Menstruation is a key indicator of underlying health conditions that are easily missed if clinicians (beyond OB/GYNs) aren’t well-versed. Delivering inclusive care requires knowledge about all people’s bodies.

Too often, the menstrual cycle is only discussed in the OB-GYN’s office—and even then, only in the most cursory terms. Rarely does the conversation extend beyond asking a patient the date of their last menstrual period. But the menstrual cycle is an important indicator of overall health, acting as a canary in the coal mine for an array of health issues. Becoming interested in your patients’ menstrual cycles can help you provide more inclusive, comprehensive, and effective care.

There is strong evidence that providers of all stripes should concern themselves with the menstrual cycle: in fact, in 2015, the American College of Obstetricians and Gynecologists (ACOG) named the menstrual cycle the “fifth vital sign”, making the case that the menstrual pattern should be considered alongside heart rate, blood pressure, and other vital signs as an indispensable tool for identifying health issues.

Irregular or absent menstrual cycles can be a sign of eating disorders, over-exercise, hormone imbalances, such as PCOS or thyroid malfunction, mental health conditions, sleep problems, STIs, and a variety of other health issues. If left unexplored and untreated, many of the conditions that manifest in menstrual irregularities can increase the long-term risk of cardiovascular disease and osteoporosis.

Despite the clear clinical value of discussing the menstrual cycle, many factors conspire to prevent meaningful conversations about it between patients and clinicians.

• Symptoms don’t always present in ways that are obviously gynecological, so patients may complain of pain or other issues to providers who are ill-equipped to help them.
• Patients might not raise the issue of their menstrual cycle with their provider if they don’t realize that their experience is abnormal.
• And providers may write off a patient’s concerns about their cycle as just part of the wide range of “normal” when it comes to menstruation.

While it’s true that not every menstruating person has a 28-day cycle and some variation in characteristics is normal, there are symptoms that fall well outside the normal range on any cycle parameter and that should be grounds for further investigation. Normalizing conversations around the diverse experiences of menstruation should not mean failing to identify and intervene in cases where falling outside of the normal range indicates a problem.

‍The four questions to ask your patients about their menstrual cycles.

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‍It’s standard practice to ask patients when their last period started, but the conversation shouldn’t end there. Here are the four additional questions you should ask your patients about their menstrual cycles:

‍1. “Are you using hormonal contraception?”

‍Before any effective conversation about the menstrual cycle can occur, it’s imperative to find out if your patient is using hormonal contraception. Hormonal contraception inhibits hormone production, limiting the information that can be gained from a discussion about the patient’s cycle.

Combination birth control methods (like the birth control pill, the patch, and the NuvaRing) suppress normal ovulatory function. Patients using these types of birth control may experience a withdrawal bleed, but unlike a true period, the withdrawal bleed is an expected effect of the medication and does not reveal anything about the patient’s underlying health status.

Patients taking progestin-only birth control methods (Mirena IUD, minipill) may still ovulate but usually do not experience regular periods; they may experience spotting or no bleeding at all. In this case, as well, a patient’s bleeding patterns should not be taken as indicative of their underlying hormonal health.

For patients using non-hormonal contraceptive methods (condom, copper IUD, fertility awareness-based methods) or not using any contraception, you can proceed with the conversation about their menstrual cycles.

Providers should also be aware that for menstruating people not using hormonal contraception, heart rate, breathing rate, and temperature are lower during the preovulatory follicular phase of the cycle, and higher during the post-ovulatory luteal phase. If you notice a change in a patient’s vital sign measurements, consider that their cycle phase may be responsible.  

‍2. “How long is a typical menstrual cycle for you?”

‍The menstrual cycle, counting from the first day of bleeding to the day before the next period, should be 21 to 35 days, with no more than five days of variation from cycle to cycle. If a patient is experiencing long, irregular cycles or more frequent bleeding, this warrants further investigation.

Long, irregular cycles or very infrequent bleeding may be a sign of polycystic ovary syndrome (PCOS), a hormonal condition affecting up to 10 percent of cisgender women, which increases the risk for insulin resistance, type 2 diabetes, fertility problems, and is associated with obesity and depression.

Although PCOS is common, it’s often not diagnosed. Proper diagnosis is important to allow long-term follow-up and screening for diabetes and cardiovascular disease, and to support the patient in preventive measures including weight management, exercise, and medication. It can be challenging to diagnose young patients with PCOS because irregular cycles are common in the years after the onset of menarche. But if a patient is still irregular after three years of menarche, or experiences any three-month interval with no bleeding, they should be further evaluated for the possibility of PCOS.

Infrequent or absent bleeding can also be a sign of hypothalamic amenorrhea (HA), a condition where the menstrual cycle stops due to chronic energy deficit and/or extreme stress. HA has deleterious effects on the cardiac, skeletal, psychological, and reproductive systems. In the short term, HA can lead to thinning hair, brittle nails, low libido, and vaginal dryness. Over the long term, HA can increase the risk for cardiovascular disease and osteoporosis.

Because HA increases the risk for bone fractures, patients with broken bones should be asked about their menstrual history in case HA is an underlying factor.

Many providers believe that HA only occurs in elite athletes or people with anorexia, but the truth is that HA can occur in people at any body weight and any level of exercise. While you don’t have to exercise excessively to develop HA, it is more common among people who exercise. Up to half of exercising cisgender women may experience disruptions to their menstrual cycles. Because these menstrual disturbances are so common, they are often normalized as just something that happens to active people. Athletes, their coaches, and even their providers may see amenorrhea as a sign of high fitness levels and commitment to sport. This is all the more reason for providers to ask athletes about their cycles and emphasize the critical importance of adequate nutritional intake to maintain regular menstrual cycles.

‍3. “How long does your bleeding last and how heavy is it?”

‍It can be challenging to discuss menstrual flow with patients because of the lack of quantified measurements. Specific signs of excessive bleeding include:

• A period lasting longer than seven days
• Soaking through one or more pads/tampons an hour for several hours in a row
• Needing to wake up during the night to change tampons/pads
• Passing clots larger than a quarter
• Restricting activities due to menstrual flow
• Symptoms of anemia (fatigue, shortness of breath)

Heavy menstrual flow is more common in adolescence and during the menopausal transition, due to higher levels of estrogen relative to progesterone during these times. Patients using a copper IUD also commonly report heavy bleeding.

When patients experience excessive menstrual bleeding outside of these situations, it’s worth looking into underlying conditions that might be responsible. These could include:

• Pregnancy complications, including miscarriage or ectopic pregnancy
• Fibroids
• Polyps
• Bleeding/clotting disorders

Patients with excessive menstrual bleeding should also be evaluated for anemia.

‍4. “Do you notice any symptoms throughout your cycle?”

‍It can be normal to experience mild pain and cramping around the time of menstruation. Younger people, those who have never been pregnant, and those approaching menopause are more likely to have worse menstrual cramping. Cramping is caused by the release of prostaglandins, and production is higher when the opening of the uterus is tight or when estrogen levels are higher.

Patients complaining of painful periods don’t need to tough it out; their pain can be effectively treated with ibuprofen at the first hint of cramps. Taking the medication right away prevents the formation of the prostaglandins that cause the pain.

People who experience severe pain during their cycles are often told that their symptoms are just part of their inherent biology. But extreme pain or other symptoms that disrupt daily life during the cycle are not normal.

One possible cause of severe menstrual pain is endometriosis. Endometriosis can cause a variety of symptoms including severe menstrual pain that increases over time, pain during intercourse, pain when using the bathroom, and excessive menstrual bleeding. Because of the broad nature of symptoms, patients often go to their general practitioners with these issues, so providers should be aware of endometriosis as a possible diagnosis.

On average, it takes four to 11 years to diagnose a patient with endometriosis, and patients often consult with multiple doctors before receiving a diagnosis. One of the reasons for the difficulty in accurately diagnosing the condition is the normalization of menstrual pain. In addition, the pain of cisgender women, in general, is often considered less intense than the same amount of pain reported by cisgender men.

Patients complaining of severe menstrual symptoms along with mental health symptoms such as irritability, anxiety, or depression should be evaluated for premenstrual dysphoric disorder (PMDD). The condition affects up to 10 percent of cisgender women, who may also experience headaches, insomnia, suicidal thoughts, and fatigue. As with endometriosis, the symptoms are so diffuse and systemic that patients may bring them to their general practitioner, who should be aware of PMDD as a possible diagnosis.

‍Two additional questions for discussing menstrual cycles with transgender and gender non-conforming patients.

‍Providers may avoid discussing menstrual cycles with transgender and gender non-conforming (TGNC) patients due to discomfort or lack of knowledge. This is a missed opportunity—for anyone who menstruates, the menstrual cycle must be taken into consideration to form a complete picture of overall health and wellness. And TGNC patients may be more at risk for hypothalamic amenorrhea compared to cisgender women since they are more likely to experience eating disorders.

Ask these questions before discussing menstrual cycles with TGNC patients:

1. Conversations about the menstrual cycle can be triggering for TGNC patients because of trauma, gender dysphoria, and more. Explain why you want to broach the topic and ask for permission before you proceed: “The menstrual cycle can provide important clues about overall health for anyone with ovaries. As part of this appointment, I was planning on asking you some questions about menstruation. Would that be okay with you?”
2. Some TGNB patients may prefer coded language when discussing the menstrual cycle to help avoid feelings of dysphoria. Ask patients what type of terminology they prefer to use: “I usually use standard clinical terms like ‘menstruation’, ‘bleeding’, and ‘menstrual cycle’. Are there alternate terms you would prefer?” Try to use anatomy-first language when there’s no preference from the patient.

If the patient agrees, you may proceed with the conversation, but remain aware of your patient’s demeanor. If they seem uncomfortable, check in by asking, “Is this conversation still comfortable for you? If not, I’m happy to end it.”