Our Bodies, Ourselves (6 page)

Some medical conditions affect reproductive development, and not all women have periods. If you haven't seen signs of puberty by age thirteen, or haven't started your period by age sixteen, see a health-care provider.

A twenty-five-year-old woman who does not menstruate says she has discovered how much menstruation is connected with normality in people's minds.

I don't menstruate, and have actually always felt kind of alienated by the way in which female experiences are sometimes centered around menstruation—the idea that menstruating makes someone a “real” woman, for example, or that menstruation is such a quintessential experience that if you haven't menstruated, you don't know what it's like to be a woman.

As you read this section, you may want to refer back to the drawings and descriptions of sexual anatomy in the first part of this chapter.

When a girl is born, her ovaries contain about 2 million balls of cells, each with an immature egg in the center. These are called follicles. The ovaries absorb more than half of these follicles during childhood. Of the 400,000 follicles still present at puberty, three hundred to five hundred will eventually develop into mature eggs.

During our reproductive years, follicles develop
throughout the cycle, but each month, under the influence of hormones, usually only one follicle develops fully. (Sometimes two or more follicles develop fully, in which case a twin or other multiple pregnancy can result.) Some of the cells in the developing follicle secrete the hormone estrogen. The follicle with the maturing egg inside moves toward the surface of the ovary. At ovulation, the follicle and the ovarian surface open, allowing the tiny egg to float out. About this time, some women feel a twinge or cramp in the lower abdomen or back (called mittelschmerz).

I never knew the word “mittelschmerz” until I was in nursing school. I thought it was such a cool word but was sure I wasn't one of those women who actually experienced it. A year or so later I began tracking all of my fertility signs when I decided to try to get pregnant. I felt a funny cramp on my left side that was a familiar sensation but I had never put two and two together to recognize that it was my body ovulating. I actually exclaimed out loud, “Mittelschmerz!”

A few women experience headaches, stomach pains, or sluggishness at the time of ovulation. Other women feel especially well.

After ovulation, the fingerlike ends (fimbria) of the nearby fallopian tube sweep the released egg into the tube's funnel-shaped end. Each tube is lined with microscopic hairlike projections (cilia) that constantly move back and forth. As the egg begins its several-day journey to the uterus, wavelike movements of the muscles in the tube (peristalsis) and the movements of the cilia help it along. If sperm enter the vagina, pass through the cervix, and travel through the uterus into the fallopian tubes, the cilia propel them toward the egg.

If the egg and sperm meet, they may join. (This is conception, or fertilization, when the sperm “fertilizes” the egg.) The fertilized egg then travels the rest of the way along the fallopian tube to the uterus. Whether or not fertilization takes place, the empty follicle that just released the egg from the ovary becomes a corpus luteum (Latin for “yellow body” because of its color). The corpus luteum continues to make estrogen and also begins making progesterone.

If a fertilized egg implants into the uterus, it sends a signal to the ovary to keep making progesterone, which will help sustain a pregnancy by keeping the uterine lining thick and nourishing. If no pregnancy occurs, the corpus luteum is reabsorbed into the ovary after two weeks and the hormone levels drop; this is the trigger that causes menstruation. (See
“The Endometrium.”
) The egg disintegrates or flows out with the vaginal secretions.

The kind of mucus or fluid produced by your cervix changes throughout the cycle in response to fluctuations in estrogen and progesterone. While there are general patterns of fluid secretion, each woman's pattern is unique. (See
“Fertility Awareness Method,”
, for more.)

The cervical fluid is a kind of gatekeeper for the uterus. At ovulation, the cervical fluid becomes slippery and thin, like egg white. It coats the vagina and protects sperm from the vagina's relatively acidic environment. The cervical fluid also nourishes the sperm and changes their structure to prepare them to fertilize an egg. Sperm can live up to five days in midcycle cervical fluid. After ovulation, as progesterone levels increase, cervical fluid thickens into a kind of plug that makes it difficult for sperm to enter the uterus. The vagina gradually becomes drier, too.

If you look at your cervix with a speculum or
feel it with your fingers, you may notice that at about the time of ovulation, the cervix is pulled up high into the vagina. It may also enlarge and soften, and the os (the opening to the uterus) may open a little.

The lining of the uterus, called the endometrium, thickens and then thins over the course of a menstrual cycle and thickens considerably during pregnancy. Embedded in this lining are glands that can secrete a fluid that will help nourish a pregnancy until a placenta is formed. In a typical menstrual cycle, estrogen made by the maturing ovarian follicle causes the glands to grow and the endometrium to thicken (partly through an increased blood supply). This thickening of the uterine lining is called the proliferative phase of the menstrual cycle. It can vary in length, generally lasting between six and twenty days. Progesterone, made by the corpus luteum (ruptured follicle) after the egg is released, stimulates the glands in the endometrium to begin secreting their nourishing substance. This is the secretory phase of the cycle and is the only time when a fertilized egg can implant in the lining. In women who have irregular periods, it is the proliferative phase that is variable; for example, a woman with twenty-eight-day cycles ovulates on day fourteen, while a woman with thirty-five-day cycles ovulates on day twenty-one.

If conception does not occur, the corpus luteum produces estrogen and progesterone for about twelve days, with the amount lessening in the last few days. As the estrogen and progesterone levels drop, the tiny arteries bringing blood supply to the endometrium close off. The lining, deprived of nourishment and oxygen, collapses and breaks off starting about fourteen days after ovulation. This is menstruation: the menstrual period or flow.

During menstruation, most of the lining is shed, but the bottom third remains to form a new lining. Then, as a new follicle starts growing and secreting estrogen, the uterine lining thickens, and the cycle begins again.

Women's menstrual cycles vary widely. Counting from the first day of one period to the first day of the next, most cycles last between twenty-three and thirty-six days. For teens the variation can be even broader, from twenty-one to forty-five days. Often we think of periods as occurring once per month (in fact, the word “menstruation” is from the Latin word
mensis
, for “month”). While some women have periods that do occur exactly every month, other women have cycles that are longer or shorter. Some women have consistently regular cycles (bleeding every twenty-eight or thirty-five days, for instance), while other women's cycles vary in length from one cycle to the next. Hormonal contraceptives or breastfeeding may alter the length of our cycles or even stop them altogether. After we have been pregnant—whether we have an abortion, a miscarriage, or give birth—our cycles may change.

Most women's periods last between two and eight days, with four to six days being the average. The flow stops and starts, though this is not always noticeable.

The fluid that flows from the vagina during the menstrual period includes much of the uterine lining that has built up during that cycle. In addition to blood (sometimes clotted) and endometrial cells, menstrual fluid contains cervical fluid and vaginal secretions. This mixed content is not obvious, since the blood colors the fluid red or brown. A usual discharge for a menstrual period is about two to five tablespoons, though it often looks like more.

Across time and cultures, women have used and continue to use a variety of products for catching menstrual flow. The choice often comes down to comfort, availability, convenience, and price. You might find the perfect match right away, or you might try different options, looking for more comfort or a better fit.

TAMPONS AND PADS

Many women use commercial tampons or pads (also called sanitary napkins) to catch menstrual blood. These are the products most easily available. Whether you use a product worn outside your body (such as a pad) or a product worn inside your body (such as a tampon) is a personal choice.

COMMON QUESTIONS ABOUT TAMPONS

Will a tampon get lost inside me?
No, absolutely not. The vagina is a closed space, and the opening of the cervix is far too small for the tampon to get inside. It is true, though, that a tampon can be forgotten and may slip into a vaginal fold, becoming difficult to find and remove. This can result in a strong odor and brown discharge after a few days. If you have trouble finding the string, you can squat down and reach the tampon with your fingers. For a
funny and informative video about this, see “The Lost Tampon” at docgurley.com.

Will tampons make me sick?
No. You may have heard that tampons cause toxic shock syndrome (TSS). TSS is a serious but rare condition caused by bacteria. Keeping tampons in longer than eight hours can increase the risk of TSS. If used according to the directions on the package and changed regularly, though, tampons are safe.

If I use a tampon, does that affect my virginity?
No again. Virginity generally refers to whether or not someone has had sexual intercourse, not to menstruation or tampons. Tampon use may be one of the factors that play a role in the disintegration of your hymen, but whether you have a visible hymen says nothing about whether you have had sex. For more information on
hymens and virginity
and
“Virginity.”

MORE OPTIONS

For many reasons, including comfort, environmental concerns such as a preference for reusable products, and worries about chemical residues, many of us use modified or alternative products to collect menstrual blood. These include all-cotton (sometimes organic) chlorine-free tampons, chlorine-free disposable pads, washable cloth pads, and devices that collect rather than absorb the menstrual fluid. All-cotton and all-organic cotton, chlorine-free tampons are often sold in health food stores and online, and increasingly at some drug and grocery stores. Also, you can make your own cloth pads. There are make-your-own sites online, showing very economical alternatives.

Some women use natural sea sponges that work like tampons. These are also available in health food stores and online. They are reusable and relatively inexpensive. Unfortunately, many pollutants are dumped into oceans and it's possible that sponges may absorb some of these pollutants and cause problems. Therefore, some users boil a sponge for five to ten minutes before using it for the first time and between uses. Doing so, however, shrinks and toughens the sponge and reduces its lifetime.

Some women prefer products that collect rather than absorb the menstrual fluid. The Keeper, the DivaCup, and the Mooncup are three examples of menstrual cups—elongated cups made of rubber or medical-grade silicone that are held in place by suction in the vagina. They can be worn during swimming and other physical activities but not during intercourse or other insertive sex. Some women use a diaphragm or a cervical cap in the same way as a cup. A disposable device called Instead is worn in the upper vagina to collect menstrual flow. The rim softens in response to body temperature and creates a seal to protect against leakage and slipping. (For more information on these products, see youngwomenshealth.org/alternative_menstrual.html.)

In mainstream Western culture, menstruation is largely taboo. We may hear jokes about it on television, or we may see advertisements for menstrual products, but rarely is menstruation talked about in honest terms. When's the last time you heard menstrual blood even mentioned? Being “fresh” or “clean” is emphasized, and the fact that we menstruate is hidden. Until recently, most menstrual product advertisements tried to be subtle, showing women staying fresh and wearing white while practicing yoga or dancing on the beach. Kotex came out with an ad campaign in 2010 making fun of the genre—to which Kotex readily acknowledged contributing. (Older ads used to include a strange blue liquid representing menstrual blood.) But honesty could go only so far, as none
of the three major television networks would allow the word “vagina” to be used.