Menstruation and Menstrual Rehab

Original Editor - Chelsea McLene

Top Contributors - Kim Jackson  

Introduction[edit | edit source]

Menstruation, also known as a period is the process of discharging blood and other material from the lining of the uterus at regular intervals of about one lunar month from puberty until the menopause, except during pregnancy. The first period usually begins between twelve and fifteen years of age, a point in time known as menarche.

Each month, one of the ovaries releases an egg — a process called ovulation[1]. At the same time, hormonal changes prepare the uterus for pregnancy. If ovulation takes place and the egg isn't fertilised, the lining of the uterus sheds through the vagina.[2]


Phases[edit | edit source]

Phases of menstruation.png

The day count for menstrual cycle begins on the first day of menstruation when blood starts to come out of the vagina. The typical cycle is of 28 days. The cycle may be short as 21 days or long as 40 days.

There are 2 cycles to be understood.

  1. Uterine cycle - Menstrual phase, Proliferative phase and Secretory phase.
  2. Ovarian cycle - Follicular phase, Ovulation, Luteal phase.

Uterine Cycle[edit | edit source]

MENSTRUAL PHASE (day 1-5)[edit | edit source]

Menstrual phase begins on the first day of menstruation and lasts till the 5th day of the menstrual cycle. The uterus sheds its inner lining of soft tissue and blood vessels which exits the body from the vagina in the form of menstrual fluid. Blood loss of 10 ml to 80 ml is considered normal. Abdominal cramps can be experienced. These cramps are caused by the contraction of the uterine and the abdominal muscles to expel the menstrual fluid. Shedding of endometrium oestrogen and progesterone are at the lowest levels.

PROLIFERATIVE PHASE (day 6-14)[edit | edit source]


There is maturation of graffian folllicles and secretion of oestrogen by theca interna of graffian follicle. Endometrial cells increase in number. There is increase in thickness of endometrium from 1mm to 4.6mm. Because of secretion of oestrogen, formation of new endometrial layer is initiated.

SECRETORY PHASE (day 15-28)[edit | edit source]

During the secretory phase, progesterone (as well as oestrogen) is secreted by the corpus luteum, which develops from the Graafian follicle. Progesterone secreted by the corpus luteum stimulates the further build-up of the cells in the endometrium of the uterus. It also stimulates the glands in the uterus to secrete substances that maintain the endometrium and keep it from breaking down. Thickness of endometrium further increases and the endometrial cells also increase in number. Smooth muscles show relaxation. Endometrium becomes receptive to implantation and thus supports early pregnancy.

Ovarian Cycle[edit | edit source]

FOLLICULAR PHASE (day 1-13)[edit | edit source]

This phase also begins on the first day of menstruation, but it lasts till the 13th day of the menstrual cycle. The pituitary gland secretes a hormone that stimulates the egg cells in the ovaries to grow. One of these egg cells matures. While the egg cell matures, its follicle secretes a hormone that stimulates the uterus to develop a lining of blood vessels and soft tissue called endometrium.

OVULATION (day 14)[edit | edit source]

The pituitary gland secretes a hormone and causes the ovary to release the matured egg cell. The released egg cell is swept into the fallopian tube by the cilia of the fimbriae. Under the influence of LH surge the Graafian follicle ruptures and releases ovum.

LUTEAL PHASE (day 15-28)[edit | edit source]

This phase begins on the 15th day and lasts till the end of the cycle. Under the effect of pituitary hormone, FSH and LH causes development of corpus luteum and increases progesterone levels. The egg cell released during the ovulation phase stays in the fallopian tube for 24 hours. If a sperm cell does not impregnate the egg cell, the egg cell disintegrates and causes the menstrual phase of the next cycle to begin.[4]

Menstrual Health And Hygiene Management[edit | edit source]

Menstrual health management is human right.[5] Women and adolescent girls must use clean menstrual management material to absorb or to collect the blood. soap and water must be used to cleanse and there must be proper facilities to dispose the used menstrual management material. Menstruation is a natural process, but in most parts of the world it is taboo. It has to be properly managed or it can result in health problems.[6]

Different Menstrual Products[edit | edit source]

  • Sanitary napkins: These are menstrual pads available in different size, shape, length and thickness. They may be disposable or reusable. Some have wings which folds at the sides of the underwear.[7]
  • Cloth pads: They are reusable but they absorb the menstrual blood, making them soggy and ineffective for period protection.[8]
  • Tampons: It absorbs blood and vaginal secretions by insertion into the vagina during menstruation. Unlike a pad, it is placed internally, inside of the vaginal canal. Once inserted correctly, a tampon is held in place by the vagina. It expands while blood gets absorbed.[9]
  • Menstrual cups: It is ecofriendly, reusable, flexible cone shaped which can be inserted into the vagina. It can collect menstrual fluid. The collected flid can then be disposed and the cup can be reused after cleaning it properly.[10]
  • Menstrual discs: It is round in shape and has flexible ring with a catch that sits at the base of the cervix in a place called the vaginal fornix.[11]
  • Menstrual panty: They look and feel like regular underwear but can collect blood. They are washable and can be reused[12]
Sanitary pad.jpg

Disposal Methods[edit | edit source]

Appropriate disposal of used menstrual material is still lacking in many countries of the world. Most women dispose of their sanitary pads or other menstrual articles into domestic solid wastes or garbage bins that ultimately become a part of solid wastes. Best choice is to use reusable and non-commercial sanitary materials like reusable pads, menstrual cups and thus generate lesser amount of menstrual waste as compared to use of commercial disposable pads. If the product used is reusable, clean it with water, sterilize and store it clean for the next use. If it is disposable, use proper guidelines.[13][14]

Menstrual Dysfunctions[edit | edit source]

  • PREMENSTRUAL SYNDROME - It is unpleasant or uncomfortable symptom which includes hot flushes, vertigo, muscle cramps, breast soreness, acne, bloating, headache etc. Sudden fluctuation of hormones are responsible for this. It can sometimes be so severe that they will need to miss work or school.[15]

Period pain.png

  • POLYMENORRHOEA - Frequent menstruation at interval between 2-3 weeks. Blood loss is usually normal.[16]
  • AMENORRHEA - Absence of menstrual period for more than 3 cycles. Causes include sudden weight loss, stress, PCOS or PCOD etc.[17][18]
  • DYSMENORRHEA - It is characterized by severe pain, cramps during menstrual period. It includes 2 types; primary which means the common menstrual cramps due to uterine muscle contraction and secondary due to underlying pathology like endometriosis, adyneomyosis etc.[19][20]
  • MENORRHAGIA - Excess or prolonged bleeding at regular interval.[21]
  • METRORRHAGIA - Irregular , heavy and intermenstrual bleeding.[22]
  • POLY CYSTIC OVARIAN SYNDROME - It is the hormonal and metabolic disorder. In this type, thee ovaries fail to release egg due to numerous small fluid filled follicles. Causes include excess insulin, heredity, excess androgen. Symptoms include excess weight gain, acne, prone to diabetes etc.[23]
  • POLY CYSTIC OVARIAN DISORDER - symptoms are almost same as PCOS. Ovaries contain immature eggs which turn to cysts due to excess junk food consumption, stress or being overweight.[24]
  • ENDOMETRIOSIS - It is a condition where endometrial tissue is outside the uterus. this leads to adhesion and scar tissue formation causing severe pain and discomfort. common symptoms are dysmenorrhia, pain on urinating and intercourse, excess bleeding etc.[25]


  • PELVIC FLOOR DYSFUNCTION - Chronic and severe menstrual pain may lead to spasm of pelvic floor muscle resulting in hypertonus dysfunction. Pelvic floor muscles may become tight leading to vaginismus, dysareunia etc.
  • POST MENOPAUSAL BLEEDING - Bleeding from genital tract after menopause. Causes include malignancy, vaginitis, uterine prolapse etc.[26]

Role Of Physiotherapy In Menstrual Rehabilitation[edit | edit source]

Management includes, two categories

  • General management
  • Pelvic floor rehab for menstrual disorders : This includes pelvic floor exercises.

General Management[edit | edit source]

This includes dietary management, exercise, modalities, stress management and yoga.[27]

Dietary Management[edit | edit source]

Avoid sugary diet, Excess raw meat, fried foods, fast food , soda, alcohol and caffeinated drinks. Food to be taken include green leafy vegetables, oats, avocado, broccoli, olives, walnuts, almonds, beans and lentils, legumes. Berries, Natural processed food like milk, butter and curds also can be taken. Fish oils, salmon, tuna have great health benefits and is good to take during menstruation.

Exercises And Modalities[edit | edit source]

Aerobics[28] and resisted exercise play major role here to reduce pain[29], discomfort.[30]

Modalities : TENS, Hot pack, Acupuncture, Acupressure ,Taping.[31][32]

Stress Management[edit | edit source]

Managing stress and anxiety is very important as it can cause negative effects on menstruation. Breathing exercise and relaxation techniques can help in great way to reduce stress and anxiety. Meditation also plays an important role to manage stress. Meditation is often defined as thinking continuously about one object of thought. It is important to develop some hobbies which will help to divert mind. Having bath with Luke warm water and Epsom salt also contributed to reduce stress levels.[33][34]

Yoga[edit | edit source]

Different yoga poses like Bhujangasana, Malasana, Usthrasana, Baddha konasana and Dhanurasana help to ease pain and discomfort during menstruation.[35]


(see Yoga And Mindfulness For Pelvic Health)

Pelvic Floor Rehab[edit | edit source]

Rehabilitation depends on the findings of pelvic floor muscle grade. Individuals with PCOS, endometriosis may have tightness of pelvic floor while lactating or individuals with low oestrogen may have weakness of pelvic floor muscles. It involves treating various menstrual irregularities.[37][38] Rehabilitation includes various pelvic floor exercises.[39]Pelvic floor muscles are skeletal muscles. They can be trained, retrained, strengthened by repeating the same exercise overtime.

Rehab includes:

  • Mirror biofeedback where mirror can be used to visualize pelvic contractions and relaxations.[40]
  • Use of vaginal dilators: After menopause, vagina becomes drier, less elastic, narrower, and shorter. Vaginal dilators can be used to stretch the vagina.[41]
  • Kegel exercise: It means to find right pelvic floor muscles and make them work. Most of them contract abdominals, buttock, or inner thigh muscles and don't reap the benefits of the exercises.[42]
  • IFT, US.
  • NMR : Aids rehabilitation of shortened muscles and tendons. [43]
  • Soft tissue mobilisation: Use of hands-on techniques on your muscles, ligaments and fascia with the goal of breaking adhesions and optimizing your muscle function.
  • Lower limb stretches.
  • Identifying and activating the right muscles.
  • Relaxing tight and overactive muscles
  • Controlling and doing the right exercise at the right time
  • Learning to coordinate the pelvic floor muscles with the diaphragm, the deep abdominals and the other core muscles.
  • Controlling abdominal pressure and avoid damaging the pelvic area with high impact activities, wrong abdominals exercises or coughing.
  • Integrating functional exercises according to your daily activities and sports.[44]

References[edit | edit source]

  1. LiveScience. What is ovulation? Available from [last accessed 26/10/2020]
  2. Office of womens health. Menstrual cycle. Available from [last accessed 26/10/2020]
  3. Menstrual cycle. Osmosis. Available from [last accessed 08/10/2020]
  4. Fletcher.J. Medical News Today. What are the phases of menstrual cycle? Available from [last accessed 06/10/2020]
  5. Pitre.S. Innovations in health care. Menstrual health management is human right. [last accessed 06/10/2020]
  6. Menstrual hygiene. Environmental health group. Available from [last accessed 06/10/2020]
  7. Healthfully. How to wear sanitary napkin? Available from [last accessed 26/10/2020]
  8. Reusable cloth pad FAQ. Menstrual cup reviews. Available from [last accessed 26/10/2020]
  9. Food and Drug Administration. The Facts on Tampons—and How to Use Them Safely. [last accessed 26/10/2020]
  10. Healthline. Are Menstrual Cups Dangerous? 17 Things to Know About Safe Use. Available from [last accessed 26/10/2020]
  11. flexED. What's the difference between menstrual cup and disc? Available from [last accessed 26/10/2020]
  12. Grove collaborative. Guide to period panties. Available from [last accessed 26/10/2020]
  13. Kaur R, Kaur K, Kaur R. Menstrual hygiene, management, and waste disposal: Practices and challenges faced by girls/women of developing countries. Journal of environmental and public health. 2018 Feb 20;2018.
  14. Garg R, Goyal S, Gupta S. India moves towards menstrual hygiene: subsidized sanitary napkins for rural adolescent girls—issues and challenges. Maternal and child health journal. 2012 May 1;16(4):767-74.
  15. Premenstrual syndrome. Office of womens health. Available from,bloating%2C%20headaches%2C%20and%20moodiness. [last accessed 08/10/2020]
  16. polymenorrhoea. Health line. Available from,form%20of%20abnormal%20uterine%20bleeding. [last accessed 08/10/2020]
  17. Amenorrhea. Available from [last accessed 26/10/2020]
  18. Practice Committee of the American Society for Reproductive Medicine. Current evaluation of amenorrhea. Fertility and sterility. 2004 Sep 1;82:33-9.
  19. Dysmenorrhea. Cleaveland clinic. Available from,Dysmenorrhea%20Menu [last accessed 08/10/2020]
  20. WebMD. What Is Adenomyosis? Available from,can%20result%20in%20heavy%20periods. [last accessed 26/10/2020]
  21. CDC. Bleeding disorders in women. Available from [last accessed 26/10/2020]
  22. Very well health. Metrorrhagia. Available from [last accessed 26/10/2020]
  23. PCOS. healthline. Available from . [last accessd 26/10/2020]
  24. PCOD. Columbio Asia . Available from,difficult%20for%20her%20to%20conceive. [last accessed 08/10/2020]
  25. Endometriosis. Body and mind. Available from [ last acceseed 08/10/2020]
  26. FoxChase cancer center. 5 things to know about Postmenopausal Bleeding. Available from,a%20small%20number%20of%20cases. [last accessed 26/10/2020]
  27. Jesspreale. Can physical therapy help menstrual cramps? Available from [last accesed 08/10/2020] [last accessed 28/09/2020]
  28. Dehnavi ZM, Jafarnejad F, Kamali Z. The Effect of aerobic exercise on primary dysmenorrhea: A clinical trial study. J Educ Health Promot. 2018;7:3. Published 2018 Jan 10. doi:10.4103/jehp.jehp_79_17
  29. Lee, J. W., & Park, H. S. Relation of the factor to menstrual pain and musculoskeletal pain. Journal of exercise rehabilitation., 11(2), 108–111.
  30. Kannan P, Claydon LS. Some physiotherapy treatments may relieve menstrual pain in women with primary dysmenorrhea: a systematic review. J Physiother. 2014 Mar;60(1):13-21. doi: 10.1016/j.jphys.2013.12.003. Epub 2014 Apr 24. PMID: 24856936.
  31. Choi JH. Effects of kinesio taping and hot packs on premenstrual syndrome in females. Journal of Physical Therapy Science. 2017;29(9):1514-7.
  32. Lim C, Park Y, Bae Y. The effect of kinesio taping on menstrual pain and premenstrual syndrome. J Phys Ther Sci. 2013;25(7):761-764. Doi:10.1589/jpts.25.761
  33. Chiesa A. The difficulty of defining mindfulness: Current thought and critical issues. Mindfulness. 2013 Sep 1;4(3):255-68.
  34. Kamlesh D. Patel. Heartfulness. Available from [last accessed 26/10/2020]
  35. Chethana Prakasan. Regulate your periods with yoga: 5 yoga asanas to regulate your irregular menstrual cycle naturally. published may,15 2017.4:06 PM IST
  36. SarahBethYoga. 15 min yoga for women during periods. Available from [last accessed 12/10/2020]
  37. Pelvic Rehab. Can Pelvic Rehab Physical Therapy Help Dysmenorrhea? Available from [last accessed 26/10/2020]
  38. What are common treatments for menstrual irregularities? Eunice Kennedy Shriver National Institute of child health development. [last accessed 06/10/2020]
  39. Pedraza R, Nieto J, Ibarra S, Haas EM. Pelvic muscle rehabilitation: a standardized protocol for pelvic floor dysfunction. Adv Urol. 2014;2014:487436. doi:10.1155/2014/487436
  40. Ghaderi, F., Bastani, P., Hajebrahimi, S. et al. Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trialInt Urogynecol J 30, 1849–1855 (2019).
  41. Memorial Sloan Kettering Cancer Center. How to use a vaginal dilator. Availale from [last accessed 26/10/2020]
  42. Harvard health publishing. Harvard medical school. Step-by-step guide to performing Kegel exercises. Available from [last accessed 26/10/2020]
  43. Massage therapy. Neuromuscular Reprogramming for Rehab. Available from [last accessed 26/10/2020]
  44. PhysioForAll. Pelvic floor therapy. Available from [last accessed 26/10/2020]