Blog of the Society for Menstrual Cycle Research

Period positivity still has a way to go

May 31st, 2016 by Editor

Giuliana Serena critiques Newsweek’s period stigma cover story

Note: This piece was first published on It has been edited for length for this repost at Menstruation Matters. 

NewsweekCover_BloodI was pleasantly surprised and cautiously optimistic when I caught sight of the April 29, 2016 cover of Newsweek. It obviously got my attention.

I’m elated, and a bit discombobulated, to see menstruation and periods getting so much public and positive attention. But there’s also a lot of misinformation, subtle (& overt) shaming, and even pseudo-period positivity for profit out there, so I read the article with a fair amount of skepticism.

When it comes right down to it, this article wasn’t written for me. Maybe not for you either.

It was written for a broad audience, and I’m delighted it will be read by so many who will be learning about some of these issues for the first time.

In the opening paragraph, writer Abigail Jones goes so far as to say: “This process is as natural as eating, drinking and sleeping, and it’s beautiful too: There’s no human race without it.”

Highlighting the stigma and shame that those who menstruate are faced with worldwide is useful and relevant information for the mainstream.

Although I do take issue with certain omissions and the overall emphasis, I sincerely appreciate the coverage. And Chis Bobel, President of the Society for Menstrual Cycle Research, is quoted a few times!

Mentioned are Rupi Kaur’s banned self-portrait, the needs of those in prison and those who can’t afford “menstrual materials,” the very real health and environmental costs associated with conventional tampons and pads, the vast number of women and girls, ESPECIALLY in the Global South, who are ostracized, without resources, and face severe taboos and stigmas.

A lot was covered. A lot was not. It’s a big topic, and they couldn’t fit in everything. But here are a few issues I wish had been addressed:

It’s odd not to see women listed amongst the top “things” affected by period stigma in the subtitle: “Period Stigma is hurting the economy, schools and the environment. But the crimson tide is turning.” Although, it’s interesting to see it framed this way, and the article does address those topics.

Cups and reusables are only briefly mentioned, but deserved more attention with regards to environmental and health benefits.

Also, the opening sentence was not completely accurate: “Let’s begin with the obvious: Every woman in the history of humanity has or had a period.”

It’s true that the vast majority of those who menstruate are women (and girls), some women and girls (for various reasons) never have had or will have a period, and some who are not women and/or girls, will. We are just starting to understand how menstruation relates to transgender experience. In a time when we’re re-learning sex and gender more inclusive language could have been used. At the very least, these arising issues should have been referenced.

And I would love to see more talk about the benefits to young girls in educating and preparing them for coming-of-age, resources for doing so, and the value of ritual and ceremony in that process—but I’m not holding my breath!.

There’s more I didn’t love and I could pick it apart further, but honestly, I’d rather you read it for yourself.

This piece is bound to have a positive impact. Transforming the culture is a complex unfolding. And one cover story won’t do it. Continuing this conversation is crucial.

Periods getting this kind of attention in mainstream media would not have been possible without the tireless work of countless activists, educators, advocates, researches, and ordinary women and people destigmatizing and normalizing menstruation, body literacy, women’s bodies, sexuality, fertility, and all those other juicy topics that make us whole.

One (news) cycle at a time, we are making progress.

As Lara Owen, author of Her Blood Is Gold, commented when I shared a screen shot of the cover on Facebook:

38 years since The Wise Wound, 25 years since Dragontime, 23 years since Her Blood Is Gold: Awakening to the Wisdom of Menstruation, and since then many others. So grateful to everyone who has contributed to hauling this abusive and absurd taboo out into the light and transforming it into health and resilience.

And in reference to the article not going far enough, she added, “As we know too well, Rome wasn’t built in a day.”

Our society needs to get over our fear of periods. We need to let go of our fear of bodies and fluids, empowered women, sex, pleasure, self-determination, autonomy.

Yes, there will be blood.

Have a read, and let me know what you think!

Giuliana Serena is a Ceremonialist, Rites-of-Passage Facilitator, Menstrual Cycle Educator, and the creator of

SMCR’s re: Cycling becomes Menstruation Matters

May 28th, 2016 by Laura Wershler

SMCRPC.BackMay 28 is Menstrual Hygiene Day. All over the world events are planned in honor of this year’s theme: Menstruation matters to everyone, everywhere. 

May 28, 2016, also marks the date that re: Cycling, the blog of the Society for Menstrual Cycle Research, gets its new name:

Menstruation Matters

The Society created this weblog to increase the visibility of both SMCR and menstruation research in September 2009. We named it re: Cycling to represent our view of menstruation as more than merely bleeding, but as a cycle within the larger cycle of life. The name also pays homage to our late colleague, Randi Koeske, who first used this term.

During the blog’s seven-year history, menstrual advocacy and activism have exploded worldwide. Though it all, this blog has addressed and documented all matters menstrual, at the discretion of its many and varied authors. As noted when the blog launched:

“The views expressed are not necessarily those of SMCR, nor even the unanimous views of all blog contributors. Indeed, although we believe in holding writers accountable for their words, we also reserve the right to change our opinions on the basis of new information. We adhere to a vision of academic freedom that is ethical, fair, and responsible.”

This will not change. Readers of our blog know that our writers share and interpret research, report menstrual happenings, express strong opinions, and offer fresh, informed analyses of menstruation matters related to academia, social justice, media, the arts, advocacy and activism.

Expect this to continue as our blog takes on the name of the heavily used hashtag we founded in the lead-up to our 2013 Biennial Conference in New York City: #MenstruationMatters.

The Society for Menstrual Cycle Research has been making menstruation matter since 1977, when this nonprofit organization was founded by a multidisciplinary group of women who were pioneers in understanding the importance of menstrual cycle research to women’s health. Our 150+ members produce, publish, and convey research findings that impact menstrual health across the lifespan, and are involved in a broad range of advocacy initiatives.

We know Menstruation Matters, and now, finally, so does the media.

As leaders in the field, SMCR applauds all of today’s menstrual advocates and activists—including our members—who have made menstruation mainstream news. Our hard work to break taboos, derail stigma, share accurate information, secure menstrual rights, and meet the menstrual health needs of girls and women around the world led to 2015 being named “The Year of the Period” by Cosmopolitan, BuzzFeed, Feministing and NPR.

And the period party continues.

Newsweek Cover_Apr-2016On April 20, 2016, Newsweek’s online edition published The Fight to End Period Shame is Going Mainstream, which became the cover story for the April 29, 2016 print issue. The bright red cover featured a tampon and the bold headline There Will Be Blood–Get Over It.

The Atlantic, on April 28, 2016, published Seeing Red: The Rise of Mensesplaining. The subhead reads: With women explaining periods to men, pop culture is finally treating menstruation as a societal issue everyone should care about.

Menstruation, a societal issue everyone should care about.” 

The Society for Menstrual Cycle Research has been caring for the last 40 years!


Menstruation Matters will carry on the re: Cycling legacy as we continue to report, comment, summarize, analyze and opine on all matters menstrual.

Please keep reading.

Laura Wershler is the editor-in-chief of Menstruation Matters, the blog formerly known as re: Cycling

The Period in History: Two book reviews

May 24th, 2016 by David Linton

Menstruation in Early Modern England and Early Modern France

Menstruation in FranceObviously, menstruation has been around a long time, and while its biological purpose has been constant, its cultural significance and social construction have taken on innumerable meanings across time and space. Yet, probably due to skewed gender perspectives, taboos, and prejudices, the meanings of menses, what I think of as “the menstrual ecology,” has received relatively scant attention by historians of cultural practice. Recent efforts to redress that absence are found in two fascinating studies: Cathy McClive’s Menstruation and Procreation in Early Modern France (2015, Ashgate) and Sara Read’s Menstruation and the Female Body in Early Modern England (2013, Palgrave).

Menstruation-in-EnglandTaken together, these two volumes offer insights into the often surprising ways both French and English societies strove to make sense of this seemingly gender exclusive phenomenon. Among the many enlightening insights the authors offer is McClive’s challenge to what she calls “the myth of menstrual misogyny,” the idea that menstruation has always been viewed negatively, a notion she convincingly refutes. And Read’s examination of the role New Testament Biblical scripture played in shaping menstrual attitudes provides one answer as to why Christian beliefs surrounding the period diverged from those prevailing in the other two Abrahamic faiths.

Though both books are published by academic presses and, unfortunately, are unlikely to find wide readerships in the general public, they are well written and accessible to any curious reader. And in case contemporary scholars and activists are prone to think they are the first to grapple with the multifaceted meanings and prejudices that comprise the menstrual milieu, McClive and Read provide historical perspectives that are both useful and enlightening.

A more detailed review of each book can be found in the Society for Menstrual Research journal Women’s Reproductive Health:

Review of Menstruation and the Female Body in Early Modern England

Review of Menstruation and Procreation in Early Modern France

David Linton is an Emeritus Professor at Marymount Manhattan College. He is also Editor of the SMCR Newsletter and a member of the re: Cycling editorial board. His research focus is on media representations of the menstrual cycle as well as how women and men relate to one another around the presence of menstruation.

Women comics taking on menstruation

May 12th, 2016 by David Linton

It used to be that menstrual humor amounted to men making crass remarks about PMS and the world of stand up comedy was dominated by male performers. Well, not any more.

In the last few years there seems to have been an explosion of young women comics doing stand-up and TV comedy.  Lena Dunham, Amy Schumer, Nicki Glazer, and a host of others have followed pioneers such as  Margaret Cho, Whoopi Goldberg, Sarah Silverman, Lisa Lampanelli and an even earlier generation’s Joan Rivers and Rusty Warren, whose theme song, Knockers Up, became a forbidden ditty for the post-war generation of comedy transgressors. And at the age of 86, Rusty holds a special place in the arcane world of cabaret comedy acts. This brief list comes nowhere near capturing the richness and diversity of the comedy scene where women crack the jokes and make their audiences gasp at their audacity.

Today’s women comics revel in coming up with the most shocking ways of alluding to their own bodies and their sexual relations. For instance, a recent skit on Inside Amy Schumer had her telling several female friends about a new product that would eliminate all taste from a woman’s pussy, the word of choice when mentioning the female genitalia. To demonstrate the effectiveness of the product she puts her hand inside her pants then offers her fingers to a friend to taste. And what better topic to include when one is striving for ever more ways to shock the audience with dirty words and forbidden subjects than the menstrual cycle. There may be no subject that has more layers of taboo and “ickiness” than menstrual blood. Whoopi Goldberg worked this material some years ago in her Broadway special that was aired on HBO when she did a long piece describing her entire menstrual history from her first Kotex belt to her entry into menopause. Similarly, Margaret Cho developed a riff that was surely influenced by Gloria Steinem’s famous If Men Could Menstruate essay that described how she imagined men would behave if they had a menstrual cycle.

In this episode of Broad City, the girls are forced to improvise when Abbi gets her period on a plane and doesn't have access to a tampon.

In this episode of Broad City, the girls are forced to improvise when Abbi gets her period on a plane and doesn’t have access to a tampon.

The new spate of sit-com styled TV shows that appear on the Comedy Central cable system and elsewhere have been giving the period a full airing. One of the most amusing in recent months was an episode of Broad City in which the two lead characters and creators of the show, Llana Glazer and Abbi Jacobson, are aboard an El-Al flight to Israel when one of them gets her period and has no menstrual product with her, which leads to an escalating series of jokes and crises. The episode, titled Jews on a Plane, covers a full range of period predicaments. It’s well worth a look for many reasons. 

David Linton is an Emeritus Professor at Marymount Manhattan College. He is also Editor of the SMCR Newsletter and a member of the re: Cycling editorial board. His research focus is on media representations of the menstrual cycle as well as how women and men relate to one another around the presence of menstruation.

Writing Menopause, An Anthology: Preview #2

April 28th, 2016 by Editor

WritingMenopauseWriting Menopause, a diverse literary collection about menopause to be published in the spring of 2017 by Inanna Publicationswas first introduced to the Society for Menstrual Cycle Research in a session presented at our June 2015 biennial conference in Boston. The anthology includes about fifty works of fiction, creative nonfiction, poetry, interviews, and cross-genre pieces from contributors across Canada and the United States. With this collection, editors Jane Cawthorne and E.D. Morin hope to shine a light on a wide variety of menopause experiences and to shatter common stereotypes. This week at re: Cycling we are pleased to be able to preview excerpts from the collection. Preview #1 included a short prose piece and a poem by Tanya Coovadia. Today’s preview is by SMCR member Heather Dillaway, a piece that was previously published on this blog.

Fact and Fiction: Two Lists by Heather Dillaway

List One: Things Menopausal Women Would Love to Hear That ARE True

  1. what do i want to hear?It’s okay to be glad to be done with menstruation, the threat of pregnancy and the burdens of contraception. It’s also okay to use the menopausal transition to question whether you really wanted kids, whether you had the number of kids you wanted and whether you’ve been satisfied with your reproductive life in general. It’s normal to have all of these thoughts and feelings.
  2. You’re entering the best, most free part of your life! But, it’s okay if it doesn’t feel like that yet.
  3. Menopause does not mean you are old. In fact, potentially you are only half way through your life.
  4. You are not alone. Lots of people have the experiences you do. You are normal!
  5. I understand what you’re going through. (Or, alternatively, I don’t completely understand what you’re going through but I’m willing to listen.)
  6. It’s okay to be confused and frustrated at this time of life, or in any other time of life!
  7. You’ve had an entire lifetime of reproductive experiences and this is simply one more. How you feel about menopause is probably related to how you’ve felt about other reproductive experiences over time. It might be helpful to reflect back on all of the reproductive experiences you’ve had to sort out how you feel about menopause.
  8. Talk to other women you know. Talking about menopause helps everybody.
  9. Menopause and midlife can be as significant or insignificant as you’d like them to be. For some women, these transitions mean very important things but, for others, they mean little. Whatever it means to you is okay.
  10. Researchers are working hard to understand this reproductive transition more fully.

These represent the kind of supportive comments women might want to hear while going through menopause and, in particular, perimenopause. Items on this list also help us acknowledge that our bodies and bodily transitions cause us to reflect on our life stages, our identities and our choices.

List Two: Things Menopausal Women Would Love to Hear But Might NOT Be True

  1. This is guaranteed to be your last menstrual period. You are done! (Or, a related one: You’ve already had the worst. It gets better from here on out!)
  2. Signs and symptoms of menopause will be predictable and will not interrupt your life.
  3. No one will think negatively of you or differently about you if you tell them you’re menopausal.
  4. There are no major side effects to hormone therapies or any other medical treatments you might be considering.
  5. Doctors will be able to help you and will understand your signs and symptoms, if you need relief.
  6. Leaky bodies are no problem! No one will care if your body does what it wants, whenever it wants.
  7. Partners, children, coworkers and others will completely understand what you’re going through.
  8. Middle-aged women are respected in this society and it is truly a benefit to be at this life stage.
  9. There is a clear beginning and a clear end to this transition.
  10. Clinical researchers are researching the parts of menopause that you care about.

This reflects many of our societal norms and biases about our bodies, aging, gender, fertility and so on. This list also attests to the difficulties that menopausal women have in accessing quality health care or getting safe relief from symptoms when needed and notes the potential disconnects between research findings and women’s true needs during this transition.

Heather Dillaway is an associate professor of sociology at Wayne State University in Detroit, Michigan. Her research focuses on women’s menopause and midlife, and she often writes about the everyday experiences of going through these transitions. She teaches about women’s health, families and gender & race inequalities.

Writing Menopause, An Anthology: Preview #1

April 26th, 2016 by Editor

WritingMenopauseWriting Menopause, a diverse literary collection about menopause to be published in the spring of 2017 by Inanna Publicationswas first introduced to the Society for Menstrual Cycle Research in a session presented at our June 2015 biennial conference in Boston. The anthology includes about fifty works of fiction, creative nonfiction, poetry, interviews, and cross-genre pieces from contributors across Canada and the United States. With this collection, editors Jane Cawthorne and E.D. Morin hope to shine a light on a wide variety of menopause experiences and to shatter common stereotypes. This week at re: Cycling we are pleased to be able to preview excerpts from the collection.

Two pieces by Tanya Coovadia:

The Things We Carry

Last January, I attended a reading series during which two distinguished male authors, in separate opening remarks, said derogatory things about middle-aged women. I don’t think I would have noticed twenty years ago, but lately, for some reason, I am particularly attuned to discussions regarding women of my uncertain age, especially when they are uttered in tones suggestive of a shameful affliction.

Benign anal tumours, say.

One of these men, after his reading, went on to add further insult. He described the typical bumbling misapprehension of his work by that admiring but clueless fan who, he assured us, in his laconic drawl, was “always a middle-aged woman.” As a late-blooming member of the midlife sisterhood, this incident sparked a poem in me.

And (in a laconic drawl) it’s dedicated to Tim O’Brien.

Always a Middle-Aged Woman

(because middle-aged men are just men)

Striding up
with her staunchly held head
her opinions bared like wrinkled breasts

And those years she wears
a bitter glory of furrows and lines
etched by thousands of erstwhile smiles.

Who do they think they are,
these ladies (and we mean you, ma’am)
thriving so steadily
from their cloak of invisibility

We don’t see your once young face
we never stroked your once shining hair

We can’t hear your
sweet, barely caught breath
because you’re

As though ageing is some kind of victory
as though youth and beauty
are not mandatory

As though you can bring
something new to the world
when your womb is too old to care.

My mirror,
reflect this, true

We lift our jowls toward our ears
and smile
a spasm, a rictus. Of youth.

Tanya Coovadia is a technical writer, blogger and angry-letter-writer-cum-fictionalist who occasionally dabbles in poetry. She’s a Canadian transplant to Florida who, during the writing of this poem, realized her interminable hot flashes were not weather-related after all. Ms. Coovadia has an MFA in Creative Writing from Pine Manor College in Boston. Her first collection of short fiction, Pelee Island Stories, recently won an IPPY award.

#MenstruationMatters to Newsweek

April 21st, 2016 by Laura Wershler

The menstrual advocacy movement splashes red all over the cover of Newsweek’s upcoming April 29, 2016 edition. The story by Abigail Jones–The Fight to End Period Shaming is Going Mainstream–published online April 20, 2016, continues the mad rush of period stories that prompted Cosmopolitan to declare 2015 the “year the period went public.” Chris Bobel, President of the Society for Menstrual Research, is quoted briefly in the Newsweek piece. For Chris’s cogent analysis of the recent spate of period positivity check out her Nov. 15, 2015 re: Cycling post:  Will this 2015 menstrual moment make room for all bodies?

Newsweek Cover_Apr-2016

When breast cancer treatment leads to early menopause

April 14th, 2016 by Editor

In the same month I went from menstrual cramps to hot flashes overnight.

By Sheryl E. Mendlinger, PhD

Sheryl Mendlinger cut her hair short before undergoing treatment for breast cancer in 1994.

Sheryl Mendlinger cut her hair short before undergoing treatment for breast cancer in 1994.

In 1994, at the age of 43, I was diagnosed with stage 1 invasive breast cancer. At that time, treatment options were very limited, it was more a “one size fits all,” unlike the targeted therapies available now 20 years later. Taking into account the size of the lump—1.5 centimeters; my age—young enough that I was still pre-menopausal; and lymph nodes that all tested negative, my oncologist recommended I undergo a lumpectomy, a procedure that removed the lump and the surrounding breast tissue, followed by adjunctive chemotherapy and six weeks of daily radiation treatment. I became a statistic; although chemo was not a necessity, I was told that it would increase my chances of long term survival. I had been married to the love of my life for almost 22 years and had two teenage children, a son, 19, and my daughter Yael, 17. When I heard my diagnosis, I welcomed all options on the table, even the most extreme, as an answer to the frightening diagnosis of cancer, with hopes for a long life to see my own children grow into adulthood.

The doctor informed me only about some of the side effects of chemotherapy including: nausea, loss of appetite, hair loss and the possibility that my period might cease during treatment. However, no one addressed the fact that I would most likely go into overnight early onset menopause, which meant that not only would my ovaries stop working and vaginal dryness would set in, but my brain and cognitive abilities would experience a major shut down as well. One day I was bleeding and puking my guts up from the chemo, while days later I started to wake up in the middle of the night, in a pool of sweat, sheets kicked off the bed and I soon realized they were hot flashes. Menopause had arrived in full force.

At the end of her treatment she had short white hair and a full face.

At the end of treatment she had short, thin, white hair and a full face.

Whether from the chemo treatments or menopause, I started to gain a lot of weight and most of the clothes that hung in my closet no longer fit properly. As I wrote in my book Schlopping: Developing Relationships, Self-Image and Memories

“I ballooned from a size 8-10 to a 12-14. The additional fifteen to twenty pounds on my short frame and the new menopausal body made me feel extremely self-conscious, and the only way to continue to look good and feel better was to hide the bulges under baggy clothes, oversized blouses, or sweaters and leggings. The only pants that fit over my rounded belly were those with stretch elastic waist like old ladies wore….I dealt with the extra weight by buying clothes that fit my new changing body. I just accepted the changes that were taking place because it was a sign of me getting well….I felt the additional weight was good for me…and that my body was overcoming the illness… At the end of the treatments, I had very short, thin, white hair and a very puffy, fat, and full face…”

I remember approaching my oncologist very early in my chemo treatments and telling him that I felt my brain was fuzzy and that the connectors didn’t seem to be connecting; it was as if the entire “hard drive” in my brain had crashed and all the information was deleted. At that time, in the 1990s, doctors were convinced that “chemo does not pass the brain membrane.” To say the least, it was a strange, frightening, and terrible experience. I began to forget sentences in mid-thought in addition to having a lot of other medical problems. This memory loss happened at the onset of chemo, even when I was still getting my period. Once my period ceased, near the end of treatment, my cognitive abilities seemed to take a turn for the worse.

Several years after my treatments, in 2000, when I saw one of the first papers on “cognitive function and chemotherapy” in which the word “chemo-brain” was used, I felt a sense of relief that I was not the only person to have experienced this. Although this concept has finally been accepted in the medical world, and scientific research is being conducted in the area, there are still questions as to what causes the cognitive decline. Is it the inflammation from the cancer itself, is it the chemo, is it changes in thyroid functioning or B12, or is it the sudden loss of estrogen with the early onset of menopause? When speaking to young women who have undergone hysterectomies, they too complained of many of the same issues of cognitive decline.

Early onset menopause can affect so many aspects of overall health and the quality of life. More research, knowledge and information will better equip young women in coping with their changing bodies and understanding that it’s not “only in their heads.”

Sheryl E. Mendlinger, PhD, is an author, advocate for women’s health, daughter, wife, mother, and grandmother. She co-authored, with her daughter Yael Magen, “Schlopping (schlep+love+shopping): Developing Relationships, Self-Image and Memories” a book about finding answers to life’s challenges through schlepping with a loved one while shopping. Sheryl’s expertise is inter-generational transmission of knowledge and health behaviors in mother-daughter dyads from multicultural populations with a focus on menstruation.  

Premenopause / Early Menopause / Primary Ovarian Insufficiency (or Failure) / Perimenopause / Menopause / Postmenopause: Why these names matter

April 5th, 2016 by Editor

Making sense of the many names for women’s reproductive aging by Dr. Jerilynn C. Prior

Jerilynn C. Prior BA, MD, FRCPC, ABIM, ABEM is a Professor of Endocrinology and Metabolism at the University of British Columbia in Vancouver, B.C. She is the founder (2002) and Scientific Director of the Centre for Menstrual Cycle and Ovulation Research(CeMCOR).

The process of aging of women’s reproductive system, like puberty and most biological transitions, occurs in a generally standardized but variable way and over many years. Also, there are broad age ranges at which we consider something normal or not. Then add on top of that cultural presuppositions, chief among them that “menopause means estrogen deficiency” (rather than that menopausal estrogen and progesterone levels are normally low), and we have real confusion and a situation that is not helpful1 for women or for their communication with health care providers.

I will do my best to describe some of these standardized ways that women’s physiology changes during reproductive aging. I will mention the current terms and the words that have some physiological relevance and should be used. Because I am a physician, I believe that understanding of “the story” of life phases and the “why” of experiences is helpful. It is also necessary to appreciate the whole woman in her social, cultural, physical and experiential environments markedly influence her experiences.

After extensive research to understand mine and my patient’s puzzling midlife experiences, I learned that the ovaries start to make less Inhibin (really Inhibin B) while cycles are still regular2;3. Inhibin is small hormone made in the follicular cells surrounding stored eggs; its job is to control levels of follicle stimulating hormone (FSH). Because FSH stimulates follicles to grow, Inhibin is necessary to limit the number of stimulated follicles and to prevent us having litters. As shown (Figure below), by very early perimenopause there are fewer remaining ovarian follicles (B), Inhibin is decreased and this allows higher FSH levels and more stimulated follicles. Since each recruited follicle makes some estrogen, levels rise and the higher estrogen levels are also not reliably able to control FSH3.


Legend: The ovaries are shown as a stylized oval with follicles in various degrees of maturation. A. shows what is occurring in the follicular phase of a premenopausal ovary; B. illustrates the normal changes that occur in perimenopause. Reprinted from Prior Endocrine Reviews 1990

The same normal reproductive aging pattern of lower Inhibin, higher FSH and estrogen occurs when the ovary is injured; this can be by chemotherapy or radiotherapy for cancer, partial removal, more rapidly than normal after hysterectomy or tubal ligation/removal and in those with immune or genetic problems. The chaos of women’s reproductive aging occurs for these Inhibin-related reasons but also because the hypothalamic-pituitary ovarian feedbacks are disrupted (so a normal midcycle estrogen peak may not trigger the luteinizing hormone (LH) peak or the LH peak may not stimulate ovulation4). An FSH level, even one that is taken on cycle day 3, is not diagnostic of perimenopause. That estrogen levels average 20% higher in perimenopausal than in premenopausal women 3, I learned from a systematic review of studies within each of several centres; but symptomatic women may have double or triple normal cycle phase-specific levels that create the “perimenopausal ovarian hyperstimulation syndrome” because this situation resembles an adverse effect that may occur in IVF 3.

With this understanding we can define the three terms for normal reproductive life phases, the term used for perimenopause or menopause that comes too early and also identify some inappropriate labels.

Premenopause is the entire time (usually 30-40 years) from the first menstruation (menarche) until the changes of perimenopause start.

Perimenopause begins when cycles are still regular (called very early perimenopause and this phase lasts 2-5 years) but an observant woman notices typical experience changes5. Because the current official classification of reproductive aging begins with irregular cycles6, no one knows at what age on average this may start; likely it is normal from as young as age 35. At least three of nine typical experience changes, especially the start of night sweats, sleep problems or heavy flow, can be used to determine that you have begun this phase5. Additional potential perimenopause changes are: increased cramps, increased premenstrual physical and emotional unwanted experiences, shorter cycles (usually ≤25 days), increased or new breast tenderness, increased or new migraines and weight gain without important changes in exercise or food intake7. Perimenopause’s early menopausal transition starts when cycles become irregular and lasts a year or so; the late menopause transition begins with the first skipped cycle (60 days without flow) and late perimenopause is the year after the last flow.

Menopause is the life phase that lasts from a year after the final flow for the rest of women’s lives. It is normal for both estrogen and progesterone levels to be low. Hot flushes/flashes and night sweats may continue for many years but heavy flow, cramps, breast tenderness, premenstrual-type symptoms and severe migraine are usually gone.  (The term “postmenopause” is sometimes used interchangeably with menopause but is double-speak and refers to an erroneous use of the word “menopause” to mean the literal final menstrual flow).

“Endo What?” documentary sets the record straight about endometriosis

March 31st, 2016 by Laura Wershler

Endo what screen shotThe facts are eye-opening, the experts are compelling, but it is the voices of women talking about their lived experience with endometriosis that have the biggest impact in Endo What?, the documentary about the disease that premiered in New York City on March 16, 2016, during #EndometriosisAwarenessMonth.

In one early scene, woman after woman states the number of years it took for their endometriosis to be diagnosed: 18 years, 20 plus years, more than 15, 22 plus, 13, 6, 13, 12, 10 years, years during which many were told their intense pain was normal, or it was in their heads, or they needed to see a psychiatrist, or they were drug-seeking, or worse.

One later describes her pain: “It just feels like someone is taking a roller and rolling up my insides, and it’s tighter and tighter, and then rubbing barbed wire through it.”

The pain caused by endometriosis is NOT normal.

The film’s director and co-producer Shannon Cohn experienced symptoms at 16 and was finally diagnosed at 29. She, too, was told her debilitating pain was normal. In a recent Newsweek article she said, “Millions of other women are basically told the same thing.”

If it takes on average 8 to 10 years from the onset of symptoms to be diagnosed with endometriosis, getting a diagnosis is no guarantee you will receive appropriate or effective medical care.The film makes clear how few real endometriosis experts there are, and how much unhelpful care and how many ineffective, even damaging, treatments are provided by medical professionals who don’t know the facts or still believe the myths about endometriosis.

Contrary to what you may have heard, very young women DO get endo (symptoms can start before the onset of menstruation), it is NOT a career women’s disease, pregnancy is NOT a cure, and hysterectomy—definitely—is NOT a cure.

Endometriosis is also a disease of associated conditions including irritable bowel syndrome, interstitial cystitis, pelvic floor muscular dysfunction, thyroid problems and chronic fatigue—all of which can complicate diagnosis and treatment.

As for treatment options, hormonal manipulation with birth control pills may manage symptoms for awhile but in no way treats the disease. Stronger drugs like Lupron and other GnRH agonists offer few benefits and many negative side effects, some of which may be permanent.

As Deborah Metzger, MD, PhD, puts it,

“The way we practice medicine is not conducive for what women with endometriosis need…It’s a chronic systemic issue and it needs solutions that are long-term….and using hormones and all those other things, those are Band-Aids.”

The best long-term treatment for endometriosis is surgery, but one of the most startling messages of the film is how few surgeons have the skill to perform laparoscopic excision surgery, considered the gold standard by experts. As one endo surgeon says, “It cannot be done by regular gynecologists as a routine surgery.” To be effective all lesions must be completely excised. Most surgeons use a laser to burn the surface of endometriosis, rather than cut it out, leading to continued pain and repeat surgeries. What endometriosis sufferers need, a voice in the film tells us, is “One surgery, done right.”

Endo What? also explores the connection between infertility and endometriosis—distortion of the reproductive tract by endometrial lesions and inflammation are key factors. Excision surgery can greatly improve the chance of conceiving.

The second half of the film focuses on what women can do post-surgery to restore their health and well-being. Physical therapy to relieve pelvic floor pain, nutritional counselling to restore digestive health and reduce inflammation, exercise, stress reduction strategies, and reducing exposure to environmental toxins and everyday chemicals can help aid recovery to health. A key message is that the disease is individual; what works for some may not work for others.

If the film’s goal is to make people care about endometriosis, it does this effectively by making the viewer care about the women who live with this disease. Be we friends, parents, family members or health-care providers of women with endometriosis, the onus is on all of us to learn the facts about a disease that affects one in 10, and an estimated 176 million worldwide. Medical students should not graduate until they’ve watched this documentary.

The film ends on a hopeful note. ‘There is life after endometriosis.” But to get there, women must be their own best advocates.

“Don’t accept what one or two or 10 doctors tell you is normal when you know that something is wrong,” one interview subject tells us. “Keep pushing until you find the right provider, they are out there.”

Let’s hope, as a result of this film, there will be more of them soon.

Endo What? will be available widely online on April 15th in the US and UK via digital download and DVDs. Watch the trailer here.

Laura Wershler is a veteran sexual and reproductive health advocate and writer, SMCR member, and editor-in-chief of re: Cycling.

NOTE: March 31, 2016, is Transgender Day of Visibility. The film Endo What? does not address the unique concerns trans people may have with endometriosis. “Endometriosis and Being a Trans Person: Beyond Gendered Reproductive Health,” published by Hormones Matter, Jan. 22, 2014, provides a trans perspective on this disease.

Readers should note that statements published in re: Cycling are those of individual authors and do not necessarily reflect the positions of the Society as a whole.