Kristina Conner, ND
We’ve come a long way in attitudes about menstruation. In many native cultures, women were often separated during menstruation, forbidden to perform household tasks or communicate with other group members. It was considered natural, but also mysterious, foreign and sometimes dangerous. The feminist movement shifted our focus to menstruation as merely an inconvenience, but still not welcome. Now we have advanced tools for decreasing abnormal symptoms or the menses themselves, yet the goal is still to eliminate the evidence.
Conventional medical models treat normal menstruation as uneventful. Women report as though menstrual problems, being common non-pathology, hold little interest for their doctor, so concerns are minimized during the visit (Byles, 1997). At the same time, menstrual abnormalities are increasingly medicalized. Menstrual disorders are treated with oral contraceptives (OCPs), stopping a natural cycle. The development of extended OCPs to suppress all menstrual flow reveals our society’s attitude that menstruation is bothersome and unnecessary.
In contrast, naturopathic physicians recognize the difference between the typical experience of the menstrual cycle and what is truly healthy and normal for that patient. The cycle is a reflection of functioning: not something to minimize, but rather to consider as an important aspect of health. Although there is a growing awareness of this attitude, it needs to be cultivated. This is an area where our profession can make a significant impact, simply by following our naturopathic principles.
Docere
Teaching women of all ages about normal menstrual cycles is the first place to start. We know that education leads to understanding, which leads to a greater acceptance of menses as a part of life. When done in a neutral or positive way, improved knowledge leads to a reduction in peri-menstrual symptoms (Koff and Rierdan, 1996; McPherson and Korfine, 2004).
An active approach to menstrual education is more effective than a passive one. A multi-sensory program using models, music, group work and story telling was most effective for girls shortly before menarche (Rembeck and Gunnarsson, 2004). This is one intervention that we encourage for our patients.
Beyond adolescence, there is still a need to educate. There are misconceptions and incomplete knowledge about ovulation, menopause and the menstrual cycle, even among well-educated women (Koff et al., 1990).
Instruction on fertility awareness and cycle tracking is a valuable tool. Not only does the patient learn about her body, she learns about family planning. First directing patients to resources like books (see References) and Web sites (such as www.ovulation-calculator.com or www.ovulation-calendar.net), then following up with discussion is an effective way to do this. Monitoring her own fertility gives a woman objective information on her cycle. When women recall their menstrual experience after the menses, they will base their perception on societal norms, not on their own experience (Marvan and Cortes-Iniestra, 2001). Since outside influences like media have negative attitudes about the menstrual cycle (Sveinsdottir, 2002), this leads many women to exaggerate symptoms in recall. A tracking method gives them reliable information, providing more efficient care and empowerment over symptoms.
Treat the Whole Person
We should discuss not only normal menstruation, but also how it is an indicator of overall health. New recommendations from the American Academy of Pediatrics recognize using the menses as a “vital sign”; adding a powerful tool to the assessment of normal development and the exclusion of pathological conditions such as polycystic ovary syndrome (PCOS) and anorexia (AAP Committee on Adolescence, 2006). To naturopathic physicians, this is not new. While adhering to the principle of treating the whole person, we find that the menstrual cycle gives us information about common areas of naturopathic management. This includes adrenal and thyroid health, nutritional deficiencies, anemia and emotional health, among other conditions commonly considered gynecological.
Tolle Causam
Treating the underlying cause is something we always strive to do as naturopathic physicians. Further, we can guide patients to respect normal function and anatomy if there is nothing to treat. This topic came about after a woman asked me when she should get a hysterectomy, since she was approaching menopause. She had no medical reason for it, but assumed that she would, since every woman she knew had done so.
Think about the disempowerment assumed by so many women who believe the same thing: If you’re done with that uterus, take it out, because it will cause trouble. Our natural instinct is to preserve our bodies; even among women who had severe abnormal uterine bleeding (AUB) that negatively impacted their everyday life, they did not want a hysterectomy (Geller et al., 1999). We should encourage our patients to maintain this view despite attitudes to the contrary.
First Do No Harm
As healers, we always offer patients our compassion. And women report that they want comfort and understanding from physicians when they discuss menstrual problems (Byles, 1997). They also desire a cooperative doctor-patient approach towards treatment.
Prevention
Attitudes before and at menarche can impact the experience of menstruation, both positively and negatively (Anson, 1999; McPherson and Korfine, 2004; Rierdan and Koff, 1990). Yet, when given support, basic information and detailed instructions on what to do during menstruation, girls develop fewer symptoms and a more positive attitude (Koff and Rierdan, 1995). Less helpful is detailed anatomical/physiological information and emphasizing menses as the start of womanhood.
When working with adult women, menstrual attitudes can be reframed, resulting in an improved ability to cope with perimenstrual symptoms (Morse, 1997, 1999). One of the areas that help with this reframing is increased social support (Lee and Rittenhouse, 1992; Morse, 1999). With our emphasis on treating all aspects of a patient’s life, we already address the area through naturopathic management, but knowing this can give us extra incentive to do so.
Vis Medicatrix Naturae
Discussion of this area of a woman’s life, including education, compassion and importance as a health indicator, can rightly lead her to the conclusion that a conventional attitude about the menstrual cycle (and the tools that come out of it) is a significant obstacle to cure. This is a difficult area to address, because even the most dedicated of natural enthusiasts will find it hard to accept. We have diminished the view of menses as a natural process, with little appreciation of it as unique and universal to all women. In less developed countries, attitudes are different, with more understanding of the “naturalness” of the menstrual cycle (Chaturvedi and Chandra, 1991; Hoerster et al., 2003); however, some of these women also report menses as more bothersome or debilitating (Anson, 1999).
Have we lost this sense completely, which to many is tantamount to losing our natural female power? I don’t think so. There is some remnant of the appreciation of the power of the menstrual cycle in individual women, and in our society. Despite the availability of extended OCPs, a majority (59%) of women stated they would be interested in them, but only one-third of them would choose to never have a period (Andrist, 2004). Women who were not interested in menstrual suppression said they would be anxious about not having a menstrual flow and that it would not be normal (Andrist, 2004).
By using our unique tools and principles as naturopathic physicians, we are in an excellent position to help women regain and appreciate the power of menstruation. As with many things naturopathic, we start to change attitudes one patient at a time.
References
American Academy of Pediatrics Committee on Adolescence, Pediatrics 118(5):2245-2250, 2006.
Andrist LC et al: The need to bleed: women’s attitudes and beliefs about menstrual suppression, J Am Acad Nurse Pract 16(1):31-7, 2004.
Andrist LC et al: Women’s and providers’ attitudes toward menstrual suppression with extended use of oral contraceptives, Contraception 70(5):359-63, 2004.
Anson O: Exploring the bio-psycho-social approach to premenstrual experiences, Soc Sci Med 49(1):67-80, 1999.
Byles JE et al: ‘It would be good to know you’re not alone’: the health care needs of women with menstrual symptoms, Fam Pract 14(3):249-54, 1997.
Chaturvedi SK and Chandra PS: Sociocultural aspects of menstrual attitudes and premenstrual experiences in India, Soc Sci Med 32(3):349-51, 1991.
Geller SE et al: Differences in menstrual bleeding characteristics, functional status, and attitudes toward menstruation in three groups of women, J Womens Health Gend Based Med 8(4):533-40, 1999.
Hoerster KD et al: Attitudes toward and experience with menstruation in the US and India, Women Health 38(3):77-95, 2003.
Koff E and Rierdan J: Premenarcheal expectations and postmenarcheal experiences of positive and negative menstrual related changes, J Adolesc Health 18(4):286-91, 1996.
Koff E and Rierdan J: Preparing girls for menstruation: recommendations from adolescent girls, Adolescence 30(120):795-811, 1995.
Koff E et al: Conceptions and misconceptions of the menstrual cycle, Women Health 16(3-4):119-36, 1990.
Lee KA and Rittenhouse CA: Health and perimenstrual symptoms: health outcomes for employed women who experience perimenstrual symptoms, Women Health 19(1):65-78, 1992.
Marvan ML and Cortes-Iniestra S: Women’s beliefs about the prevalence of premenstrual syndrome and biases in recall of premenstrual changes, Health Psychol, 20(4):276-80, 2001.
McPherson ME and Korfine L: Menstruation across time: menarche, menstrual attitudes, experiences, and behaviors, Womens Health Issues 14(6):193-200, 2004.
Morse GG: Positively reframing perceptions of the menstrual cycle among women with premenstrual syndrome, J Obstet Gynecol Neonatal Nurs 28(2):165-74, 1999.
Morse GG: Effect of positive reframing and social support on perception of perimenstrual changes among women with premenstrual syndrome, Health Care Women Int 18(2):175-93, 1997.
Rembeck GI and Gunnarsson RK: Improving pre- and post-menarcheal 12-year-old girls’ attitudes toward menstruation, Health Care Women Int 25(7):680-98, 2004.
Rierdan J and Koff E: Premenarcheal predictors of the experience of menarche: a prospective study, J Adolesc Health Care 11(5):404-7, 1990.
Sveinsdottir H et al: Whose voice? Whose experiences? Women’s qualitative accounts of general and private discussion of premenstrual syndrome, Scand J Caring Sci 16(4):414-23, 2002.
Kristina Conner, ND graduated in 2001 from Bastyr University. She completed her residency at the University of Bridgeport, College of Naturopathic Medicine, where she also served as clinical faculty and clinic coordinator. Following that, she had a private practice in Indiana. Dr. Conner recently joined the faculty in the naturopathic medicine department at the National University of Health Sciences in Lombard, Ill.
