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

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Hi there, welcome to In the Clinic with Camille. My name is Camille Freeman,

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and this podcast is for herbalists and nutritionists who are in clinical practice.

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I've been doing this work for, gosh, more than 25 years now with a focus on

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menstrual health, fertility, pregnancy, postpartum, perimenopause, all that sort of thing.

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And somehow I've been an educator for most of that time, and I've never actually

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put together a longer training course for other practitioners specifically on menstrual health.

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And I'm delighted that that's going to change in the next week or two.

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Leanne Mocha, a friend and colleague of mine, we are launching an eight-week

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menstrual health intensive for practitioners.

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It's going to start later in September.

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And in honor of this new course that we're putting out there,

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I wanted to share just a couple of episodes over the next few weeks having to

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do with menstrual health.

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And whether you are somebody who focuses in this area or not,

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I'm pretty sure if you stay in practice long enough, you will have clients who

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menstruate. So I hope it's going to be helpful for everybody,

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regardless of your specific focus area.

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And if you want to know more about the intensive, you can check the link in

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the show notes. I'll put some more info there, and you can find out when it

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becomes available for registration.

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All right, so the thing I thought we would start out with talking about is how

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do we know a menstrual cycle is, quote, normal?

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Now, of course, there's really no such thing as a completely normal cycle.

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We're all weird in our own special ways.

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But there is such a thing as a cycle that is outside of what we consider normal parameters.

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And I wanted to go over what those are so that you will know.

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When does somebody fit within these guidelines, and when do you maybe need to

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send them out to a primary care, a gynecologist, whomever seems appropriate,

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so they can get a better sense of what's going on and any kind of diagnosis,

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care, or treatment that might be needed.

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So, of course, we want to stay within our scope of practice.

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We don't want to try to diagnose anybody or directly treat anything,

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but just understanding these parameters helps us do better work and helps us

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know when can we safely and effectively work with somebody and when do they really need to,

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go in and get some testing and medical assessment to see what's going on and so forth.

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All right, so the five things that I generally look for are the frequency of

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menses, meaning how long is it between the start of one cycle and the start of the next cycle.

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I look for how long the flow is lasting, the bleeding.

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I look for approximate volume of menstrual fluid.

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I want to check the post-ovulatory phase, so how long is it between ovulation and bleeding.

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And then I want to see if they have cervical fluid.

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And if I check these five things and they seem to be within the parameters we're

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going to discuss, then I think we can safely say that this person has a quote

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normal and healthy menstrual cycle, and that is a great starting place.

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All right, so let's get into each one of those in a little bit more detail.

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So we'll start with frequency of menses, meaning how long is it from one cycle starting to the next.

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And of course, a cycle starts on day one. That's considered the first day of heavy bleeding.

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So according to the International Federation of Gynecology and Obstetrics,

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a normal menstrual cycle should have consistency when it comes to frequency,

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regularity, duration, and volume of flow.

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So it's not necessarily the same for everybody, but within an individual person,

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it should be pretty consistent.

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Okay, so what we're looking for in a normal range of how many days a cycle lasts

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is usually somewhere between 24 and 38.

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And again, we want to see that length be pretty consistent within the same person.

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So for example, when somebody is between the ages of about 26 to 41,

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you want to see no more than seven days of variation between one cycle and the

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next to be considered kind of a normal, consistent variability.

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Up until the age of 26, you are still, in many cases, establishing a regular

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cycle, so it's a little bit different.

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But really, 26 to early 40s, late 30s, something like that, those are the most

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consistent menstrual years for most people.

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So for people who are more like teens early 20s you're looking for nine days or less again there's,

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a lot more variability there and same thing once we get over about 41 42 something like that

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also nine days is considered a kind of normal pattern there so as we ramp up

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and as we wind down they start to get a little bit more erratic but we do want

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to see relative consistency there in the middle.

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If it has been consistent and it starts to get a little wackadoodle,

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that's a good reason to investigate further, send somebody out for additional

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assessment, and so forth.

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Let's talk about the duration of the flow. Normal is considered up to eight days.

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And anything beyond eight days, again, warrants a referral.

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If it seems extremely light, well, we'll talk about that when we talk about volume.

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So let's just say anything longer than eight days, if somebody's bleeding for

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longer than eight days, we start to have concerns about clotting.

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We have to start to have concerns about fibroids. Is there something going on

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where the uterus can't clamp down enough to stop the bleeding.

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So again, we want to send that person in to get an evaluation.

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We want to make sure they're getting their iron and ferritin and things like

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that checked and so forth.

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So when it comes to volume of menstrual fluid, this is a really challenging

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one because a lot of people are not necessarily, you don't have a great objective

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measurement of how much menstrual fluid is being lost in any given period of bleeding.

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So this is a hard one to assess. It is generally considered a subjective assessment.

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There are ways that you can technically measure, for example,

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if you use a menstrual cup or if you weigh a menstrual product before and after

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use, you can technically figure out

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the actual, you know, either weight or volume of how much is coming out.

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But for most people, it is more of a subjective sense.

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So if it is interfering with somebody's social life, if they're not able to

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go somewhere because they're bleeding so heavily, emotional,

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if it's interfering with their life and they feel that it's heavy,

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then it's considered heavy under most measurements.

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Technically, the total volume of menstrual fluid in a given cycle,

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not just a day, but the full cycle, is considered normal anywhere between 10

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milliliters and 160 milliliters.

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And about half of that is blood. The rest of it is fluid.

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So the blood loss is somewhere between 5 mils and up to 80 mils.

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More than that is considered heavy in the official sense.

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But again, heavy is in practice a subjective term.

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So a lot of times with heavy bleeding, you'll see people who are really struggling.

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You know, they're like, I'm using a full tampon and a pad, and I still am bleeding

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into my car seats or on my sheets or something like that.

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Those are things where we're like, oh, yes, okay. Again, we need to have an

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assessment there to figure out why the bleeding is so heavy.

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There's various, you know, clotting factors and fibroids and different things

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that might be causing that. And we want to make sure that the cause is identified

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so that the person can get the care that they need. Okay.

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Post-ovulatory phase, so that means between ovulation and bleeding,

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we want to see that generally between 12 and 14 days, although 11 to 17 is considered still normal,

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and generally we want to see that being relatively stable within that person.

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So if the person's luteal phase or post-ovulatory phase tends to be 13 days

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and it's almost always 13 days, that's great.

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In some people's it's 12, some people's it's 14, some people's it's 15.

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Generally speaking, you will see it be approximately the same number of days each cycle.

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If it's way shorter or way longer, that can be a sign that something else is going on.

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Side note, a lot of clients don't know how long this is because they haven't

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been taught how do you know when you're ovulating. That's a whole separate podcast.

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We're going to get into it in the class too.

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But generally speaking, we're looking for some indicator that the luteal phase

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or the post-ovulatory phase is between 12 and 14 days in an ideal world,

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or maybe 11 to 17 sometimes in some people.

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Like the outliers might have that and still be in normal range.

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And then lastly, the one that I am looking for is cervical fluid,

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which builds and peaks at ovulation.

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So a lot of people, this hurts my heart a lot, but a lot of people are not taught

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in their early years as teens, early 20s, etc.

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They're not really taught the basic physiology of what's happening in a menstrual

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cycle, and so they're not aware that cervical fluid is a part of a healthy menstrual cycle.

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Under the influence of estradiol, cervical fluid goes from a kind of sticky

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baseline to a more creamy lotion-like texture to a more kind of.

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Peak estradiol levels, which is right around when ovulation is coming pretty soon.

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So we want to see that egg white cervical fluid as an indicator that estrogen

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levels are dramatically increasing.

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That's a great outward marker that estradiol levels are going up,

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which generally means that the body is preparing for ovulation and so forth.

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So if we understand that that's happening, that gives us a good sign that at

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least some of the hormonal pieces are in place to run a smooth menstrual cycle.

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Okay, so these are the things that I'm looking for. If I'm seeing,

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you know, signs that look pretty consistent and steady in these,

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then I feel good that the person has a healthy cycle and we move on from there

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to try to figure out how to best support them.

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And if things are outside of these ranges, that is a sign to me that we need

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to do some deeper digging and potentially send the person to a referral,

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for somebody who has different kind of medical training that can really get

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to the bottom of what's happening, and that can inform our work.

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Okay, I hope that's helpful. I will put a reference that summarizes some of

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this in the show notes in case you want to look into it more.

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Otherwise, stay tuned. Next week, we will talk a little bit more about menstrual

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health and go from there.

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All right, thank you so much for the work that you do. I hope you have an amazing

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rest of your day, and I will talk to you soon.