Menstrual Health

    Researchedby:
    Brady Holmer, Rachel Hathcock

    Fact-checked

    by:

    Marina Shkayeva, Nick Milazzo
    Last Updated: July 6, 2023

    Menstrual health refers to physical, mental, and social well being in relation to a woman’s menstrual cycle. This includes proper hygiene, comfort, and safety during the menstrual cycle as well as access to information about the menstrual cycle.

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    Menstrual Health falls under the Women’s Health category.

    107 references on this page
    16,837 participants in 10 trials and 1 meta-analysis

    What is the menstrual cycle?

    The menstrual cycle is a carefully regulated sequence of events that prepares the female body for a potential pregnancy. It starts with the follicular phase, which includes menstruation and the maturation of the ovarian follicle. This is followed by ovulation (mature follicle releases egg) and then by the luteal phase (during which the egg moves through fallopian tubes); if pregnancy doesn’t occur, then the cycle re-starts again with the follicular phase and menstruation.[1]

    These events are primarily driven by hormonal communication between the brain (specifically, the hypothalamus and pituitary gland) and the female reproductive system, collectively called the hypothalamic-pituitary-ovarian (HPO) axis.[2] The first menstruation (menarche) occurs around age 12 (median; range of 10-16), and reoccurs regularly every 24 to 38 days,[3] stopping at menopause (near age 50), which signifies the end of reproductive fertility. The menstrual cycle also stops during pregnancy and often during lactation.[4]

    What are the phases of the menstrual cycle?

    What are the signs and symptoms of the menstrual cycle?

    How is menstrual cycle health measured?

    The menstrual cycle is an important component of overall health. As such, the menstrual cycle is considered a vital sign by some clinicians.[5] There are a variety of ways to measure menstrual cycle health, ranging from simple, at-home tracking methods to bloodwork and ultrasound imaging. A basic assessment of the menstrual cycle starts with measurements of frequency (menstruation or bleeding occurs every 24 to 38 days), regularity (the number of days between menstruation is similar each month), duration (bleeding does not last longer than eight days), and volume (loss of no more than 80 mL of menstrual blood per cycle).[6] The phases of the menstrual cycle are sometimes measured via basal body temperature and hormone levels in saliva, urine, or blood.[1] If there are abnormalities, like infrequent menstruation (oligomenorrhea), too frequent menstruation (polymenorrhea), the total absence of menstruation (amenorrhea), or very heavy bleeding (menorrhagia), a clinician can perform additional assessments to better understand the underlying cause of the abnormality.

    These additional assessments may include bloodwork and imaging. Blood tests can detect the levels of different hormones that affect the menstrual cycle (e.g., progesterone, estrogen, thyroid hormone, androgens, prolactin). They can also measure iron levels, which are sometimes affected by menstrual bleeding, and may aid in the diagnosis of underlying bleeding disorders or infections. In some cases, imaging of the reproductive system is also necessary, usually beginning with an ultrasound. Serial transvaginal ultrasounds can visualize the changes that occur in the ovaries and endometrial lining throughout the menstrual cycle.[7]

    Can menstrual cycle measurements aid in achieving or preventing pregnancy?

    How does physical activity affect menstrual cycle health?

    Regular exercise may alleviate pain and other negative symptoms before and during menstruation.[8][9][10] Regular exercise can also shorten the length of menses.[11]

    Conversely, too much exercise can be detrimental to menstrual cycle health, causing menstrual irregularities or even the total absence of menstruation.[12][13] This is not a normal response to exercise and should be evaluated by a clinician. It may be a sign of relative energy deficiency in sport (RED-S), a condition indicating that the body does not have enough energy to meet its demands.[14] The consequences of RED-S are far-reaching, serious, and potentially irreparable.[15][16]

    Can the menstrual cycle affect exercise performance?

    Have any supplements been studied for menstrual cycle health?

    Supplements for the menstrual cycle are often studied in the context of correcting deficiencies and/or reducing the symptoms of conditions like premenstrual syndrome, endometriosis, dysmenorrhea, and polycystic ovary syndrome. For example, vitamin D deficiency is associated with dysmenorrhea and abnormal menstrual bleeding patterns, in which case supplementing with vitamin D to correct the deficiency could be beneficial.[17][18] Additional supplements that might improve menstrual-related symptoms (with varying levels of efficacy) include chaste tree, magnesium, vitamin B6 and B1, ginger, calcium, selenium, omega-3 fatty acids, curcumin, and inositol.[19][20][21][22][23][24][18]

    Another supplement that is often studied in menstruating people is iron because blood loss via menstruation can reduce iron levels in the body, especially if the bleeding is heavy.[17] Iron may also be lost during exercise.[25] Because iron is used to make red blood cells, a deficiency in iron can lead to anemia, which means that the blood cannot carry enough oxygen throughout the body. Iron supplementation is an effective treatment for iron deficiency.[26][27]

    Before beginning any supplements, it is important for menstrual-related symptoms to be evaluated by a clinician. Some supplements, like iron, can cause damage if excessive amounts accumulate in the body. Such accumulation is rarely the result of excessive oral intake and is instead secondary to other underlying medical problems, both congenital and acquired. [28]

    How can diet affect menstrual cycle health?

    Eating a nutritious diet with an appropriate amount of kilocalories is integral to menstrual cycle health. Dietary patterns that include a diversity of fruits and vegetables, dairy products, fish, green tea, and plant-derived compounds and avoid excessive intakes of alcohol, red and processed meats, and caffeine are correlated with fewer menstrual-related disorders.[29][30][31] There are also associations (but no robust data) between a more “proinflammatory” dietary pattern and reduced levels of sex hormone binding globulin, which might affect menstrual-related symptoms in some people.[32]

    Diet is also implicated in the timing of menarche (or the first menses). Menstruation requires energy, so malnourishment and low body weight can result in a later onset of menarche, whereas overnutrition and obesity are associated with an earlier age at menarche.[33][34][35]

    Are there specific diets that are better for menstrual cycle health?

    Could the menstrual cycle affect dietary cravings?

    Could the menstrual cycle affect dietary intake and metabolism?

    Should dietary intake change throughout the menstrual cycle?

    Is “seed cycling” beneficial for hormonal health?

    Which other factors affect the menstrual cycle?

    The menstrual cycle is affected by numerous internal and external factors, all of which can alter the cycle’s length, regularity, and symptoms. Some of these factors are not modifiable, such as race/ethnicity, age, intrauterine exposures, family history, adverse childhood events, and genetics.[36][37] Other factors are related to the environment, like exposure to air pollution, endocrine-disrupting chemicals, and certain viruses and bacteria, as well as the geographic climate.[36][38] There are also important personal and lifestyle factors to consider, including mental health,[39][40], sleep health,[41][42] body mass index,[43][44][45] use of tobacco and cannabis,[46][43] lactation,[47][48] use of contraceptives (oral medications, intrauterine devices, ect.),[49][50] shift work,[37] and possibly even a history of concussions.[51]

    Of these factors, psychological stress is a common target for interventions aimed at restoring normal menses, reducing menstrual-related symptoms, and improving fertility. For example, acupuncture and acupressure may help some people with premenstrual syndrome or menstrual irregularity.[52][53] Psychosocial interventions, particularly cognitive behavioral therapy and mindfulness-based therapies, may increase pregnancy rates in people with infertility[54] and improve mood in people with premenstrual syndrome.[55][56]

    Adapted from Campbell et al., 2021[37]

    How do contraceptives affect the menstrual cycle?

    Can endocrine-disrupting chemicals affect the menstrual cycle?

    Examine Database: Menstrual Health

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    Frequently asked questions

    What is the menstrual cycle?

    The menstrual cycle is a carefully regulated sequence of events that prepares the female body for a potential pregnancy. It starts with the follicular phase, which includes menstruation and the maturation of the ovarian follicle. This is followed by ovulation (mature follicle releases egg) and then by the luteal phase (during which the egg moves through fallopian tubes); if pregnancy doesn’t occur, then the cycle re-starts again with the follicular phase and menstruation.[1]

    These events are primarily driven by hormonal communication between the brain (specifically, the hypothalamus and pituitary gland) and the female reproductive system, collectively called the hypothalamic-pituitary-ovarian (HPO) axis.[2] The first menstruation (menarche) occurs around age 12 (median; range of 10-16), and reoccurs regularly every 24 to 38 days,[3] stopping at menopause (near age 50), which signifies the end of reproductive fertility. The menstrual cycle also stops during pregnancy and often during lactation.[4]

    What are the phases of the menstrual cycle?

    The menstrual cycle is divided into two main phases: the follicular (or proliferative) phase and the luteal (or secretory) phase, both of which contain subphases (e.g., early follicular, late follicular, ovulatory, early luteal, late luteal). Each subphase is marked by a unique hormonal profile and an accompanied response from the reproductive organs.[57] The follicular phase lasts approximately 14 to 21 days, begins with menstruation (colloquially known as “a period”), and ends with ovulation. During this phase, follicle stimulating hormone causes follicles in the ovaries (which store eggs) to grow, and the lining of the uterus thickens as estrogen levels rise. About halfway through the cycle (around day 14), a surge in luteinizing hormone stimulates ovulation or the release of a mature egg(s) from the follicle.

    During the approximately 14 days of the luteal phase, the egg travels through the fallopian tube and into the uterus. Meanwhile, the follicle that released the egg (now called the corpus luteum) releases hormones, primarily progesterone, which prepares the uterus for implantation of the egg, should it become fertilized. If the egg is not fertilized, the corpus luteum stops releasing hormones, progesterone and estrogen levels fall, and the lining of the uterus sheds in the form of bloody discharge through the vaginal canal. The time when bleeding begins is considered day 1 of the next menstrual cycle and the start of a new follicular phase.[58]

    The above description, although factual, does not capture the unique complexities of the menstrual cycle. The exact timing and amplitude of the peaks and troughs of reproductive hormones (as well as the menstrual cycle phases they bring about) vary both between and within individuals. Most of this dissimilarity is prompted by differences or changes in the length of the follicular phase, whereas the luteal phase remains relatively constant. On average, a person’s onset of menses can deviate by up to 4 days, compared to a previous cycle. The regularity of the menstrual cycle is also affected by age, with younger and older people more likely to experience cycle irregularities and anovulatory cycles (menstrual cycles that do not result in the release of an egg).[58]

    What are the signs and symptoms of the menstrual cycle?

    Many people experience certain signs and symptoms during different phases of the menstrual cycle, especially a few days before and during menstruation. This is usually due to hormone fluctuations, which can affect everything from digestion to mood to acne to joint laxity to sleep. Although each person’s menstrual cycle is unique, there are some common symptoms to note and track to better manage them.

    During menstruation, estrogen and progesterone are at their lowest, and, for some people, energy levels are equally low. Abdominal cramping, bloating, irritability, headaches, tender breasts, mood swings, and low back pain may also be experienced during this phase. If cramping is particularly intense and recurrent with each menses, it may be diagnosed as dysmenorrhea and should be assessed by a clinician for secondary causes, like endometriosis.[59]

    As the follicular phase progresses and estrogen rises, the symptoms of menstruation should subside. Mood and energy levels often improve,[60] and, as ovulation nears, sexual desire may increase while hunger/appetite decreases.[61][62] When ovulation occurs, some people feel abdominal pain (called mittelschmerz), likely related to the rise in luteinizing hormone that stimulates prostaglandin production and the consequential contraction of the ovary to release an egg.[63]

    With ovulation complete, the luteal phase begins, and progesterone levels rise. The precise effects of progesterone on mood are unclear and likely affect people differently.[64] However, if a pregnancy does not occur, the subsequent drop in circulating progesterone and estrogen levels can cause negative symptoms. This is why the late luteal phase is often associated with food cravings, mood swings, gastrointestinal discomfort, breast tenderness, and poor sleep.[65][66][67] If the symptoms are severe, it may be a sign of premenstrual syndrome (PMS).

    How is menstrual cycle health measured?

    The menstrual cycle is an important component of overall health. As such, the menstrual cycle is considered a vital sign by some clinicians.[5] There are a variety of ways to measure menstrual cycle health, ranging from simple, at-home tracking methods to bloodwork and ultrasound imaging. A basic assessment of the menstrual cycle starts with measurements of frequency (menstruation or bleeding occurs every 24 to 38 days), regularity (the number of days between menstruation is similar each month), duration (bleeding does not last longer than eight days), and volume (loss of no more than 80 mL of menstrual blood per cycle).[6] The phases of the menstrual cycle are sometimes measured via basal body temperature and hormone levels in saliva, urine, or blood.[1] If there are abnormalities, like infrequent menstruation (oligomenorrhea), too frequent menstruation (polymenorrhea), the total absence of menstruation (amenorrhea), or very heavy bleeding (menorrhagia), a clinician can perform additional assessments to better understand the underlying cause of the abnormality.

    These additional assessments may include bloodwork and imaging. Blood tests can detect the levels of different hormones that affect the menstrual cycle (e.g., progesterone, estrogen, thyroid hormone, androgens, prolactin). They can also measure iron levels, which are sometimes affected by menstrual bleeding, and may aid in the diagnosis of underlying bleeding disorders or infections. In some cases, imaging of the reproductive system is also necessary, usually beginning with an ultrasound. Serial transvaginal ultrasounds can visualize the changes that occur in the ovaries and endometrial lining throughout the menstrual cycle.[7]

    Can menstrual cycle measurements aid in achieving or preventing pregnancy?

    Outside of general health, many people measure the menstrual cycle with the goal of achieving or preventing a pregnancy. This requires detecting the time of ovulation because the likelihood of pregnancy is highest when sexual intercourse occurs during the period from 2 days before to the day of ovulation.[68] In people with a normal menstrual cycle, there are several simple, inexpensive ways to potentially predict the time of ovulation. These include menstrual cycle charting, oral basal body temperature monitoring, and assessing cervical mucus changes, although the reliability of these methods is questionable.[69]

    There are more accurate ways to detect ovulation. Commercially available tests determine the time of ovulation by measuring the levels of luteinizing hormone and/or estrogen metabolites in a urine sample or by carefully monitoring body temperature, either under the arm or in the vagina, with special devices.[7] People with an irregular menstrual cycle or difficulty getting pregnant may require more extensive testing to determine when and if ovulation is occurring, such as bloodwork and imaging studies (e.g., ultrasound). It is important to work with an experienced clinician for any menstruation or fertility issues.

    How does physical activity affect menstrual cycle health?

    Regular exercise may alleviate pain and other negative symptoms before and during menstruation.[8][9][10] Regular exercise can also shorten the length of menses.[11]

    Conversely, too much exercise can be detrimental to menstrual cycle health, causing menstrual irregularities or even the total absence of menstruation.[12][13] This is not a normal response to exercise and should be evaluated by a clinician. It may be a sign of relative energy deficiency in sport (RED-S), a condition indicating that the body does not have enough energy to meet its demands.[14] The consequences of RED-S are far-reaching, serious, and potentially irreparable.[15][16]

    Can the menstrual cycle affect exercise performance?

    There is speculation that the rise and fall of hormones throughout the menstrual cycle could affect exercise performance. Put very simply, one prevailing theory is that performance may be enhanced during the late follicular phase, when menstruation and its potential accompanying symptoms are gone and estrogen (an anabolic hormone) is high, compared to the luteal phase, when progesterone is elevated, which may counteract the actions of estrogen, increase body temperature, and negatively affect recovery and neuromodulation.[70] However, whether exercise performance fluctuates alongside these hormonal shifts likely depends on the individual. For example, some people find that the symptoms of menstruation, like cramping and gastrointestinal discomfort, interfere with their ability to engage in athletic pursuits (especially if they suffer from dysmenorrhea or PMS), whereas other people are unaffected by menses.[71] This heterogeneity makes it difficult to prescribe general guidelines regarding exercise and the menstrual cycle.

    In fact, studies on the menstrual cycle and exercise performance have failed to find robust and consistent differences between performance (strength or aerobic) at different phases of the menstrual cycle.[72] A 2020 meta-analysis reported that in eumenorrheic female athletes, there may be a trivial reduction in exercise performance during the early follicular phase (the time of menses).[73] Other studies find that muscle recruitment and recovery may be impaired during the luteal phase, when progesterone is at its peak, but that this does not necessarily affect performance.[72][74] Nonetheless, menstrual-related symptoms can negatively affect a person’s perception of their performance, mental sharpness, and balance.[75] Studies of higher quality are needed to determine whether training based on menstrual cycle phases provides added benefit over that of a well-structured exercise program.

    Similarly, there is insufficient evidence that the risk for exercise-related injuries (particularly ligament injuries) varies across the menstrual cycle, but it is possible that hormonal fluctuations increase the risk for injuries.[76][77][78]

    Have any supplements been studied for menstrual cycle health?

    Supplements for the menstrual cycle are often studied in the context of correcting deficiencies and/or reducing the symptoms of conditions like premenstrual syndrome, endometriosis, dysmenorrhea, and polycystic ovary syndrome. For example, vitamin D deficiency is associated with dysmenorrhea and abnormal menstrual bleeding patterns, in which case supplementing with vitamin D to correct the deficiency could be beneficial.[17][18] Additional supplements that might improve menstrual-related symptoms (with varying levels of efficacy) include chaste tree, magnesium, vitamin B6 and B1, ginger, calcium, selenium, omega-3 fatty acids, curcumin, and inositol.[19][20][21][22][23][24][18]

    Another supplement that is often studied in menstruating people is iron because blood loss via menstruation can reduce iron levels in the body, especially if the bleeding is heavy.[17] Iron may also be lost during exercise.[25] Because iron is used to make red blood cells, a deficiency in iron can lead to anemia, which means that the blood cannot carry enough oxygen throughout the body. Iron supplementation is an effective treatment for iron deficiency.[26][27]

    Before beginning any supplements, it is important for menstrual-related symptoms to be evaluated by a clinician. Some supplements, like iron, can cause damage if excessive amounts accumulate in the body. Such accumulation is rarely the result of excessive oral intake and is instead secondary to other underlying medical problems, both congenital and acquired. [28]

    How can diet affect menstrual cycle health?

    Eating a nutritious diet with an appropriate amount of kilocalories is integral to menstrual cycle health. Dietary patterns that include a diversity of fruits and vegetables, dairy products, fish, green tea, and plant-derived compounds and avoid excessive intakes of alcohol, red and processed meats, and caffeine are correlated with fewer menstrual-related disorders.[29][30][31] There are also associations (but no robust data) between a more “proinflammatory” dietary pattern and reduced levels of sex hormone binding globulin, which might affect menstrual-related symptoms in some people.[32]

    Diet is also implicated in the timing of menarche (or the first menses). Menstruation requires energy, so malnourishment and low body weight can result in a later onset of menarche, whereas overnutrition and obesity are associated with an earlier age at menarche.[33][34][35]

    Are there specific diets that are better for menstrual cycle health?

    Specific diets, such as the Mediterranean diet,[79] low-carbohydrate diet,[80] DASH diet,[81] low-fat vegetarian diet,PMID10674588 low glycemic index diet,[82] and ketogenic diet,[83] may support menstrual cycle health in people with certain conditions, but there is no evidence to support a single “best” diet for all menstruating people. In fact, some studies find that the Mediterranean diet, low carbohydrate diets, and diets with too much fiber are associated with irregular menstrual cycles.[84][85] Still other studies report that in people with overweight and obesity, weight loss improves menstrual regularity more than a specific dietary composition.[86] This variety of findings highlights the importance of an individualized approach to diet. However, it is very clear that overly restrictive diets and eating disorders negatively affect reproductive health.[14]

    Could the menstrual cycle affect dietary cravings?

    It is possible for the menstrual cycle to affect diet. In some people, cravings for sweet and salty foods, as well as overall appetite, may be increased during the luteal phase, compared to other phases.[66] This might be related, in part, to the way hormones can affect appetite, the perception of taste and smell, and water regulation.[87]

    Could the menstrual cycle affect dietary intake and metabolism?

    The body’s ability to utilize certain macronutrients for energy appears to fluctuate throughout the menstrual cycle. When estrogen is elevated during the follicular phase, carbohydrates are used more readily, and glycogen storage may be reduced. Conversely, when progesterone is elevated during the luteal phase, there is a greater breakdown of protein, increased utilization of fat, and a slight increase in basal metabolic rate.[88][89] Whether altering dietary macronutrient intake alongside these metabolic shifts is advantageous for health outcomes — including fertility, exercise performance, and menstrual-related symptoms — requires further research.

    Should dietary intake change throughout the menstrual cycle?

    There is no research to support rotating certain foods into and out of the diet based on the menstrual cycle phase with the goal of “supporting” hormonal health. Menstrual cycle-based diets usually recommend some variation of the following: eating anti-inflammatory and iron-rich foods, (like salmon, red meat, and dark leafy green vegetables) during menstruation, eating “proestrogenic” foods (like flax seeds and kimchi) during the follicular phase, and eating foods that “balance” blood sugar and support progesterone (like complex carbohydrates, avocados, tofu, dark chocolate, and pumpkin seeds) during the luteal phase. These recommendations (e.g.,like eating iron-rich foods when losing blood through menstruation) certainly aren’t unhealthful or completely unfounded, but they are not an evidence-based way to “balance hormones”.

    Is “seed cycling” beneficial for hormonal health?

    There are no controlled trials on the practice of seed cycling for hormonal health, and, consequently, there is no evidence to support or refute its benefits to the menstrual cycle. Seed cycling involves eating specific seeds (e.g., pumpkin, flax, sesame, sunflower) during certain phases of the menstrual cycle to “support” hormone production and function. The idea is that as reproductive hormones ebb and flow, so too does the body’s nutritional needs, and different seeds can be cycled in and out of the diet to “match” these needs and thereby optimize hormonal health.

    During the follicular phase, flax seeds (which contain phytoestrogens) and pumpkin seeds (for micronutrients like zinc and magnesium) are consumed to support and “balance” the rise in estrogen. During the luteal phase, sunflower seeds (for micronutrients like vitamin E and selenium) and sesame seeds (for micronutrients like calcium and B vitamins) are consumed to support progesterone production. The “dosage” for each seed is 1 to 2 tablespoons per day, preferably raw and freshly ground.

    Although there are no trials on seed cycling, there is some evidence on the effect of certain seeds and micronutrients on the menstrual cycle. For instance, a small crossover study in 18 women found that supplementation with flax seed powder reduced the number of anovulatory cycles (a menstrual cycle with no egg release), but there were no significant differences in estrogen levels.[90] Supplementation with zinc for 4 to 6 days before (and possibly during) menstruation may reduce menstrual pain in people with primary dysmenorrhea.[91] Similarly, calcium supplementation may reduce symptoms of PMS,[92] as may vitamin E supplementation.[93] A retrospective cohort study in infertile women with PCOS also found that vitamin E supplementation reduced markers of oxidative stress, but it did not improve ovulation or the chance of getting pregnant.[94]

    Seeds do contain important vitamins and minerals and can be a healthful addition to most diets. However, it is important to seek the help of a clinician if hormonal issues are suspected.

    Which other factors affect the menstrual cycle?

    The menstrual cycle is affected by numerous internal and external factors, all of which can alter the cycle’s length, regularity, and symptoms. Some of these factors are not modifiable, such as race/ethnicity, age, intrauterine exposures, family history, adverse childhood events, and genetics.[36][37] Other factors are related to the environment, like exposure to air pollution, endocrine-disrupting chemicals, and certain viruses and bacteria, as well as the geographic climate.[36][38] There are also important personal and lifestyle factors to consider, including mental health,[39][40], sleep health,[41][42] body mass index,[43][44][45] use of tobacco and cannabis,[46][43] lactation,[47][48] use of contraceptives (oral medications, intrauterine devices, ect.),[49][50] shift work,[37] and possibly even a history of concussions.[51]

    Of these factors, psychological stress is a common target for interventions aimed at restoring normal menses, reducing menstrual-related symptoms, and improving fertility. For example, acupuncture and acupressure may help some people with premenstrual syndrome or menstrual irregularity.[52][53] Psychosocial interventions, particularly cognitive behavioral therapy and mindfulness-based therapies, may increase pregnancy rates in people with infertility[54] and improve mood in people with premenstrual syndrome.[55][56]

    Adapted from Campbell et al., 2021[37]
    How do contraceptives affect the menstrual cycle?

    Certain contraceptives can affect the menstrual cycle. Two examples are oral contraceptive pills and intrauterine devices. Combined estrogen-progestin oral contraceptives (colloquially known as “the birth control pill”) externally regulate the menstrual cycle by providing sex hormones in the form of a pill and consequently suppressing the body’s production of hormones. This inhibition of internal hormone formation means that ovulation does not occur, thus preventing pregnancy.[95] Some people find that oral contraceptives alleviate the symptoms of certain conditions, like dysmenorrhea and PCOS, but they may also have adverse effects.[96] The FDA is a good resource for more information on oral contraceptives.

    A intrauterine device (IUD) is a small device that is inserted into the uterus by a clinician to prevent pregnancies. IUDs are the most common form of long-acting, reversible birth control used worldwide.[97] In the United States, there are two main types of IUDs, ones that contain copper and ones that release the hormone levonorgestrel (a form of progesterone). Because these devices work locally, they usually do not suppress the body’s hormone production, and the menstrual cycle continues. However, they can have short-term and long-term effects on menstrual-related symptoms in some people.

    IUDs can increase cramping and bleeding and can cause unscheduled bleeding and spotting; this usually subsides within the first 6 months, but it can be severe and/or prolonged enough to cause discontinuation.[98][99] Conversely, in the long term, they can cause amenorrhea and lighter bleeding and can even reduce pelvic pain and dysmenorrhea.[100][101][50]

    It is important to speak with a clinician when weighing the risks and benefits of different contraceptives because the choice is highly individualized.

    Can endocrine-disrupting chemicals affect the menstrual cycle?

    Endocrine-disrupting chemicals (EDCs) are exogenous substances that interfere with the normal functions of the endocrine system, often by disrupting hormone synthesis, secretion, metabolism, and/or transport.[102] These substances are found in the environment (air, water, soil) as well as in foods, medical devices, and personal care and household products. Some occur naturally, like the phytoestrogens in soy, whereas others are manufactured, like flame retardants and bisphenol A. Endocrine-disrupting chemicals are ubiquitous and have been detected in human urine, blood, sweat, hair, and even breastmilk.[103][104]

    There is evidence suggesting that EDCs can negatively affect reproductive health. Exposure to certain air pollutants, parabens, and polybrominated biphenyls is associated with irregular menstrual cycles,[105] and EDCs may also increase the risk for ovarian aging (which may result in a decline in fertility).[106] More research is needed to determine the causal effects of EDCs in humans as well as the dosages at which they could potentially do harm.[107]

    Update History

    References

    1. ^Schmalenberger KM, Tauseef HA, Barone JC, Owens SA, Lieberman L, Jarczok MN, Girdler SS, Kiesner J, Ditzen B, Eisenlohr-Moul TAHow to study the menstrual cycle: Practical tools and recommendations.Psychoneuroendocrinology.(2021-Jan)
    2. ^Itriyeva KThe normal menstrual cycle.Curr Probl Pediatr Adolesc Health Care.(2022-May)
    3. ^Biro FM, Pajak A, Wolff MS, Pinney SM, Windham GC, Galvez MP, Greenspan LC, Kushi LH, Teitelbaum SLAge of Menarche in a Longitudinal US Cohort.J Pediatr Adolesc Gynecol.(2018-Aug)
    4. ^Lobo RA, Gompel AManagement of menopause: a view towards prevention.Lancet Diabetes Endocrinol.(2022-Jun)
    5. ^ACOG Committee Opinion No. 651: Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign.Obstet Gynecol.(2015 Dec)
    6. ^Fraser IS, Critchley HO, Broder M, Munro MGThe FIGO recommendations on terminologies and definitions for normal and abnormal uterine bleeding.Semin Reprod Med.(2011-Sep)
    7. ^Su HW, Yi YC, Wei TY, Chang TC, Cheng CMDetection of ovulation, a review of currently available methods.Bioeng Transl Med.(2017-Sep)
    8. ^McKenna KA, Fogleman CDDysmenorrhea.Am Fam Physician.(2021-Aug-01)
    9. ^Ravichandran H, Janakiraman BEffect of Aerobic Exercises in Improving Premenstrual Symptoms Among Healthy Women: A Systematic Review of Randomized Controlled Trials.Int J Womens Health.(2022)
    10. ^Armour M, Ee CC, Naidoo D, Ayati Z, Chalmers KJ, Steel KA, de Manincor MJ, Delshad EExercise for dysmenorrhoeaCochrane Database Syst Rev.(2019 Sep 20)
    11. ^Witkoś J, Hartman-Petrycka MThe Female Athlete Triad-the impact of running and type of diet on the regularity of the menstrual cycle assessed for recreational runners.PeerJ.(2022)
    12. ^Joanna Witkoś, Grzegorz Błażejewski, Magdalena Hagner-Derengowska, Kamila MakulecThe Impact of Competitive Swimming on Menstrual Cycle Disorders and Subsequent Sports Injuries as Related to the Female Athlete Triad and on Premenstrual Syndrome SymptomsInt J Environ Res Public Health.(2022 Nov 28)
    13. ^Cesar A Hincapié, J David CassidyDisordered eating, menstrual disturbances, and low bone mineral density in dancers: a systematic reviewArch Phys Med Rehabil.(2010 Nov)
    14. ^Huhmann KMenses Requires Energy: A Review of How Disordered Eating, Excessive Exercise, and High Stress Lead to Menstrual Irregularities.Clin Ther.(2020-Mar)
    15. ^Dipla K, Kraemer RR, Constantini NW, Hackney ACRelative energy deficiency in sports (RED-S): elucidation of endocrine changes affecting the health of males and females.Hormones (Athens).(2021-Mar)
    16. ^Coelho AR, Cardoso G, Brito ME, Gomes IN, Cascais MJThe Female Athlete Triad/Relative Energy Deficiency in Sports (RED-S).Rev Bras Ginecol Obstet.(2021-May)
    17. ^Jain V, Chodankar RR, Maybin JA, Critchley HODUterine bleeding: how understanding endometrial physiology underpins menstrual health.Nat Rev Endocrinol.(2022-May)
    18. ^Rahnemaei FA, Gholamrezaei A, Afrakhteh M, Zayeri F, Vafa MR, Rashidi A, Ozgoli GVitamin D supplementation for primary dysmenorrhea: a double-blind, randomized, placebo-controlled trial.Obstet Gynecol Sci.(2021-Jul)
    19. ^Pattanittum P, Kunyanone N, Brown J, Sangkomkamhang US, Barnes J, Seyfoddin V, Marjoribanks JDietary supplements for dysmenorrhoea.Cochrane Database Syst Rev.(2016-Mar-22)
    20. ^Whelan AM, Jurgens TM, Naylor HHerbs, vitamins and minerals in the treatment of premenstrual syndrome: a systematic review.Can J Clin Pharmacol.(2009)
    21. ^Verkaik S, Kamperman AM, van Westrhenen R, Schulte PFJThe treatment of premenstrual syndrome with preparations of Vitex agnus castus: a systematic review and meta-analysisAm J Obstet Gynecol.(2017 Aug)
    22. ^Gianfranco C, Vittorio U, Silvia B, Francesco DMyo-inositol in the treatment of premenstrual dysphoric disorderHum Psychopharmacol.(2011 Oct)
    23. ^James L Nodler, Amy D DiVasta, Allison F Vitonis, Sarah Karevicius, Maggie Malsch, Vishnudas Sarda, Ayotunde Fadayomi, Holly R Harris, Stacey A MissmerSupplementation with vitamin D or ω-3 fatty acids in adolescent girls and young women with endometriosis (SAGE): a double-blind, randomized, placebo-controlled trialAm J Clin Nutr.(2020 Jul 1)
    24. ^Bahrami A, Avan A, Sadeghnia HR, Esmaeili H, Tayefi M, Ghasemi F, Nejati Salehkhani F, Arabpour-Dahoue M, Rastgar-Moghadam A, Ferns GA, Bahrami-Taghanaki H, Ghayour-Mobarhan MHigh dose vitamin D supplementation can improve menstrual problems, dysmenorrhea, and premenstrual syndrome in adolescentsGynecol Endocrinol.(2018 Aug)
    25. ^Attwell C, Dugan C, McKay AKA, Nicholas J, Hopper L, Peeling PDietary Iron and the Elite Dancer.Nutrients.(2022-May-05)
    26. ^Moisidis-Tesch CM, Shulman LPIron Deficiency in Women's Health: New Insights into Diagnosis and Treatment.Adv Ther.(2022-Jun)
    27. ^Petraglia F, Dolmans MMIron deficiency anemia: Impact on women's reproductive health.Fertil Steril.(2022-Oct)
    28. ^Gattermann N, Muckenthaler MU, Kulozik AE, Metzgeroth G, Hastka JThe Evaluation of Iron Deficiency and Iron Overload.Dtsch Arztebl Int.(2021-Dec-10)
    29. ^Sadia Afrin, Abdelrahman AlAshqar, Malak El Sabeh, Mariko Miyashita-Ishiwata, Lauren Reschke, Joshua T Brennan, Amanda Fader, Mostafa A BorahayDiet and Nutrition in Gynecological Disorders: A Focus on Clinical StudiesNutrients.(2021 May 21)
    30. ^N D Barnard, A R Scialli, D Hurlock, P BertronDiet and sex-hormone binding globulin, dysmenorrhea, and premenstrual symptomsObstet Gynecol.(2000 Feb)
    31. ^Łagowska K, Strock NCA, Koltun KJ, Williams NI, De Souza MJAssociation of diet quality and hormonal status in exercising women with menstrual disturbances.Appl Physiol Nutr Metab.(2022-Nov-01)
    32. ^Liu N, Feng Y, Luo X, Ma X, Ma FAssociation Between Dietary Inflammatory Index and Sex Hormone Binding Globulin and Sex Hormone in U.S. Adult Females.Front Public Health.(2022)
    33. ^Ramezani Tehrani F, Mirmiran P, Gholami R, Moslehi N, Azizi FFactors influencing menarcheal age: results from the cohort of tehran lipid and glucose study.Int J Endocrinol Metab.(2014-Jul)
    34. ^Juul F, Chang VW, Brar P, Parekh NBirth weight, early life weight gain and age at menarche: a systematic review of longitudinal studies.Obes Rev.(2017-Nov)
    35. ^Chen LK, Wang G, Bennett WL, Ji Y, Pearson C, Radovick S, Wang XTrajectory of Body Mass Index from Ages 2 to 7 Years and Age at Peak Height Velocity in Boys and Girls.J Pediatr.(2021-Mar)
    36. ^Saei Ghare Naz M, Farahmand M, Dashti S, Ramezani Tehrani FFactors Affecting Menstrual Cycle Developmental Trajectory in Adolescents: A Narrative Review.Int J Endocrinol Metab.(2022-Jan)
    37. ^Campbell LR, Scalise AL, DiBenedictis BT, Mahalingaiah SMenstrual cycle length and modern living: a review.Curr Opin Endocrinol Diabetes Obes.(2021-Dec-01)
    38. ^Cherenack EM, Salazar AS, Nogueira NF, Raccamarich P, Rodriguez VJ, Mantero AM, Marsh A, Gerard S, Maddalon M, Jones DL, Klatt NR, Alcaide MLInfection with SARS-CoV-2 is associated with menstrual irregularities among women of reproductive age.PLoS One.(2022)
    39. ^Kappen M, Raeymakers S, Weyers S, Vanderhasselt MAStress and rumination in Premenstrual Syndrome (PMS): Identifying stable and menstrual cycle-related differences in PMS symptom severity.J Affect Disord.(2022-Dec-15)
    40. ^Green SA, Graham BMSymptom fluctuation over the menstrual cycle in anxiety disorders, PTSD, and OCD: a systematic review.Arch Womens Ment Health.(2022-Feb)
    41. ^Sihan Song, Hansol Choi, Yanghee Pang, Oksoo Kim, Hyun-Young ParkFactors associated with regularity and length of menstrual cycle: Korea Nurses' Health StudyBMC Womens Health.(2022 Sep 1)
    42. ^Kathryn E R Kennedy, Chidera Onyeonwu, Sara Nowakowski, Lauren Hale, Charles C Branas, William D S Killgore, Chloe C A Wills, Michael A GrandnerMenstrual regularity and bleeding is associated with sleep duration, sleep quality and fatigue in a community sampleJ Sleep Res.(2022 Feb)
    43. ^Risa Mitsuhashi, Akemi Sawai, Kosuke Kiyohara, Hitoshi Shiraki, Yoshio NakataFactors Associated with the Prevalence and Severity of Menstrual-Related Symptoms: A Systematic Review and Meta-AnalysisInt J Environ Res Public Health.(2022 Dec 29)
    44. ^Seif MW, Diamond K, Nickkho-Amiry MObesity and menstrual disorders.Best Pract Res Clin Obstet Gynaecol.(2015-May)
    45. ^McKinnon CJ, Hatch EE, Rothman KJ, Mikkelsen EM, Wesselink AK, Hahn KA, Wise LABody mass index, physical activity and fecundability in a North American preconception cohort study.Fertil Steril.(2016-Aug)
    46. ^Lammert S, Harrison K, Tosun N, Allen SMenstrual Cycle in Women Who Co-use Marijuana and Tobacco.J Addict Med.(2018)
    47. ^Calik-Ksepka A, Stradczuk M, Czarnecka K, Grymowicz M, Smolarczyk RLactational Amenorrhea: Neuroendocrine Pathways Controlling Fertility and Bone Turnover.Int J Mol Sci.(2022-Jan-31)
    48. ^Prosperi Porta R, Sangiuliano C, Cavalli A, Hirose Marques Pereira LC, Masciullo L, Piacenti I, Scaramuzzino S, Viscardi MF, Porpora MGEffects of Breastfeeding on Endometriosis-Related Pain: A Prospective Observational Study.Int J Environ Res Public Health.(2021-Oct-10)
    49. ^Dragoman MVThe combined oral contraceptive pill -- recent developments, risks and benefits.Best Pract Res Clin Obstet Gynaecol.(2014-Aug)
    50. ^Adeyemi-Fowode OA, Bercaw-Pratt JLIntrauterine Devices: Effective Contraception with Noncontraceptive Benefits for Adolescents.J Pediatr Adolesc Gynecol.(2019-Sep)
    51. ^Snook ML, Henry LC, Sanfilippo JS, Zeleznik AJ, Kontos APAssociation of Concussion With Abnormal Menstrual Patterns in Adolescent and Young Women.JAMA Pediatr.(2017-Sep-01)
    52. ^Lim CED, Ng RWC, Cheng NCL, Zhang GS, Chen HAcupuncture for polycystic ovarian syndrome.Cochrane Database Syst Rev.(2019-Jul-02)
    53. ^Mike Armour, Carolyn C Ee, Jie Hao, Tanya Marie Wilson, Sofia S Yao, Caroline A SmithAcupuncture and acupressure for premenstrual syndromeCochrane Database Syst Rev.(2018 Aug 14)
    54. ^Frederiksen Y, Farver-Vestergaard I, Skovgård NG, Ingerslev HJ, Zachariae REfficacy of psychosocial interventions for psychological and pregnancy outcomes in infertile women and men: a systematic review and meta-analysis.BMJ Open.(2015-Jan-28)
    55. ^Faeze Panahi, Mahbobeh FaramarziThe Effects of Mindfulness-Based Cognitive Therapy on Depression and Anxiety in Women with Premenstrual SyndromeDepress Res Treat.(2016)
    56. ^Busse JW, Montori VM, Krasnik C, Patelis-Siotis I, Guyatt GHPsychological intervention for premenstrual syndrome: a meta-analysis of randomized controlled trials.Psychother Psychosom.(2009)
    57. ^Messinis IE, Messini CI, Dafopoulos KNovel aspects of the endocrinology of the menstrual cycle.Reprod Biomed Online.(2014-Jun)
    58. ^Hampson EA brief guide to the menstrual cycle and oral contraceptive use for researchers in behavioral endocrinology.Horm Behav.(2020-Mar)
    59. ^Proctor M, Farquhar CDiagnosis and management of dysmenorrhoeaBMJ.(2006 May 13)
    60. ^Hromatko I, Mikac UA Mid-Cycle Rise in Positive and Drop in Negative Moods among Healthy Young Women: A Pilot Study.Brain Sci.(2023-Jan-05)
    61. ^Roney JR, Simmons ZLHormonal predictors of sexual motivation in natural menstrual cycles.Horm Behav.(2013-Apr)
    62. ^Roney JR, Simmons ZLOvarian hormone fluctuations predict within-cycle shifts in women's food intake.Horm Behav.(2017-Apr)
    63. ^Brott NR, Le JKMittelschmerzStatPearls.(2023-05)
    64. ^Standeven LR, McEvoy KO, Osborne LMProgesterone, reproduction, and psychiatric illness.Best Pract Res Clin Obstet Gynaecol.(2020-Nov)
    65. ^Brown SG, Morrison LA, Calibuso MJ, Christiansen TMThe menstrual cycle and sexual behavior: relationship to eating, exercise, sleep, and health patterns.Women Health.(2008)
    66. ^Gorczyca AM, Sjaarda LA, Mitchell EM, Perkins NJ, Schliep KC, Wactawski-Wende J, Mumford SLChanges in macronutrient, micronutrient, and food group intakes throughout the menstrual cycle in healthy, premenopausal women.Eur J Nutr.(2016-Apr)
    67. ^Fiona C Baker, Kathryn Aldrich LeeMenstrual Cycle Effects on SleepSleep Med Clin.(2018 Sep)
    68. ^Practice Committee of the American Society for Reproductive Medicine in collaboration with the Society for Reproductive Endocrinology and Infertility. Electronic address: ASRM@asrm.org, Practice Committee of the American Society for Reproductive Medicine in collaboration with the Society for Reproductive Endocrinology and InfertilityOptimizing natural fertility: a committee opinionFertil Steril.(2017 Jan)
    69. ^Peipert BJ, Harris BS, Selter JH, Ramey-Collier K, Blenden R, Unnithan S, Erkanli A, Price TMDirect-to-consumer fertility testing: utilization and perceived utility among fertility patients and reproductive endocrinologists.Reprod Biomed Online.(2023-Mar)
    70. ^Georgie Bruinvels, Anthony C Hackney, Charles R PedlarMenstrual Cycle: The Importance of Both the Phases and the Transitions Between Phases on Training and PerformanceSports Med.(2022 Jul)
    71. ^Georgie Bruinvels, Esther Goldsmith, Richard Blagrove, Andrew Simpkin, Nathan Lewis, Katie Morton, Ara Suppiah, John P Rogers, Kathryn E Ackerman, John Newell, Charles PedlarPrevalence and frequency of menstrual cycle symptoms are associated with availability to train and compete: a study of 6812 exercising women recruited using the Strava exercise appBr J Sports Med.(2020 Nov 16)
    72. ^Colenso-Semple LM, D'Souza AC, Elliott-Sale KJ, Phillips SMCurrent evidence shows no influence of women's menstrual cycle phase on acute strength performance or adaptations to resistance exercise training.Front Sports Act Living.(2023)
    73. ^Kelly Lee McNulty, Kirsty Jayne Elliott-Sale, Eimear Dolan, Paul Alan Swinton, Paul Ansdell, Stuart Goodall, Kevin Thomas, Kirsty Marie HicksThe Effects of Menstrual Cycle Phase on Exercise Performance in Eumenorrheic Women: A Systematic Review and Meta-AnalysisSports Med.(2020 Oct)
    74. ^Benito PJ, Alfaro-Magallanes VM, Rael B, Castro EA, Romero-Parra N, Rojo-Tirado MA, Peinado AB,Effect of Menstrual Cycle Phase on the Recovery Process of High-Intensity Interval Exercise-A Cross-Sectional Observational Study.Int J Environ Res Public Health.(2023-Feb-13)
    75. ^Ekenros L, von Rosen P, Solli GS, Sandbakk Ø, Holmberg HC, Hirschberg AL, Fridén CPerceived impact of the menstrual cycle and hormonal contraceptives on physical exercise and performance in 1,086 athletes from 57 sports.Front Physiol.(2022)
    76. ^Martínez-Fortuny N, Alonso-Calvete A, Da Cuña-Carrera I, Abalo-Núñez RMenstrual Cycle and Sport Injuries: A Systematic Review.Int J Environ Res Public Health.(2023-Feb-13)
    77. ^Nédélec E, Foli E, Shultz SJ, Swinton PA, Dolan E, Enright K, Piasecki J, Matthews JJ, Sale C, Elliott-Sale KJEffect of menstrual cycle phase, menstrual irregularities and hormonal contraceptive use on anterior knee laxity and non-contact anterior cruciate ligament injury occurrence in women: a protocol for a systematic review and meta-analysis.BMJ Open Sport Exerc Med.(2021)
    78. ^Herzberg SD, Motu'apuaka ML, Lambert W, Fu R, Brady J, Guise JMThe Effect of Menstrual Cycle and Contraceptives on ACL Injuries and Laxity: A Systematic Review and Meta-analysis.Orthop J Sports Med.(2017-Jul)
    79. ^Onieva-Zafra MD, Fernández-Martínez E, Abreu-Sánchez A, Iglesias-López MT, García-Padilla FM, Pedregal-González M, Parra-Fernández MLRelationship between Diet, Menstrual Pain and other Menstrual Characteristics among Spanish Students.Nutrients.(2020-Jun-12)
    80. ^Yujie Shang, Huifang Zhou, Ruohan He, Wentian LuDietary Modification for Reproductive Health in Women With Polycystic Ovary Syndrome: A Systematic Review and Meta-AnalysisFront Endocrinol (Lausanne).(2021 Nov 1)
    81. ^Líška Dávid, Záhumensky JozefConservative possibilities influencing PCOS syndrome - the importance of nutrition.Ceska Gynekol.(2021)
    82. ^Maryam Kazemi, Amir Hadi, Roger A Pierson, Marla E Lujan, Gordon A Zello, Philip D ChilibeckEffects of Dietary Glycemic Index and Glycemic Load on Cardiometabolic and Reproductive Profiles in Women with Polycystic Ovary Syndrome: A Systematic Review and Meta-analysis of Randomized Controlled TrialsAdv Nutr.(2021 Feb 1)
    83. ^Barrea L, Verde L, Camajani E, Cernea S, Frias-Toral E, Lamabadusuriya D, Ceriani F, Savastano S, Colao A, Muscogiuri GKetogenic Diet as Medical Prescription in Women with Polycystic Ovary Syndrome (PCOS).Curr Nutr Rep.(2023-Mar)
    84. ^Andrews MA, Schliep KC, Wactawski-Wende J, Stanford JB, Zarek SM, Radin RG, Sjaarda LA, Perkins NJ, Kalwerisky RA, Hammoud AO, Mumford SLDietary factors and luteal phase deficiency in healthy eumenorrheic women.Hum Reprod.(2015-Aug)
    85. ^Megan A Kuikman, Margo Mountjoy, Trent Stellingwerff, Jamie F BurrA Review of Nonpharmacological Strategies in the Treatment of Relative Energy Deficiency in SportInt J Sport Nutr Exerc Metab.(2021 Jan 19)
    86. ^L J Moran, M Noakes, P M Clifton, L Tomlinson, C Galletly, R J NormanDietary composition in restoring reproductive and metabolic physiology in overweight women with polycystic ovary syndromeJ Clin Endocrinol Metab.(2003 Feb)
    87. ^Žana Stanić, Ajka Pribisalić, Maria Bošković, Jasna Bućan Cvitanić, Kristina Boban, Gabriela Bašković, Antonija Bartulić, Suzana Demo, Ozren Polašek, Ivana KolčićDoes Each Menstrual Cycle Elicit a Distinct Effect on Olfactory and Gustatory Perception?Nutrients.(2021 Jul 22)
    88. ^Daniel R Moore, Jennifer Sygo, James P MortonFuelling the female athlete: Carbohydrate and protein recommendationsEur J Sport Sci.(2022 May)
    89. ^Michaela M Rogan, Katherine E BlackDietary energy intake across the menstrual cycle: a narrative reviewNutr Rev.(2023 Jun 9)
    90. ^Phipps WR, Martini MC, Lampe JW, Slavin JL, Kurzer MSEffect of flax seed ingestion on the menstrual cycle.J Clin Endocrinol Metab.(1993-Nov)
    91. ^Nasiadek M, Stragierowicz J, Klimczak M, Kilanowicz AThe Role of Zinc in Selected Female Reproductive System Disorders.Nutrients.(2020-Aug-16)
    92. ^Abdi F, Ozgoli G, Rahnemaie FSA systematic review of the role of vitamin D and calcium in premenstrual syndrome.Obstet Gynecol Sci.(2019-Mar)
    93. ^Alikamali M, Mohammad-Alizadeh-Charandabi S, Maghalian M, Mirghafourvand MThe effects of vitamin E on the intensity of primary dysmenorrhea: A systematic review and meta-analysis.Clin Nutr ESPEN.(2022-Dec)
    94. ^Jie Chen, Qian Guo, Ying-Hao Pei, Qing-Ling Ren, Lei Chi, Rong-Kui Hu, Yong TanEffect of a short-term vitamin E supplementation on oxidative stress in infertile PCOS women under ovulation induction: a retrospective cohort studyBMC Womens Health.(2020 Apr 6)
    95. ^Kirsty J Elliott-Sale, Kelly L McNulty, Paul Ansdell, Stuart Goodall, Kirsty M Hicks, Kevin Thomas, Paul A Swinton, Eimear DolanThe Effects of Oral Contraceptives on Exercise Performance in Women: A Systematic Review and Meta-analysisSports Med.(2020 Oct)
    96. ^Anita L NelsonCommunicating with patients about extended-cycle and continuous use of oral contraceptivesJ Womens Health (Larchmt).(2007 May)
    97. ^Buhling KJ, Zite NB, Lotke P, Black K,Worldwide use of intrauterine contraception: a review.Contraception.(2014-Mar)
    98. ^Christelle K, Norhayati MN, Jaafar SHInterventions to prevent or treat heavy menstrual bleeding or pain associated with intrauterine-device use.Cochrane Database Syst Rev.(2022-Aug-26)
    99. ^Hobby JH, Zhao Q, Peipert JFEffect of baseline menstrual bleeding pattern on copper intrauterine device continuation.Am J Obstet Gynecol.(2018-Nov)
    100. ^Sergison JE, Maldonado LY, Gao X, Hubacher DLevonorgestrel intrauterine system associated amenorrhea: a systematic review and metaanalysis.Am J Obstet Gynecol.(2019-May)
    101. ^Bofill Rodriguez M, Lethaby A, Jordan VProgestogen-releasing intrauterine systems for heavy menstrual bleeding.Cochrane Database Syst Rev.(2020-Jun-12)
    102. ^Diamanti-Kandarakis E, Bourguignon JP, Giudice LC, Hauser R, Prins GS, Soto AM, Zoeller RT, Gore ACEndocrine-disrupting chemicals: an Endocrine Society scientific statement.Endocr Rev.(2009-Jun)
    103. ^Genuis SJ, Beesoon S, Lobo RA, Birkholz DHuman elimination of phthalate compounds: blood, urine, and sweat (BUS) study.ScientificWorldJournal.(2012)
    104. ^M Stefanidou, C Maravelias, C SpiliopoulouHuman exposure to endocrine disruptors and breast milkEndocr Metab Immune Disord Drug Targets.(2009 Sep)
    105. ^Karissa C Hammer, Alexis Veiga, Shruthi MahalingaiahEnvironmental toxicant exposure and menstrual cycle lengthCurr Opin Endocrinol Diabetes Obes.(2020 Dec)
    106. ^Ting Ding, Wei Yan, Ting Zhou, Wei Shen, Tian Wang, Milu Li, Su Zhou, Meng Wu, Jun Dai, Kecheng Huang, Jinjin Zhang, Jiang Chang, Shixuan WangEndocrine disrupting chemicals impact on ovarian aging: Evidence from epidemiological and experimental evidenceEnviron Pollut.(2022 Jul 15)
    107. ^A C Gore, V A Chappell, S E Fenton, J A Flaws, A Nadal, G S Prins, J Toppari, R T ZoellerEDC-2: The Endocrine Society's Second Scientific Statement on Endocrine-Disrupting ChemicalsEndocr Rev.(2015 Dec)

    Examine Database References

    1. Vaginal Irritation - Mags E Beksinska, Jenni Smit, Ross Greener, Catherine S Todd, Mei-ling Ting Lee, Virginia Maphumulo, Vivian HoffmannAcceptability and performance of the menstrual cup in South Africa: a randomized crossover trial comparing the menstrual cup to tampons or sanitary padsJ Womens Health (Larchmt).(2015 Feb)
    2. Vaginal Irritation - Courtney Howard, Caren Lee Rose, Konia Trouton, Holly Stamm, Danielle Marentette, Nicole Kirkpatrick, Sanja Karalic, Renee Fernandez, Julie PagetFLOW (finding lasting options for women): multicentre randomized controlled trial comparing tampons with menstrual cupsCan Fam Physician.(2011 Jun)
    3. Vaginal Irritation - Anna Maria van Eijk, Garazi Zulaika, Madeline Lenchner, Linda Mason, Muthusamy Sivakami, Elizabeth Nyothach, Holger Unger, Kayla Laserson, Penelope A Phillips-HowardMenstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysisLancet Public Health.(2019 Aug)
    4. Capacity (Menstrual Cup vs. Usual Product) - K Stewart, R Greer, M PowellWomen's experience of using the MooncupJ Obstet Gynaecol.(2010 Apr)
    5. Ease of Use (Menstrual Cup vs. Usual Products) - Anna Maria van Eijk, Kayla F Laserson, Elizabeth Nyothach, Kelvin Oruko, Jackton Omoto, Linda Mason, Kelly Alexander, Clifford Oduor, Aisha Mohammed, Alie Eleveld, Isaac Ngere, David Obor, John Vulule, Penelope A Phillips-HowardUse of menstrual cups among school girls: longitudinal observations nested in a randomised controlled feasibility study in rural western KenyaReprod Health.(2018 Aug 17)
    6. Ease of Use (Menstrual Cup vs. Usual Products) - Barbara B North, Michael J OldhamPreclinical, clinical, and over-the-counter postmarketing experience with a new vaginal cup: menstrual collectionJ Womens Health (Larchmt).(2011 Feb)
    7. Leakage (Menstrual Cup vs. Usual Product) - M Cheng, R Kung, M Hannah, D Wilansky, J ShimeMenses cup evaluation studyFertil Steril.(1995 Sep)
    8. Vaginal Infection Risk - Penelope A Phillips-Howard, Elizabeth Nyothach, Feiko O Ter Kuile, Jackton Omoto, Duolao Wang, Clement Zeh, Clayton Onyango, Linda Mason, Kelly T Alexander, Frank O Odhiambo, Alie Eleveld, Aisha Mohammed, Anna M van Eijk, Rhiannon Tudor Edwards, John Vulule, Brian Faragher, Kayla F LasersonMenstrual cups and sanitary pads to reduce school attrition, and sexually transmitted and reproductive tract infections: a cluster randomised controlled feasibility study in rural Western KenyaBMJ Open.(2016 Nov 23)
    9. IUD Expulsion Risk - Ellen R Wiebe, Konia J TroutonDoes using tampons or menstrual cups increase early IUD expulsion rates?Contraception.(2012 Aug)
    10. Hemoglobin - Fernández-Gaxiola AC, De-Regil LMIntermittent iron supplementation for reducing anaemia and its associated impairments in adolescent and adult menstruating womenCochrane Database Syst Rev.(2019 Jan 31)
    11. Estrogen - Fukui H, Toyoshima K, Komaki RPsychological and neuroendocrinological effects of odor of saffron (Crocus sativus)Phytomedicine.(2011 Jun 15)