Nursing Role for Menstrual Cycle

What is Menstrual Cycle

     The
menstrual cycle is a truly gender-specific process that has a profound effect
on women’s lives. When viewed in the general context of biological rhythms, the
menstrual cycle requires a complex sequence of physiological events coordinated
by the hypothalamus in conjunction with the pituitary glands, ovaries, and
uterus, along with the adrenal and thyroid systems, and that adapts to
environmental phenomena.

Physiological Background

    Derived
from the Latin mensis (month), the menstrual cycle is marked by the shedding of
the uterine lining-menstruation, or a menstrual “period.” We start
menstruating at 11-12 years of age (menarche) and have our last menstruation at
about 51 years (menopause). 

    With a few interruptions, such as pregnancy or
taking the pill, women will have about 400 periods during their lifetime.
Menstrual period and menstrual cycle are not one and the same: menstrual period
refers to the days that a woman bleeds. An average length of a period is 5
days; about half of all women bleed for 3-4 days and another 35% bleed for 5-6
days (Voda, Morgan, Root, & Smith, 1991). 

    The term menstrual cycle (or
menstrual cycle interval) refers to the span of time from the start of one
period to the start of the next. The length of a menstrual cycle can range from
21 to 35 days, with 29 days as the average.

Facts About Menstrual Cycle

    The
basic facts about the cyclical changes in hormonal levels and in the
reproductive organs are well-known and appear in many medical and nursing
textbooks (Fogel & Woods, 1995; Speroff, Glass, & Kase, 1999). 

    The
neuroendocrine mechanisms which control the reproductive cycle is by no means
completely understood. Most interest has focused on the ovarian hormones
estrogen and progesterone, and on their influence on the release of follicle
stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland
at the base of the brain.     

Not only a physiological process, menstruation is
associated with feminine role development and feelings of health and
well-being, and it is embedded in the sociocultural context of women’s experience.

Nursing Studies on Menstrual Cycle

    Nursing
scholarship and science focused on menstrual cycle phenomena can be traced to
the care our profession provided to women and their children beginning with
Lillian Wald’s work among the poor women of New York, Margaret Sanger’s efforts
to help women control their fertility, and Mary Breckenridge’s efforts to
provide maternity care in the rural Kentucky Hills.

Unique Nursing Contribution

    Since
the late 1970s, nursing research has contributed in unique ways to
understanding menstrual cycle events menarche, menstruation, and menopause-as
normative experiences and symptoms related to the menstrual cycle and menopause
as illness experiences. 

    In contrast, during the same period, biomedical
research has focused on understanding the problems related to menstruation and
menopause as disease or risk factors for disease with little attention to the
interaction of psychosocial, behavioral, cultural, or health factors. 

     science and scholarship have contributed new conceptual models, advanced
research methods, and new interventions that link therapeutics with advocacy.

Phenomenon Believes and Attitude and Menstrual Cycle

    Nurse
investigators have explored phenomena such as beliefs and attitudes among
menarche heal girls, menstrual cycle characteristics and premenstrual changes
among adult women, experiences typical of menopausal transition among midlife
women, as well as examining the menstrual cycle experiences in populations
seldom studied, such as disabled women, athletes, shift workers, toxic
exposures in oncology nurses, diabetic women, and beyond those of gynecology
clinic populations to the broader spectrum of healthy community samples. 

    They
have contributed to work complementing biomedical research in describing
physiologic patterns across the menstrual cycle, developing diagnostic
categories and criteria for phenomena such as dysmenorrhea, premenstrual
syndrome, premenstrual dysphoric disorder, and therapies for problems related
to menstruation and menopause.

Nursing and Women Health Concerns

    Nurses
with a concern for women’s health have historically included feminist
approaches in their clinical practice as well as their research. 

    Angela McBride
(McBride & McBride, 1981) was one of the first nurse scholars to embrace
feminist theory as a research paradigm, calling for a reframing of
gynecological disease within the greater context of a woman’s everyday life. 

    The
early nursing literature related to the menstrual cycle reflects a definition
of health grounded in everyday life (gynecology) and not just clinical
definitions of health such as risk factors and diseases (gynecology) (McBride,
1993).     

Nurses have focused their study on biopsychosocial response patterns,
normative or developmental transitions, functional status, role performance,
adaptation to environmental demands, and high-level wellness (Woods, 1988). 

    Nursing research has helped to focus women’s development and normative
transitions (menarche and menopause) as normal rather than deficiency
conditions that need medical treatment (Andrist & MacPherson, 2002).
Feminist methods of inquiry have been expanded by nurse researchers to provide
information “for” women rather than merely “about” women. 

    For example, nurse investigators’ use of methods such as
researcher-in-relation, reflexivity, and social transformation to understand
women’s perimenstrual and menopausal symptom experiences provides the basis for
women- centered therapeutics.

Multidisciplinary  Efforts 

    In
the past decade, multidisciplinary of forts have increased our power to
institute change in women’s health status through cross disciplinary research,
building on the wisdom of early pioneers. 

    For example, the Society for
Menstrual Cycle Research (SMCR), a multidisciplinary organization with strong
nursing leadership, has been the vanguard of the movement away from a
reductionist perspective to a more comprehensive approach to the study of
women’s health (SMCR web site). 

    Since 1977, the Society’s published research
conference proceedings have provided an invaluable chronology of research on
the menstrual cycle and advanced thinking across several disciplines: nursing.
psychology, sociology, epidemiology, anthropology, biostatistics, physiology,
medicine, and literature (SMCR web site). 

    Instead of a circumscribed phenomenon
peculiar to sex hormones, the Society defined the menstrual cycle in the
context of other biorhythms of human variability or a sociocultural network of
meanings, and of a new understanding of how the endocrine system interacts with
other functions.

Menstrual Cycle and Nursing Research

    Nursing
research has been at the forefront in the study of normative experiences of
menstrual cycle events. Menarche presents nurses with a unique opportunity to
address health promotion issues, particularly those related to reproductive and
sexual health of school-age girls. 

    In a review of nursing research
contributions to menstrual cycle research (Woods, Mitchell, & Taylor,
1999), investigators addressed images of menstruation presented to menarcheal
girls, menstrual attitudes, symptoms, and the relationship of called menarcheal
experiences and attitudes to adult women’s subsequent experiences of symptoms. 

    Since the last Encyclopedia of Nursing Research review by Reame, Medline and
CINAHL searches yielded 34 published papers related to menstrual function and
alterations related to daily activities, menstrual attitudes and knowledge, and
preparation for menarche across multiple cultures. 

    In contrast to the last
review, the cultural and ethnic context is addressed by nurse researchers more
than by other disciplines. These studies of menarcheal experiences and programs
for menarcheal preparation in 12 cultures, including African-American girls,
provides an expansive understanding of the developmental opportunity presented
by menarche. 

    More recently, nurses have been at the fore-front of translating
research to practice in the development of menstrual health advocacy groups
(Red Web Foundation) and internet-based education (www.redspot.org).

Past Events and Menstrual Experiences

    Early
efforts to understand the normative experience of menstruation and menstrual
symptoms as illness experiences have included studies of healthy
community-based populations of women. From these studies, we have been able to
estimate the normative experiences of women and identify some that are
idiosyncratic.

    The
Tremin Trust Database, first administered by Ann Voda at the University of Utah
and now at Pennsylvania State University, represents a national resource of
information about women’s menstrual cycles that includes data from over 5,000
women spanning four generations (Voda, 1991). 

    From the Tremin Trust Database it
is possible to follow women from menarche through menopause and in some
instances to do so for three generations. This database has provided important
information about menstrual cyclicity across the reproductive years, length of
cycles and bleeding episodes, regularity, and estimates of menopause.

Nursing Research and Menstrual Experiences

    Since
the early 1980s, nurse researchers have expanded the scope of explanatory models
and methods for menstrual cycle research. 

    Woods and colleagues have examined
how symptoms synchronized to the menstrual cycle are influenced by the context
of social class, education, race, marital status, self-esteem, occupation, and
menstrual attitudes (Woods, Most, & Longenecker, 1985). 

    They have
documented the dynamic nature of symptom formation across and within
individuals in response to their changing social environments (Taylor, Woods,
Lentz, & Mitchell, 1991).

    A
byproduct of nursing studies has been the development of improved designs and
methods for the biobehavioral assessment of menstrual cycle phenomena (Woods,
Most, & Dery, 1982; Shaver & Woods, 1986; Taylor, D., 1990; Mitchell,
Lentz, & Woods, 1991; Reame, Kelch, Beitins, Yu, Zawacki, &
Padmanabhan, 1996; Woods, Mitchell, & Lentz, 1999; Mitchell, Woods, &
Mariella, 2000; Woods, Mitchell, & Mariella, 2002). 

    Such methods have
included the measurement of menstrual flow absorbency, assessment of
perimenstrual symptom patterns and cluster types, statistical methods for
handling the detection of LH pulsatile secretion, and comparison of daily
menstrual symptoms across cycles of the same individual. 

    The Washington Women’s
Daily Health Diary includes a menstrual symptom severity list of positive and
negative experiences. It has been used by several nurse researchers to define a
variety of menstrual cycle symptom patterns, including menarcheal and
menopausal experiences.

Nursing Research on Menopause

    Nursing
research on menopause, like that on the menstrual cycle, has emphasized studies
of normative experiences. A review of the literature contains rich descriptions
of symptoms associated with menopause, including studies of hot flashes, sleep
problems, and depression (Woods, Mitchell, & Taylor, 1999). 

    In addition,
nurses have focused on the meanings of menopause, women’s attitudes toward the
experience, and the social context in which it occurs and how the social
context modifies the experience. 

    In a recent review of nursing research on the
menopausal transition, Andrist and MacPherson (2002) demonstrated that nursing
research has helped to refocus women’s development and developmental
transitions as normal rather than deficiency conditions that need medical
treatment. 

    Nursing scholars have also focused on the experience of menopause
across cultures (George, 1996; Punyahotra & Street, 1998; Meleis &
Park, 1999; Berg & Taylor, 1999), studies of decision processes women use
in arriving at a commitment to use ( or not use) hormone therapy (Rothert &
O’Connor, 2002), and more recently on nonhormonal symptom management strategies
(Cohen, Rousseau, & Carey, 2003).

Nursing Research and Community Efforts

    Nursing
research results reflect a wide range of studies with women seeking care in
clinical settings as well as community based populations of women. 

    Comorbidity
in these samples remains a challenge, as does accounting for the influences of
oral contraceptives, other drugs, psychiatric history, age, ovulatory status,
and characteristics of the menstrual cycle. 

    ncouraging is the promotion of the
menstrual cycle as the “fifth vital sign” to be incorporated into all
women’s health assessments.

    There
is only beginning work focusing on biological changes surrounding menarche and
in relation to symptoms. More studies of menarcheal preparation are needed to
provide young girls with optimum preparation for healthy experiences of
menstruation and their sexuality. 

    The type of information girl’s needs, beyond
how to cope with the hygienic challenge of menstruating, is yet to be defined.
Psychoeducational interventions for school age girls provided by school nurses
are in area for continuing study.

    What
is needed for future menopause related research are studies of health education
interventions, such as those designed to reduce women’s uncertainty about the
experience. 

    In addition, primary care models of therapeutics for menopause are
needed. There is an acute need to find non-pharmacological and culturally appropriate
options for symptom management for symptoms such as hot flashes and sleep
disturbances.