yoga,
exercise reading books talking with friends etc. whic helps to reduce anxiety

Exercise regularly:
 Exercise has many health benefits that can help periods. It can help to maintain healthy
weight and is commonly recommended as part of a treatment plan for polycystic ovarian
syndrome (PCOS). PCOS can cause menstrual irregularity.
 Women who performed the exercises reported less pain associated with their menstrual
periods.
 Exercise can help control weight, which may, in turn, help to regulate menstrual periods.
It may also reduce pain before and during period. Thirty minutes of moderate physical
activity on most days of the week found effective during menstruation.
 Massaging your stomach or back can reduce menstrual pain.

Yoga:

•Yoga has been shown to be an effective treatment for different menstrual issues.

•It reduces menstrual pain and emotional symptoms associated with menstruation, such as
depression and anxiety, and improve quality of life in women with primary dysmenorrhea.

Practicing yoga 35 to 40 minutes a day, 5 times a week, may help regulate hormones and
menstrual cycles. Yoga may also help reduce premenstrual symptoms

BELIEFS AND FACTS RELATED TO MENSTRUATION:

1. Belief: Menstrual blood is bad blood

Fact: The blood that is shed during menstruation is not impure blood. This is actually
the shedding of the lining of the endometerium of the uterus which is thickened
during the cycle in anticipation of a fertilized egg. There is no impurity in the blood
associated with menstruation. Cleanliness and hygiene are related to the management
of menstrual flow.
2. Belief: The blood stinks a lot.
Fact: If hygienically handled, the bad odour can be contained. It’s only if one does
not change the napkin/cloth regularly that it smells. Good hygiene practices like
bathing, washing of genital areas, periodic change of pads help maintain cleanliness
and keep away any odour.
3. Belief: Menstrual bleeding make women weak and unhealthy.
 Fact: Though they experience fatigue while menstruating, regular menstruation is a
sign of good health.
4. Belief: There is no correlation between nutrition and menstrual cycle.
Fact: There is a definite correlation between the two. Nutritious food enables the
hormones to facilitate menstruation.
5. Belief: Girls get pimples when they look at men.
Fact: No. The onset of acne and pimples are triggered by the production of hormones
called androgens. The production of androgen usually goes into full force between the
ages of 11 to 14 when most young girl and boys go through puberty.
6. Belief: Periods are some kind of disease.
Fact: This is absolutely a normal process and not a symptom of any disease. It is
medically safe to do anything that one does normally, during menstruation.
7. Belief: One should eat separately from family members while having periods.
Fact: There is no reason for a girl/woman to eat separately while having her periods
8. Belief: Is it risky and dangerous to engage in sports and playing games during
menstruation.
Fact: As already mentioned, it is medically safe to do anything that one normally
does, however some girls may feel tired or get cramps which may restrict such
activities. One may want to rest more than normal during this period, though this
varies from person to person.
9. Belief: When a used sanitary napkin/cloth is thrown outside the house and if a snake
crawls on it, you will suffer from infertility
Fact: It‟s not true. There is no scientific evidence for this.
10. Belief: We should not touch anyone while menstruating.
Fact: We can. There is nothing unclean about menstruating. Women and girls should
not let anyone make them feel bad about it. Menstruation is a sign of good health.

11. Belief: We should not go to temples, carry babies, wear flowers on the head, water
plants, touch pickles, or go out in the afternoons as the evil spirits might attack you.
Fact: None of these are true.
12. Belief: If birds fly over a sanitary napkin/cloth, you will be cursed by the bird.
 Fact: Not true. This belief was probably promoted to ensure hygiene (so that the cloth
does not come in contact with bird droppings thereby causing infection) and safe
disposal of the napkins or cloth.

 MENSTRUAL HYGIENE MANAGEMENT INITIATIVES IN INDIA

 In India, number of women in the reproductive age group (15–49 years) is more than
31 crores (Census 2011).Taking cognizance of the quantum of morbidity and poor quality
of life that a woman would have to bear in the absence of proper MHM (Menstrual
Hygiene Management) perception and practices in the country.
 Government of India has incorporated MHM into national policies and programs as part
of initiatives for improving health, well-being, and nutritional status of adolescent girls
and women, as well as for reducing school absenteeism of adolescent girls.
 UNICEF has also been instrumental in providing technical guidance and support toward
raising awareness, addressing behavior change, capacity building of frontline community
cadre, sensitization of key stakeholders, and creation of WASH facilities including safe
disposal options.
 “Swachh Bharat: Swachh Vidyalaya” campaign has been launched by Prime Minister
Narender Modi on 2nd October 2014 to ensure that every school in India has a set of
functioning and well-maintained WASH facilities including soap, private space for
changing, adequate water for washing, and disposal facilities for used menstrual
absorbents. MHM has been made an integral part of the Swachh Bharat Mission
Guidelines. Ministry of Drinking Water and Sanitation has published operational
guidelines to be implemented by state governments, district-level officials, engineers, and
school teachers for improved MHM in the country.
  Ministry of Health and Family Welfare has also focused MHM as a priority area in
National Health Mission and in the RMNCH+A strategy. High quality and highly
subsidized sanitary napkins are being made available to the adolescent girls in rural areas
by Accredited Social Health Activists (ASHAs) and “Training Module for ASHA on
Menstrual Hygiene” are also used for their capacity building.
  Efforts are being made to provide sanitary napkins to school-going girls by installing
napkin-vending machines at schools and to increase accessibility of environmentally safe
disposal mechanisms such as low-cost incinerators attached to the girls' toilets in schools
for disposal of used MHM products. On International Women's Day on March 8, 2018,
Government has launched 100% oxy-biodegradable sanitary napkins “Suvidha” in packs
of four priced at Rs. 10 which is available at Pradhan Mantri Bhartiya Janaushadhi
Pariyojana Stores.