122 | The "Normal" Menstrual Cycle: When to Refer and When to Support

0:00 Hi there, welcome to In the Clinic with Camille. My name is Camille Freeman, and this podcast is for herbalists and nutritionists who are in clinical practice. I've been doing this work for, gosh, more than 25 years now with a focus on menstrual health, fertility, pregnancy, postpartum, perimenopause, all that sort of thing. And somehow I've been an educator for most of that time, and I've never actually put together a longer training course for other practitioners specifically on menstrual health. And I'm delighted that that's going to change in the next week or two. Leanne Mocha, a friend and colleague of mine, we are launching an eight-week menstrual health intensive for practitioners. It's going to start later in September. And in honor of this new course that we're putting out there, I wanted to share just a couple of episodes over the next few weeks having to do with menstrual health.

0:47 And whether you are somebody who focuses in this area or not, I'm pretty sure if you stay in practice long enough, you will have clients who menstruate. So I hope it's going to be helpful for everybody, regardless of your specific focus area. And if you want to know more about the intensive, you can check the link in the show notes. I'll put some more info there, and you can find out when it becomes available for registration. All right, so the thing I thought we would start out with talking about is how do we know a menstrual cycle is, quote, normal? Now, of course, there's really no such thing as a completely normal cycle. We're all weird in our own special ways. But there is such a thing as a cycle that is outside of what we consider normal parameters. And I wanted to go over what those are so that you will know.

1:30 When does somebody fit within these guidelines, and when do you maybe need to send them out to a primary care, a gynecologist, whomever seems appropriate, so they can get a better sense of what's going on and any kind of diagnosis, care, or treatment that might be needed. So, of course, we want to stay within our scope of practice. We don't want to try to diagnose anybody or directly treat anything, but just understanding these parameters helps us do better work and helps us know when can we safely and effectively work with somebody and when do they really need to, go in and get some testing and medical assessment to see what's going on and so forth. All right, so the five things that I generally look for are the frequency of menses, meaning how long is it between the start of one cycle and the start of the next cycle.

2:17 I look for how long the flow is lasting, the bleeding. I look for approximate volume of menstrual fluid. I want to check the post-ovulatory phase, so how long is it between ovulation and bleeding. And then I want to see if they have cervical fluid. And if I check these five things and they seem to be within the parameters we're going to discuss, then I think we can safely say that this person has a quote normal and healthy menstrual cycle, and that is a great starting place. All right, so let's get into each one of those in a little bit more detail. So we'll start with frequency of menses, meaning how long is it from one cycle starting to the next. And of course, a cycle starts on day one. That's considered the first day of heavy bleeding.

3:03 So according to the International Federation of Gynecology and Obstetrics, a normal menstrual cycle should have consistency when it comes to frequency, regularity, duration, and volume of flow. So it's not necessarily the same for everybody, but within an individual person, it should be pretty consistent. Okay, so what we're looking for in a normal range of how many days a cycle lasts is usually somewhere between 24 and 38. And again, we want to see that length be pretty consistent within the same person. So for example, when somebody is between the ages of about 26 to 41, you want to see no more than seven days of variation between one cycle and the next to be considered kind of a normal, consistent variability.

3:50 Up until the age of 26, you are still, in many cases, establishing a regular cycle, so it's a little bit different. But really, 26 to early 40s, late 30s, something like that, those are the most consistent menstrual years for most people. So for people who are more like teens early 20s you're looking for nine days or less again there's, a lot more variability there and same thing once we get over about 41 42 something like that also nine days is considered a kind of normal pattern there so as we ramp up and as we wind down they start to get a little bit more erratic but we do want to see relative consistency there in the middle. If it has been consistent and it starts to get a little wackadoodle, that's a good reason to investigate further, send somebody out for additional assessment, and so forth.

4:38 Let's talk about the duration of the flow. Normal is considered up to eight days. And anything beyond eight days, again, warrants a referral. If it seems extremely light, well, we'll talk about that when we talk about volume. So let's just say anything longer than eight days, if somebody's bleeding for longer than eight days, we start to have concerns about clotting. We have to start to have concerns about fibroids. Is there something going on where the uterus can't clamp down enough to stop the bleeding. So again, we want to send that person in to get an evaluation. We want to make sure they're getting their iron and ferritin and things like that checked and so forth. So when it comes to volume of menstrual fluid, this is a really challenging one because a lot of people are not necessarily, you don't have a great objective measurement of how much menstrual fluid is being lost in any given period of bleeding.

5:32 So this is a hard one to assess. It is generally considered a subjective assessment. There are ways that you can technically measure, for example, if you use a menstrual cup or if you weigh a menstrual product before and after use, you can technically figure out the actual, you know, either weight or volume of how much is coming out. But for most people, it is more of a subjective sense. So if it is interfering with somebody's social life, if they're not able to go somewhere because they're bleeding so heavily, emotional, if it's interfering with their life and they feel that it's heavy, then it's considered heavy under most measurements.

6:13 Technically, the total volume of menstrual fluid in a given cycle, not just a day, but the full cycle, is considered normal anywhere between 10 milliliters and 160 milliliters. And about half of that is blood. The rest of it is fluid. So the blood loss is somewhere between 5 mils and up to 80 mils. More than that is considered heavy in the official sense. But again, heavy is in practice a subjective term. So a lot of times with heavy bleeding, you'll see people who are really struggling. You know, they're like, I'm using a full tampon and a pad, and I still am bleeding into my car seats or on my sheets or something like that.

6:53 Those are things where we're like, oh, yes, okay. Again, we need to have an assessment there to figure out why the bleeding is so heavy. There's various, you know, clotting factors and fibroids and different things that might be causing that. And we want to make sure that the cause is identified so that the person can get the care that they need. Okay. Post-ovulatory phase, so that means between ovulation and bleeding, we want to see that generally between 12 and 14 days, although 11 to 17 is considered still normal, and generally we want to see that being relatively stable within that person. So if the person's luteal phase or post-ovulatory phase tends to be 13 days and it's almost always 13 days, that's great.

7:37 In some people's it's 12, some people's it's 14, some people's it's 15. Generally speaking, you will see it be approximately the same number of days each cycle. If it's way shorter or way longer, that can be a sign that something else is going on. Side note, a lot of clients don't know how long this is because they haven't been taught how do you know when you're ovulating. That's a whole separate podcast. We're going to get into it in the class too. But generally speaking, we're looking for some indicator that the luteal phase or the post-ovulatory phase is between 12 and 14 days in an ideal world, or maybe 11 to 17 sometimes in some people. Like the outliers might have that and still be in normal range.

8:17 And then lastly, the one that I am looking for is cervical fluid, which builds and peaks at ovulation. So a lot of people, this hurts my heart a lot, but a lot of people are not taught in their early years as teens, early 20s, etc. They're not really taught the basic physiology of what's happening in a menstrual cycle, and so they're not aware that cervical fluid is a part of a healthy menstrual cycle. Under the influence of estradiol, cervical fluid goes from a kind of sticky baseline to a more creamy lotion-like texture to a more kind of. Peak estradiol levels, which is right around when ovulation is coming pretty soon.

9:01 So we want to see that egg white cervical fluid as an indicator that estrogen levels are dramatically increasing. That's a great outward marker that estradiol levels are going up, which generally means that the body is preparing for ovulation and so forth. So if we understand that that's happening, that gives us a good sign that at least some of the hormonal pieces are in place to run a smooth menstrual cycle. Okay, so these are the things that I'm looking for. If I'm seeing, you know, signs that look pretty consistent and steady in these, then I feel good that the person has a healthy cycle and we move on from there to try to figure out how to best support them. And if things are outside of these ranges, that is a sign to me that we need to do some deeper digging and potentially send the person to a referral, for somebody who has different kind of medical training that can really get to the bottom of what's happening, and that can inform our work.

9:57 Okay, I hope that's helpful. I will put a reference that summarizes some of this in the show notes in case you want to look into it more. Otherwise, stay tuned. Next week, we will talk a little bit more about menstrual health and go from there. All right, thank you so much for the work that you do. I hope you have an amazing rest of your day, and I will talk to you soon.