Health and Healthcare

Menstruation: a woman’s health clock from adolescence to menopause

What are we talking about in this article?

The reproductive life of the woman is regulated by a biological clock that is activated at the beginning of adolescence with the first menstruation and ends with menopause, the moment of the last menstruation. The watch is adjusted on monthly: a loss of blood for a few days that is repeated every month, that stops with the conception of a pregnancy and resumes after the period of lactation. For centuries the menstruating woman has been seen with suspicion and with so many prejudices: from the moment that the cellular and hormonal mechanisms behind it have been known, it became a sign of health or disease for medicine. Absence of menstruation, heavy menstrual bleeding and painful menstruation have become an indicator of the woman’s health and a warning of gynecological and not gynecological alterations.  In the last 50 years we are witnessing denatality and first pregnancies in older ages, these phenomena have put even more light on menstruation disorders. The menopause that puts an end to menstruation, however, represents the beginning of other issues for women health and that go beyond the reproductive phenomenon, influencing entirely the well-being of women and representing an example of gender medicine.

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Menstruation in history and culture to this day

Gender medicine teaches us that women’s health is regulated by estrogens, hormones produced by the ovary gland. These hormones are essential for the reproduction of the human species by acting on the uterus, breast and vagina, but they also have effects on the brain, heart, liver, skin and bone. This action is regulated by an internal clock, at a monthly rate, which starts in the adolescent with the first menstruation and ends with menopause around 50 years. Menstruation has meant curses and prejudices for centuries, and absence of menstruation was the only pregnancy test available! Modern medicine studies it as a normal index of both reproductive function and the very well-being of women.

Menstruation is a normal part of women’s life even if in the past it was considered a taboo. The unique phenomenon of menstruation, the associated symptoms and the consequences that came with it have generated a huge literature both in modern and ancient times. Myths and taboos have greatly influenced literature on the subject. Interestingly, the same word ‘taboo’ comes from the Polynesian word ‘Tabu’, which originally meant menstruation.

The first written reference to menstruation is contained in what is also the first known medical document the Egyptian papyrus of Kahun. Dated around 1800 BC, it contains 35 different paragraphs relating to women’s health and reports ancient Egyptian knowledge of menstruation.

From Ancient Greece come other interesting testimonies written by Aristotle and Hippocrates. In the treatise “De generatione animalium”, Aristotle theorized that sperm and menstrual blood contribute to the formation of the embryo.  Within two important works of Hippocrates, the “De natura muliebri” and the “De morbis muliebribus”, the reference to menstruation is very frequent. Hippocrates treats diseases related to the menstrual cycle, rather than describing its physiology. The condition described more is the amenorrhea, the disappearance of menstruation; when not caused by pregnancy, it was considered a manifestation of the impossibility of conceiving. Moreover, according to Hippocrates, amenorrhea caused considerable disturbances in the woman and the remedies adopted were the same used also for other gynecological pathologies such as fumigations, purgations, pessaries, potions, emollients. The need to restore menstrual flow, if it disappeared is reported in several steps of the “De natura muliebri” and the best remedy in these cases, according to Hippocrates, consisted in sexual activity. 

The Pantheon of ancient Rome included two deities protecting women, fertility and menstrual flow: Fluonia and Mena. Fluonia, epithet of the goddess Juno, was the protector of the gestation of women. The name itself, according to Festus’ testimony, is a derivative of the verb fluo, “to flow”. Fluonia, in fact, took care of the menstrual flow (sanguinis fluorem) of women. The goddess Mena, however, was considered a minor deity, twenty-first daughter of Zeus, protector of fertility and menstruation, often identified with the Moon. The word “menarche”, from the Greek μήναρχή (menarchè), composed of mén, month and arkhé, beginning or origin, translatable as “beginning of menstruation”, alludes in fact to the name of the Goddess. The word “mensis” (month) is also linked to divinity. The term comes from an episode in mythology in which it is said that Juno for jealousy punished one of the nymphs of Jupiter with a monthly sting of horsefly.  After all, the menstruat with its 28-day cycle is associated with the lunar cycle, which the ancient Romans used to divide into a barren period, the Black moon, and a fertile period, the Pregnant Moon or Full Moon.  

Sorano from Efeso, a doctor in Rome in the second century AD, in his work on gynecology, described with precision every aspect related to the physiology and pathology of the menstrual cycle. He reports some terms with which menstruation is defined: καταμήνιον (catamenion), which indicates the monthly periodicity of menstrual flow, ἐπιμήνια (epimenia) relating to the nutritional role of the embryos, and κάθαριsis (catharticsis), purify the body. Sorano provides a very precise description of the menstrual phenomenon, dealing with the duration and rhythm of menstrual flow, explaining that it does not occur in the same lunar phase in all women. In addition, he talks about the amount of menstrual flow and describes some premenstrual symptoms (difficulty in movement and heaviness of the pelvis, sometimes even pain and numbness). Unlike Hippocrates, who believed that the woman enjoyed good health only if menstruating and fertile, Sorano insinuates the suspicion that menstruation can be useful only to procreation, resulting outside of it substantially harmful to female health. Women who were sterile or in amenorrhea no longer had to be treated at all costs and with ferocity. For Sorano in fact amenorrhea was even physiological not only in childhood and senile and during pregnancy, but also in athletes and women with masculine appearance. 

The attitudes of the physicians and the communities of ancient Rome towards the theme have been strongly influenced by the writings of Pliny the Elder, historian and author who lived in the first century A.D. His testimony precedes by less than a century that of Sorano, however the two thoughts are very distant. Sorano’s medical writing has a more “scientific” and neutral approach, while Pliny’s anthropological approach reflects the thought of time, seen from a male perspective. The period told by Pliny in his “Historia Naturalis” is something «that generates monsters», but also prodigious, magical. To it are attributed an extraordinary power and strength but to prevail is its destructive aspect and its ability to contaminate. It is not by chance that Pliny indicates it also with the terms of venenum (poison) or virus, with the meaning of something lethal and infectious. Some excerpts from books VII and XXVIII of the “Historia Naturalis” give an idea of his doctrine: “Wine sour if they pass by, the vine withers, the grass dies and the shoots wither. If a woman with menstruation sits under a tree, the fruit will fall. A mirror will discolor in his eyes, and a knife will no longer be sharp. Bees will die and dogs that taste his blood will go mad.” These ideas influenced common thought well into the late Middle Ages.

Also in the Old Testament there is considerable emphasis on the laws of the niddāh «impurity», the Hebrew term used to describe the woman during menstruation. The main teachings related to the subject in the Holy Scriptures are found in Leviticus. According to the Bible, a woman is impure for seven days from the beginning of her menstrual flow, anyone who touches her is impure until evening (Lv 15,19) and sexual intercourse during this period is prohibited (Lv 18,19; Ezek 18,6; 22,10). The lack of observance of menstruation laws was considered one of the three transgressions by which women died in childbirth (Shabbat 2:6). Thus, because of these long periods of isolation due to their alleged ritual impurity, women were marginalized and deprived of the opportunity to participate in public activities and community religious life.

In the Middle Ages, in the Salernitan Medical School, menstruation was considered as a way of purification “Therefore, because women do not have enough heat to drain the surplus of bad moods that are formed daily in them […], then nature itself, in the absence of heat, has given them a special form of purification, namely menstruation, which ordinary people call “flowers”. For just as trees without flowers produce no fruit, so women without flowers are deprived of the power to conceive.”  Despite being a cutting-edge school for that time, the forerunner of the modern University of Medicine, born from the union of the Greek-Latin tradition with the Arab and Jewish tradition, and also open to women as students (Mulieres Salernitanae). He still had a very distorted view of menstruation.

However, even in more recent times, Sir Beckwith Whitehouse, a prominent British gynecologist, in an article published in 1914 in Lancet magazine, called menstruation “one of the sacrifices that women must offer at the altar of evolution and civilization”. 

The stigma that characterized menstruation and the normalization of menstrual pain can still have severe consequences on women’s health. About 50% of women say they have little or no knowledge of menstruation. Women often have little awareness of their condition and are not informed about the possibilities of treatment of disorders related to the menstrual cycle, therefore they require with delay a medical assessment. Poor health literacy has hampered and made scientific research more difficult.

In recent years, thanks to the progress of communication through social media also in the gynecological field, menstrual health is a concept that tends to assert itself more and more, eliminating taboos on menstruation and associated symptoms. The use of mobile technologies for health has proven effective, it allows to collect information for monitoring the menstrual cycle and also allows the dissemination of scientific content. Currently, there are more than 300 femtech reproductive health products in the most widely used app stores, mostly designed for women of childbearing age, with a focus on menstruation and fertility monitoring.

Menstruation physiology

Menstruation is a natural process that occurs in women from menarche (first menstruation) (between 11 and 14 years) to menopause (last menstruation) (around 50 years) and is recognized as a sign of reproductive well-being of a woman of childbearing age. With the maturation of the ovary and oocytes, the body, through the hormones estrogen and progesterone, prepares the uterus as a container of the product of conception. In fact, menstruation is an indication of pregnancy failure and consists of the flaking of the cells of the uterus (the inner part, called the endometrium) and blood cells (which give the reddish color to menstruation) that are eliminated through the vagina. The duration of these losses is 3-6 days, and occur on average every 28 days (hence “menstruation”, monthly). It does not occur if conception occurs at the time of ovulation (which occurs about 14 days of the cycle).

During menstruation, the uterus produces substances that stimulate its contractility and thus a pain of the lower abdomen (dysmenorrhea) to allow menstrual blood to flow out.  Hormonal variations and such mediators, such as prostaglandins, also cause abdominal cramps, headaches, fatigue and mood changes in some women. These symptoms can be annoying and affect a woman’s quality of life during her menstrual period, affecting her school performance, work, sports and social life. It is especially in adolescence that these symptoms prevail and have always been considered “in the norm” because then with the first pregnancy (which until the 20th century was sought between 18 and 22 years) and with subsequent, such symptoms tended to disappear.


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During the last century, the impact of menstruation on the life of women in Western societies has greatly increased. In the past, in fact, having numerous children involved long periods of no menstruation due to pregnancy and lactation and therefore a smaller number of menstrual cycles. In the last 100 years, however, there has been a decrease in the number of children per woman, resulting in a greater total number of menstrual cycles. Considering that today women in Italy look for the first pregnancy on average over 30 years (with 8% over 40 years) and have a maximum of 2 pregnancies, we have gone from 120-150 menstruation to 450-500 during the fertile life.  A momentous change, both in the structuring of society but also in the health of women.

Menstruation can become a sign of pathologies that have an impact on the life of a woman, and require medical care and treatment. The main pathological variants derive from: absent menstruation (amenorrhea), abundant menstruation (uterine fibroids) and significantly painful menstruation (endometriosis), with accompanying psychiatric symptoms (premenstrual syndrome).


Failure to menstruate can physiologically depend on pregnancy, lactation or menopause, but in our society the most frequent cause is stress.  The modern woman is exposed to a wide range of physical stress (professional sports), metabolic (the search for an ideal weight with diets that allow rapid slimming) in addition to the classic psychological stress (death, physical violence and ill-treatment, labour and social performance).  The brain inhibits the hormonal mechanisms that regulate the menstrual cycle and menstruation to save energy. These forms of amenorrhea are sudden and unforeseen, they can cause fear for future reproductive difficulties, but in reality they are transient forms, of variable duration (even years), but with a benign prognosis. In many cases the use of hormonal drugs is used to facilitate an “artificial” menstruation, but the most suitable solution is the overcoming of the stress that induced the blockade.  Sometimes even knowledge of the mechanisms that lead to amenorrhea can help patients overcome the problem, even with the help of new lifestyles and psychological support.

Heavy menstrual bleeding

When the menstruation is too abundant the reduction of iron reserves and the resulting anemia make women feel sick. Patients are more tired, get up badly in the morning, lose energy in a few hours: they need iron to restore their blood to normal values. But above all they want to know why this abundant bleeding: fault of hormones once again, because they poorly regulate the uterus or is the uterus itself having benign alterations (fibroids, adenomyosis, endometrial polyps)? Or, even worse, is there a malignant tumor of the uterus that manifests itself in this way? This last hypothesis is only rarely valid in young women, but it is a fear that must be excluded with the diagnostic means we have available. The woman who loses a lot of blood with menstruation and between menstruation is always afraid of having a tumor and resorts to often unnecessary medical examinations with hypermedicalization.  Although hormonal or benign causes clearly prevail, in different parts of the world these situations can still lead many women to death from severe anemia, due to the absence of diagnostic and therapeutic means (health deficiencies in an globalized world).  Even in the Gospel there is talk of a “hemorrhage” for 13 years that to save life seeks the miracle, and in some parts of the Earth we are still stuck in that state! In addition to anemia and asthenia, the presence of these abundant menstruation is associated with reduced fertility, both for difficulty at conception and for recurrent miscarriage. A problem sometimes not easily overcome even with the new techniques of assisted reproduction. The culmination of modern medicine is that even today there is no simple and scientific method that allows you to calculate menstrual blood loss, and you resort to the question of how many days and how many pads have been changed during the day.

Painful menstruation

The evaluation of menstrual pain is also subjective: a scale from 0 to 10 is used empirically to ask the woman the level of pain perceived in the days of menstruation. That is why menstrual pain has been considered for centuries as a purely physiological phenomenon, a normal pain that the woman had to suffer.  This may be partly true for the first menstruation in adolescence (and can be treated with analgesic or hormonal drugs), but it becomes a disease spy in one in ten women of childbearing age: endometriosis. A benign disease but of great impact on the life of the woman, with menstrual pains that also radiate to nearby organs (vulvodynia, intestinal and urinary pains). This disease is exploding in the last 30 years both because the means for making diagnoses have improved, but also because the woman has changed her reproductive rhythms by postponing the first pregnancy by many years and reducing the number of pregnancies.  The conquest of a role in the world of work, society and politics has affected the choice of new reproductive plans compared to previous centuries.  In addition, new chemical pollutants have entered the diet and daily life that act on the organs and reproductive function of women (and men) and can influence the appearance of diseases. Endometriosis is accompanied not only by pain, but also infertility precisely because conception is often made difficult by the inflammation present in the pelvis, or because the uterus becomes inhospitable for the implantation of the embryo.

Premenstrual syndrome is a set of physiological mood disorders that precede and accompany menstruation.  It is not easy to diagnose and treat, a real very complex medical puzzle. 

All these diseases, although benign, are not easy to treat and often require the use of drugs and surgery to restore less abundant and less painful menstruation, and make the woman fertile. Even today there are many partial successes or therapeutic failures for uterine fibroids, adenomyosis and endometriosis.  


Menopause is the natural event that marks the end of the woman’s reproductive phase and solves these pathologies of menstruation. There is an interruption in the production of ovarian hormones, such as estrogen and progesterone, and the disappearance of the menstrual cycle and menstruation. It usually occurs around the age of 50-55, but varies from person to person. Women who suffer from menstruation diseases see the irritations and injuries disappear but a fair percentage of all women (between 50 and 70%) see a series of menopause disorders appear:

  • Hot flashes, with sudden increases in body heat, accompanied by sweating and redness of the skin that can worsen the quality of sleep (up to insomnia);
  • Vaginal dryness with pain during sexual intercourse, for reduced vaginal lubrication;
  • An easy emotional lability with mood disorders, with irritability anxiety, depression, anxiety and mood swings.

In the following months/years, bone density loss is also observed, with an increased risk of osteoporosis and fractures.

Paradoxically, in some women, we go from the terror of menstruation due to the symptoms of pain and bleeding, to the desire of the return of menstruation to restore the hormonal levels of childbearing age.  For this reason, over the past 60 years, attempts have multiplied to administer “substitutes” of ovarian hormones, by means of menopausal hormone therapy. There were phases of great enthusiasm (“Feminine for Ever”), with phases of great fear due to unwanted effects on some women (breast cancer, venous thromboembolism). We are still looking for the right product and the right dose, but the most used and appropriate approach is the customization of therapy. There are also other options to manage menopause-related disorders that provide relief from symptoms through lifestyle changes, such as a balanced diet, regular exercise, and stress control.

Meanwhile another big change has occurred in the last 70 years: the lengthening of the average life of women to over 85 years that revealed the long-term pathologies of menopause.  The heart, the brain, the connective tissue become more fragile and expose women to important pathologies. The possible protection of estrogen hormones on these organs and systems is witnessed by many experimental studies but always difficult to transfer this data to the clinic, due to the adverse effects that are revealed in some patients



Menstruation became from object of mystery to index of health of the woman.  Her monthly control is one of the most typical hormonal signs of gender medicine: the woman has a watch that controls her reproductive function but then affects the whole body. The diseases that are reported by the absence of menstruation or by the abundant or painful menstruation are also increasing because the number of menstruation of women today is increasing, as a result also of the reduced birth rate, especially in countries with high economic content.   These diseases come from the disruption of the hormonal axis that connects the brain, ovary and uterus but then reverberate on the health of the woman causing diseases of various organs and functions. Menopause puts an end to these diseases but triggers a new series of disorders with a high impact on women.


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  • Menstrual Cycle Related Disorders – Volume 7: Frontiers in Gynecological Endocrinology. Editors Sarah L. Berga, Andrea R. Genazzani, Frederick Naftolin, Felice Petraglia. 2019 Springer Nature
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Felice Petraglia

Full Professor of Gynecology and Obstetrics, University of Florence;

Head of Gynecology and Obstetrics, AOU Careggi;

Director of the School of Specialization in Gynecology and Obstetrics;

Director of the Integrated Mother and Child Care Department of AOU Careggi.

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Vincenzina Bruni

University of Florence, Gynecology and Obstetrics, Experimental and Clinical Biomedical Sciences “Mario Serio”

Angela Gallone

University of Florence, Gynecology and Obstetrics, Experimental and Clinical Biomedical Sciences “Mario Serio”

Silvia Vannuccini

University of Florence, Gynecology and Obstetrics, Experimental and Clinical Biomedical Sciences “Mario Serio”