Place · Level 3 · Condition
Menstrual Cycle · Period Care
HPO 轴 4 期 · FIGO 正常上限 · 前列腺素 → NSAID 时机窗 · PMDD vs PMS · 经前/中/后三段实操 · 经期禁忌拆穿
Story path
Chapter 1
4 phases · HPO axis
4 phases · HPO axis
Menstruation is not "the uterus performing on its own" — it is the hypothalamus → pituitary → ovary → endometrium four-tier choreography, a precise chemical relay reset every month. Understanding this axis = understanding the source of all the pain / mood / bleeding changes that follow.
1. The HPO axis (Hypothalamic-Pituitary-Ovarian):
Hypothalamus: pulsatile GnRH (gonadotropin-releasing hormone) secretion — the master metronomeAnterior pituitary: receives GnRH → secretes FSH (follicle-stimulating hormone) + LH (luteinizing hormone)Ovary: receives FSH/LH → follicle development + secretes estradiol (E2) + progesterone (P)Endometrium + systemic tissues: receive E2/P → proliferation / differentiation / shedding + systemic effects (mood / temperature / sleep / sebum / appetite)Feedback loop: at moderate-high levels E2, positive feedback triggers the LH surge (the chemical trigger of ovulation); during the luteal phase, E2/P provide negative feedback suppressing GnRH
2. The 4 phases of a standard 28-day cycle (counting from Day 1 of menstruation):
Menstrual phase (Day 1-5): endometrium sheds + bleeds; FSH has quietly begun rising, recruiting the next cycle's follicleFollicular phase (Day 1-13): FSH ↑ → follicle development + gradually rising E2; endometrium proliferates (proliferative phase)Ovulation (Day 13-15): E2 peaks → positive feedback triggers the LH surge → follicle rupture and ovulation within 24-36 h; basal body temperature (BBT) rises 0.3-0.5 °C afterwardsLuteal phase (Day 15-28): the ovulated follicle collapses into the corpus luteum → secretes P + some E2; endometrium differentiates (secretory phase) to prepare for possible implantation; lasts a fixed ~ 14 ± 2 days — the physiological limit of the corpus luteum
3. Key concept: the luteal phase is fixed; almost all cycle-length variation is in the follicular phase:
Normal cycle length range: 21-35 days (FIGO 2018 / Munro)A woman with a 35-day cycle is not "long-cycle," she has a long follicular phase; the luteal phase is still ~ 14 daysA 21-day cycle is not "a problem," just a short follicular phasePractical value: to estimate ovulation / pre-menstrual phase, count back 14 days from the predicted next period — more accurate than "Day 14"
The next pages cover the evolutionary logic of menstruation + the atlas perspective on "detox blood", the cycle's influence on whole-body rhythms (BBT / sleep / appetite / sebum), and the FIGO quantification of "is anything other than 28 days abnormal?".
1. The HPO axis (Hypothalamic-Pituitary-Ovarian):
Hypothalamus: pulsatile GnRH (gonadotropin-releasing hormone) secretion — the master metronomeAnterior pituitary: receives GnRH → secretes FSH (follicle-stimulating hormone) + LH (luteinizing hormone)Ovary: receives FSH/LH → follicle development + secretes estradiol (E2) + progesterone (P)Endometrium + systemic tissues: receive E2/P → proliferation / differentiation / shedding + systemic effects (mood / temperature / sleep / sebum / appetite)Feedback loop: at moderate-high levels E2, positive feedback triggers the LH surge (the chemical trigger of ovulation); during the luteal phase, E2/P provide negative feedback suppressing GnRH
2. The 4 phases of a standard 28-day cycle (counting from Day 1 of menstruation):
Menstrual phase (Day 1-5): endometrium sheds + bleeds; FSH has quietly begun rising, recruiting the next cycle's follicleFollicular phase (Day 1-13): FSH ↑ → follicle development + gradually rising E2; endometrium proliferates (proliferative phase)Ovulation (Day 13-15): E2 peaks → positive feedback triggers the LH surge → follicle rupture and ovulation within 24-36 h; basal body temperature (BBT) rises 0.3-0.5 °C afterwardsLuteal phase (Day 15-28): the ovulated follicle collapses into the corpus luteum → secretes P + some E2; endometrium differentiates (secretory phase) to prepare for possible implantation; lasts a fixed ~ 14 ± 2 days — the physiological limit of the corpus luteum
3. Key concept: the luteal phase is fixed; almost all cycle-length variation is in the follicular phase:
Normal cycle length range: 21-35 days (FIGO 2018 / Munro)A woman with a 35-day cycle is not "long-cycle," she has a long follicular phase; the luteal phase is still ~ 14 daysA 21-day cycle is not "a problem," just a short follicular phasePractical value: to estimate ovulation / pre-menstrual phase, count back 14 days from the predicted next period — more accurate than "Day 14"
The next pages cover the evolutionary logic of menstruation + the atlas perspective on "detox blood", the cycle's influence on whole-body rhythms (BBT / sleep / appetite / sebum), and the FIGO quantification of "is anything other than 28 days abnormal?".
Evolution + body rhythms
4. Why menstruation at all? (the evolutionary logic of endometrial shedding)Most mammals do not menstruate — their endometrium is resorbed rather than shed when pregnancy doesn't occurHumans + primates + bats + elephant shrews show "spontaneous decidualization": the endometrium differentiates into decidua during the luteal phase even without an embryoResult: P withdrawal (corpus luteum apoptosis) → decidualized endometrium cannot simply revert → ischemia + shedding + bleeding = menstruationEvolutionary hypothesis (Emera 2012): the human embryo's implantation is highly invasive → maternal endometrium needs to "rehearse" its defence → spontaneous decidualization → menstruation as a by-product
5. Atlas perspective: menstruation is not "detoxifying waste blood"
Menstrual fluid = endometrial tissue (~ 35-50%) + blood (~ 30-50%) + cervical mucus + vaginal microbiome metabolitesContains no toxins, and does not need to be "flushed clean" — one of the most common cognitive errors in Chinese internet discourseThe mystification of "menstrual blood colour = a health indicator" is overdone — colour is primarily affected by oxidation time (bright red = fresh / dark or brown = oxidised), not directly mapping to "cold-dampness" or "toxins"
6. The cycle and whole-body rhythms
Basal body temperature (BBT): rises 0.3-0.5 °C in the luteal phase → can confirm ovulation (but cannot predict it)Core-temperature threshold: narrowed in the luteal phase → the same room temperature feels warmer (some shared pathway with KNDy neurons, see the perimenopause island)Sleep architecture: in late luteal phase REM ↓ + awakenings ↑ (allopregnanolone, a P metabolite, is a GABA modulator — early helpful for sleep, late rebound)Appetite + preference: luteal energy intake on average ↑ 100-300 kcal/day (Buffenstein 1995 meta), preference for carbs + high fatSebum + acne: post-ovulation P ↑ → sebaceous gland activity → acne peak 3-5 days pre-menstrualBreasts: late-luteal proliferation → tenderness, a normal P effect
Bottom line: menstruation is not "an inconvenience to endure" or "mystical feminine energy" — it is an endocrine process that can be understood, measured, and intervened upon. The next 5 scenes turn that understanding into actionable tools.
Is non-28 abnormal?
"A normal cycle is 28 days" is a common misconception.FIGO 2018 / ACOG 2023 normal ranges:
Cycle length: 21-35 days (up to 45 days in the first 5 years post-menarche, can shorten to 17 days in perimenopause)Period duration: 2-7 daysBlood volume: 5-80 mL (Hallberg 1966 classic; > 80 mL = heavy menstrual bleeding, HMB)Cycle-to-cycle variation: a difference of ≤ 7-9 days between adjacent cycles is normal
True abnormality signals (next scene details):
< 21 days or > 35 days for ≥ 3 consecutive cyclesPeriod > 7 days or < 2 daysSubjective sense of substantially heavier flow (saturating 1 pad per hour / large clots) — semi-quantify with the PBAC scoreIntermenstrual bleedingPostcoital bleedingAmenorrhea (no menses for 3+ months) without pregnancy / breastfeeding
Common physiological causes of irregularity (not necessarily disease):
First 2-5 years post-menarche: immature HPO axis; anovulatory cycles commonPerimenopause (45+): HPO rhythm dysregulation, see atlas perimenopause islandStress (hypothalamic–pituitary–adrenal axis: The body's stress-response chain (hypothalamus → pituitary → adrenal) that releases cortisol. → HPO suppression): acute / chronic stress delays ovulationEnergy deficit: dieting / heavy training + low intake → functional hypothalamic amenorrhea (FHA), see sarcopenia + low energy availability literatureSharp weight changes: rapid loss of 10% body weight or sudden gain → cycle disturbanceTime-zone changes + shift work: see atlas shift-work-circadian island
Practical value of cycle tracking
A 3-6 cycle log = the cheapest diagnostic tool (more informative than any single blood hormone draw)Required: period start date / duration / volume (light / medium / heavy) / pain (0-10) / abnormal bleeding / key symptoms (PMS / mood / headache)Optional: basal body temperature (measured upon waking before getting up) + cervical mucus (Billings method) → for fertility awareness in conception planning, not a standalone contraceptiveApps: Clue / Flo / Apple Health built-in — for privacy prefer locally-stored apps; be cautious of cross-border data (since Roe v. Wade, US courts have subpoenaed data in some states)
Chapter 2
Normal vs AUB
Normal vs AUB
"Can my period wait to be checked" is one of the most-deferred medical decisions. Let's quantify it using FIGO 2018 PALM-COEIN — the global gynaecology common language.
1. PALM-COEIN: 9 causes of abnormal uterine bleeding (AUB) (Munro 2018)
PALM (structural, visible on imaging):
P olyp — endometrial or cervical polypA denomyosis — endometrium invading myometriumL eiomyoma — uterine fibroid (FIGO L0-L7 sub-classification)M alignancy — endometrial / cervical cancer or precancer
COEIN (non-structural):
C oagulopathy — most commonly vWD, highly underdiagnosed — 13% of women with severe HMB have vWDO vulatory dysfunction — PCOS / hypothyroidism / hyperprolactinemia / stress-related FHAE ndometrial — local endometrial factors (endometritis / prostaglandin imbalance)I atrogenic — hormonal IUD / anticoagulants / chemotherapyN ot otherwise classified
2. Quantifying menstrual bleeding: is your "a lot" actually a lot?
80 mL/cycle is the evidence-based threshold for HMB (Hallberg 1966, Janbu 1979 → adopted by WHO)80 mL = 16 fully soaked standard pads or 8 fully soaked super-absorbent padsPrecise daily quantification is hard → use PBAC (Pictorial Blood Loss Assessment Chart):Lightly soaked pad = 1 pointModerately soaked = 5 pointsFully soaked = 20 pointsPBAC ≥ 100 points/cycle ≈ 80 mL ≈ HMBQuick subjective signs: "saturating one standard pad per hour for 2+ hours" / "need to change during the night" / "large clots > 2.5 cm" → suggest HMB
The next page covers tiered red flags (ER / this-month), the real cost of "just endure it", and the standard work-up checklist for an abnormal-bleeding visit.
1. PALM-COEIN: 9 causes of abnormal uterine bleeding (AUB) (Munro 2018)
PALM (structural, visible on imaging):
P olyp — endometrial or cervical polypA denomyosis — endometrium invading myometriumL eiomyoma — uterine fibroid (FIGO L0-L7 sub-classification)M alignancy — endometrial / cervical cancer or precancer
COEIN (non-structural):
C oagulopathy — most commonly vWD, highly underdiagnosed — 13% of women with severe HMB have vWDO vulatory dysfunction — PCOS / hypothyroidism / hyperprolactinemia / stress-related FHAE ndometrial — local endometrial factors (endometritis / prostaglandin imbalance)I atrogenic — hormonal IUD / anticoagulants / chemotherapyN ot otherwise classified
2. Quantifying menstrual bleeding: is your "a lot" actually a lot?
80 mL/cycle is the evidence-based threshold for HMB (Hallberg 1966, Janbu 1979 → adopted by WHO)80 mL = 16 fully soaked standard pads or 8 fully soaked super-absorbent padsPrecise daily quantification is hard → use PBAC (Pictorial Blood Loss Assessment Chart):Lightly soaked pad = 1 pointModerately soaked = 5 pointsFully soaked = 20 pointsPBAC ≥ 100 points/cycle ≈ 80 mL ≈ HMBQuick subjective signs: "saturating one standard pad per hour for 2+ hours" / "need to change during the night" / "large clots > 2.5 cm" → suggest HMB
The next page covers tiered red flags (ER / this-month), the real cost of "just endure it", and the standard work-up checklist for an abnormal-bleeding visit.
Red flags + impact + work-up
3. Red flags — see these → gynaecology without delayAcute (this week):
Abnormal heavy bleeding + dizziness / ↑ HR / pallor → ER, rule out decompensated anemiaAny vaginal bleeding during pregnancySevere postcoital bleedingUnexplained abdominal mass + cycle disturbance
Subacute (this month):
Cycle > 35 days or < 21 days for ≥ 3 cyclesPeriod > 7 daysRecurrent postcoital bleedingIntermenstrual bleeding (outside the ovulatory spotting window)Any postmenopausal vaginal bleeding — highest priority to rule out endometrial cancerSevere dysmenorrhea + NSAIDs ineffective + impacting work/school → screen for endometriosisAmenorrhea > 3 months (exclude pregnancy)Heavy menstrual bleeding + easy bruising / nosebleeds / gum bleeding → coagulopathy screen (vWD!)
4. Don't underestimate "period impacts life"
Nnoaham 2011 multi-country cohort: endometriosis average misdiagnosis delay 7-10 years — many women are told "period pain is normal, endure it" until infertility work-up finally finds itHMB → iron-deficiency anemia → chronic fatigue + cognition + work efficiency — chronically "tired" women should first rule out HMB + check ferritin (see atlas iron island)Dysmenorrhea / period burden reduces women's work / school output by 8-9% (Schoep 2019 BMJ Open, N=42,879)"Endure it" is not a moral virtue, it is the cost of information asymmetry
5. Standard work-up checklist (common at first AUB visit)
Must: pregnancy test (β-hCG) → exclude pregnancy / ectopicCBC + ferritin + thyroid-stimulating hormone: A pituitary hormone that prods the thyroid to work — it rises when the thyroid is underactive. + PRL (prolactin)Coagulation panel + vWF antigen + activity (especially adolescent HMB since menarche)Pelvic ultrasound (transvaginal preferred) — fibroids / polyps / endometrial thickness / ovariesAs needed: hysteroscopy (polyp / endometrial cancer) + endometrial biopsy (45+ HMB / endometrium > 11 mm postmenopausal) + MRI (deep adenomyosis + complex endometriosis)
Bottom line: medical decisions about abnormal periods do not require heroism. "Endure" is not a virtue — "quantify + check early" is.
Chapter 3
Primary dysmenorrhea · PG
Primary dysmenorrhea · PG
Dysmenorrhea splits into two types with completely different management:
Primary dysmenorrhea: no organic pathology, functional pain driven by prostaglandins — affects ~ 45-95% of reproductive-age women (Iacovides 2015), peaks in adolescence and early 20sSecondary dysmenorrhea: organic disease (endometriosis / fibroid / adenomyosis / PID) — usually new-onset after 25; new/escalating pain. See next scene.
This scene covers the chemistry of primary dysmenorrhea, one of the cleanest "understand the mechanism → use medication precisely" cases on the atlas.
1. The chemical root: PGF2α + PGE2 surge on cycle days 1-2
Corpus luteum apoptosis → P withdrawal → endometrial lysosome release → phospholipase A2 cleaves phospholipids → arachidonic acid (AA)AA → COX-2 → PGF2α + PGE2 mass synthesis (Iacovides 2015)Endometrial PGF2α rises to 3-7× follicular-phase levels on cycle days 1-2PGF2α actions:Strong uterine smooth-muscle contraction → intrauterine pressure ↑ to ~ 150-180 mmHg (normal < 80) → ↓ blood supply → uterine ischemic pain (same mechanism as angina)Sensitises peripheral nociceptors → ↓ pain thresholdPGE2 drives systemic symptoms: nausea / vomiting / diarrhea / headache
Primary dysmenorrhea: no organic pathology, functional pain driven by prostaglandins — affects ~ 45-95% of reproductive-age women (Iacovides 2015), peaks in adolescence and early 20sSecondary dysmenorrhea: organic disease (endometriosis / fibroid / adenomyosis / PID) — usually new-onset after 25; new/escalating pain. See next scene.
This scene covers the chemistry of primary dysmenorrhea, one of the cleanest "understand the mechanism → use medication precisely" cases on the atlas.
1. The chemical root: PGF2α + PGE2 surge on cycle days 1-2
Corpus luteum apoptosis → P withdrawal → endometrial lysosome release → phospholipase A2 cleaves phospholipids → arachidonic acid (AA)AA → COX-2 → PGF2α + PGE2 mass synthesis (Iacovides 2015)Endometrial PGF2α rises to 3-7× follicular-phase levels on cycle days 1-2PGF2α actions:Strong uterine smooth-muscle contraction → intrauterine pressure ↑ to ~ 150-180 mmHg (normal < 80) → ↓ blood supply → uterine ischemic pain (same mechanism as angina)Sensitises peripheral nociceptors → ↓ pain thresholdPGE2 drives systemic symptoms: nausea / vomiting / diarrhea / headache
NSAIDs first-line + timing
2. Why NSAIDs are first-line (Marjoribanks 2015 Cochrane, Level A)NSAIDs = non-selective COX inhibitors (ibuprofen / naproxen / diclofenac) or selective COX-2 inhibitors (celecoxib)Directly block the AA → PG pathway = target the rootvs acetaminophen (Tylenol): NSAIDs are substantially more effective (Marjoribanks 2015)NNT (number needed to treat): ibuprofen 400 mg vs placebo = 2.4 (a hallmark of a highly effective drug)
3. The critical timing window (this is what many women first learn on the atlas)
"Wait until it hurts to take a pill" is too late — PGs already released + pain sensitisation in progressCorrect approach: start 1-2 days before the expected period + take regularly for 2 days into the period, maintaining blood levels → prevent PG accumulationIbuprofen: 400 mg every 6 hours during the worst days 1-3 (total OTC ceiling 2400 mg/day)Naproxen: 500 mg loading → 250-500 mg every 8-12 hoursMefenamic acid: COX inhibitor + PG-receptor antagonist; some studies favour it over ibuprofen, but slightly more GI side effectsAfter 2-3 days: PG peak has passed, switch to PRN
Side effects + contraindications
4. NSAID side effects + contraindications (don't ignore)Duration caveat (ACOG / FDA OTC labels): OTC NSAIDs per cycle should not exceed 3-5 consecutive days; typical dysmenorrhea window = start 1-2 days pre-menses + 2-3 days into the period, 3-4 days total covers the PG peak. If > 5 days are still needed → gynaecology evaluation of underlying cause + consider COC / LNG-IUD, not continued NSAIDsGI: taken with food + short courses, risk is low; long-term / high-dose → gastric mucosa damage + ulcerRenal: PG inhibition → afferent arteriole vasoconstriction → transient ↓ GFR; caution in CKD + dehydration + hypertension + elderlyCV: selective COX-2 inhibitors + high-dose long-term → ↑ CV risk (FDA black box); short-term cycle use is very low-riskCoagulation: COX-1 inhibition → ↓ platelet TXA2 → ↑ bleeding risk (in short-term cycle use this actually reduces menstrual blood loss by 20-30%, a double benefit)Absolute contraindications: active GI ulcer / severe renal impairment / aspirin-induced asthma / NSAID allergyRelative: pregnancy (especially late) / breastfeeding (short OK) / concurrent anticoagulant
Alternatives + myths
5. What if NSAIDs are ineffective or contraindicated?Heat therapy (40-44 °C, 4-6 hours) — Akin 2001 OBGYN RCT: equivalent to mefenamic acid + synergistic when combinedTENS (transcutaneous electrical nerve stimulation): Level B, an option for recurrent episodesHormonal:Combined oral contraceptive (COC): suppresses ovulation + thins endometrium → ↓ PG → dysmenorrhea ↓ 70-90%LNG-IUD (Mirena): HMB ↓ 70-95% over 5 years, marked dysmenorrhea reductionSuited to: NSAIDs ineffective / also needs contraception / HMB + dysmenorrheaGnRH agonist + add-back hormone: severe endometriosis / adenomyosis, gynaecology decisionSurgery: extreme endometriosis / large fibroid / adenomyosis → laparoscopic evaluation
6. Common misconceptions
"NSAIDs stop your period": wrong, NSAIDs don't affect ovulation / cycle, and actually slightly reduce flow"Long-term NSAID use is addictive": wrong, NSAIDs are not opioids, not addictive"Period pain is good → detoxifies": wrong, dysmenorrhea = PG over-activity, no "toxins" expelled"Dysmenorrhea improves after childbirth": half true — some primary dysmenorrhea improves after delivery (pelvic nerve + endometrial remodelling), but secondary dysmenorrhea (endometriosis) may worsen
Atlas connections: fats-omega-3 (PG pathway) + magnesium/relax (uterine smooth-muscle relaxation) + vitamin-b6 + vitamin-d.
Secondary + endo screening
Secondary dysmenorrhea = period pain hiding an organic disease, with a completely different management strategy from primary.Common causes + their features:
Endometriosis:Ectopic endometrial tissue (ovary / pelvis / pouch of Douglas) bleeds + inflames + adheres with the cycleGlobal prevalence ~ 10% of reproductive-age women (Critchley 2020); estimated 6-10% in ChinaTypical: progressively worsening dysmenorrhea + dyspareunia + dyschezia + infertilityNnoaham 2011 multi-country cohort: average diagnostic delay of 7-10 years — one of the heaviest medical injustices on the atlasGold standard: laparoscopy + pathology; imaging (TVUS + MRI) can show deep lesions + ovarian endometrioma
Adenomyosis:Endometrium invading the myometrium → diffuse / focal myometrial thickeningCommon in 30-40+ multiparous womenTypical: dysmenorrhea + HMB + enlarged uterus ("early-pregnancy" appearance)Diagnosis: TVUS + MRI (T2-weighted high-signal junctional zone widening)
Leiomyoma (fibroid):Benign smooth-muscle tumorCommon 35+, earlier and more frequent in Black womenPain depends on location + size (submucosal < intramural < subserosal more painful)Main symptom: HMB > dysmenorrhea
Pelvic inflammatory disease (PID): acute / chronic, usually history of STI + fever / abnormal discharge
Cervical stenosis / uterine anomalies: outflow obstruction of menstrual blood
Red flags for secondary dysmenorrhea (different from primary)
New-onset — wasn't painful before, starts after age 25Progressively worsens — each month worse than the lastNSAIDs no longer fully relievePain not limited to cycle days 1-2 — starts 1 week pre-menses / persists outside menses / dyspareuniaAssociated symptoms — HMB / infertility / abnormal bleeding / postcoital bleeding / pain on defecation or urination
Diagnostic path
1. History + pelvic exam + pregnancy test
2. Transvaginal ultrasound (TVUS) — first-line imaging, evaluate fibroids + ovarian endometrioma + adenomyosis + endometrium
3. Pelvic MRI — deep endometriosis + complex adenomyosis + surgical planning
4. Laparoscopy + biopsy — gold standard for endometriosis; can also treat at the same time
Don't wait 7 years: persistent severe dysmenorrhea + NSAIDs ineffective + impact on life → gynaecology directly; don't be talked out of it with "period pain is normal"
Pharmacotherapy (under gynaecology guidance)
COC: suppresses ovulation + thins endometrium → first-line for most endometriosis + primary dysmenorrheaLNG-IUD (Mirena): first-line for endometriosis + adenomyosis, 5-year durationProgestin (oral / injection / SC): suppresses endometrial proliferationGnRH antagonists (elagolix / relugolix): moderate-severe endometriosis (FDA-approved 2018+), with estrogen add-back to protect boneSurgery: conservative (excision of lesions) / semi-radical (hysterectomy preserving ovaries) / radical (hysterectomy + oophorectomy) — depending on age + fertility wishes + disease
Chapter 4
PMS · PMDD · luteal mood
PMS · PMDD · luteal mood
The 5-10 days of low mood / irritability / appetite change / poor sleep before menses affect ~ 80% of women, but severity spans a huge range: from "mild and ignorable" to "functionally disabling". Split this continuum into two tiers:
1. PMS (Premenstrual Syndrome) — mild-to-moderate:
In the late luteal phase (5-10 days pre-menses), ≥ 1 mood + ≥ 1 somatic symptom appears, resolving after menses20-30% of reproductive-age women have PMSDiagnosis: prospective 2-cycle diary (retrospective is unreliable)Does not impair core work / school functioning
1. PMS (Premenstrual Syndrome) — mild-to-moderate:
In the late luteal phase (5-10 days pre-menses), ≥ 1 mood + ≥ 1 somatic symptom appears, resolving after menses20-30% of reproductive-age women have PMSDiagnosis: prospective 2-cycle diary (retrospective is unreliable)Does not impair core work / school functioning
Diagnosis: PMDD DSM-5 criteria
2. PMDD (Premenstrual Dysphoric Disorder) — severe, DSM-5 diagnosis:DSM-5 criteria (5+ symptoms, ≥ 1 from group A):
Group A (core mood, ≥ 1 required):
Marked mood lability / sudden sadness / tearfulnessMarked irritability / anger / interpersonal conflictMarked depressed mood / hopelessness / self-deprecationMarked anxiety / tension / on-edge feeling
Group B (other symptoms, total ≥ 5):
Decreased interestConcentration / thinking difficultyHypersomnia / fatigue / low energyMarked appetite change / overeating / food cravingsSleep disturbance (hypersomnia / insomnia)Feeling out of control / overwhelmedSomatic: breast tenderness / bloating / arthralgia / muscle pain / headache / edema
Key qualifiers:
Symptoms must cluster in the late luteal phase + resolve within 1-2 days after onset of menses (i.e., follow the hormone curve)Confirmed by 2-cycle prospective diary (DRSP scale standard)Causes clinically significant functional impairment (work / school / interpersonal)Not better explained by another disorder (e.g., premenstrual exacerbation (PME) of depression is not PMDD)
PMDD prevalence: 3-8% of reproductive-age women (Halbreich 2003 meta), higher than the public imaginesOften misdiagnosed as "anxiety / bipolar" — the key differentiator is whether symptoms follow the cycle
Mechanism: ALLO + GABA-A + 5-HT
3. Mechanism (the atlas doesn't pretend we fully know, but there are core pathways)Hormone levels are not abnormal — PMDD patients have the same absolute E2/P levels as controls; what matters is brain sensitivity to normal hormone fluctuationAllopregnanolone (ALLO), a P metabolite, is a GABA-A receptor positive modulator (same site as alcohol / benzodiazepines)Luteal-phase ALLO ↑ → most women feel relaxed / aided sleepPMDD women's GABA-A receptor subunit composition is altered → the same ALLO instead triggers anxiety + irritability (Bäckström 2014, etc.)5-HT system: greater luteal-phase serotonin drop + receptor density changes in PMDD → the chemical rationale for SSRI efficacyhypothalamic–pituitary–adrenal axis: The body's stress-response chain (hypothalamus → pituitary → adrenal) that releases cortisol. axis: blunted HPA response pre-menses → weak stress buffering
Treatment: SSRI + nutrition + red flags
4. SSRIs: Level A first-line for PMDD (Steiner 1995 NEJM, first RCT)Fluoxetine 20 mg/day — first FDA-approved PMDD drug (brand Sarafem)Sertraline 50-150 mg / paroxetine 20-30 mg also approvedRapid onset (unique to PMDD): unlike depression's 4-6 weeks, PMDD response within 1-2 cycles — suggesting direct neurotransmitter effect rather than neuroplasticityTwo dosing regimens:Continuous: daily — simple, stable side effectsLuteal-phase only: from ~ Day 14 post-ovulation to days 1-2 of menses → fewer side effects + lower cost, efficacy similar to continuous (Yonkers 2015 meta)
5. Other evidence-based interventions
CBT (cognitive behavioural therapy): CBT + SSRI > either alone (Lustyk 2009 meta)Exercise (moderate, 30 min × 3-5 sessions/week): improves premenstrual mood + somatic symptoms (Daley 2009 meta)Ca 1000-1200 mg/day (food + supplement) — Thys-Jacob 1998 RCT: total PMS score ↓ 48%Adequate vitamin D (Bertone-Johnson 2005 NHS II): higher D intake → lower PMS risk (Level B)B6 50-100 mg/day (Wyatt 1999 BMJ Cochrane meta): overall PMS improvementReduce alcohol + caffeine + sodium (luteal phase): helps breast tenderness + irritability + edemaMg 200-400 mg/day (Quaranta 2007): mild edema + mood improvementVitex agnus-castus (chasteberry): some small RCTs positive (Level B), but product standardisation poor
6. Ineffective / weak
Progesterone supplementation (oral / vaginal / injection): meta negative (Ford 2012 Cochrane) — contrary to the intuition that "PMS is from low P"Evening primrose oil: multiple RCTs negative"Heat-clearing" herbal mixtures (commercial TCM formulations): not standardised + may contain undeclared hormonal-activity compounds
7. Acute suicide risk
PMDD women have significantly elevated suicidal ideation + behaviour risk (vs PMS and controls 1.5-3×, Pilver 2013 meta)Suicide risk concentrates 1-3 days pre-mensesAny self-harm ideation → immediate psychiatry, not "it'll pass when the period comes"
Bottom line: PMS / PMDD is not a character flaw + not "loss of self-control" + not "period being too severe" — it is the nervous system's differential sensitivity to normal hormonal fluctuation. The rapid onset of SSRIs in PMDD is itself mechanistic evidence.
Chapter 5
Before / during / after · checklist
Before / during / after · checklist
This scene is the operational core of the atlas menstrual island — distilling the upstream mechanisms into an executable checklist for pre / during / post-period, ordered by evidence strength + time sensitivity.
🌙 7-10 days pre-period (luteal phase — dysmenorrhea prevention + PMS buffering)
Prophylactic NSAIDs (history of dysmenorrhea + moderate-to-severe pain) — start 1-2 days before the expected period, not after pain begins (PGs already released)Ibuprofen 400 mg q6h × 2-3 daysNaproxen 250-500 mg q8-12h × 2-3 daysWith food + don't exceed OTC ceilingMg 200-400 mg/day (citrate / glycinate) — smooth-muscle relaxation + NMDA modulation + migraine reduction (Peikert 1996 RCT); from luteal phase through cycle day 2B1 (thiamine) 100 mg/day — Gokhale 1996 large RCT: significant dysmenorrhea improvementB6 50-100 mg/day — Wyatt 1999 BMJ Cochrane: overall PMS improvement; do not chronically exceed 100 mg/day (peripheral neuropathy risk, see vitamin-b6 island)Omega-3 EPA + DHA 1-2 g/day — Rahbar 2012 RCT + Pattanittum 2016 Cochrane: dysmenorrhea + inflammatory PG modulation (atlas fats-omega-3 + fish-oil)Ginger (Zingiber officinale) 250 mg × 4/day — start 3 days pre-menses + first 3 days of period, Ozgoli 2009 RCT: equivalent to mefenamic acid + ibuprofenCa 1000-1200 mg/day (food-first) + adequate vitamin D — Bertone-Johnson 2005 NHS II: PMS risk significantly ↓Reduce sodium + alcohol + caffeine (luteal phase) — reduces edema + breast tenderness + irritabilityAdequate sleep + reduce blue-light exposure — sleep loss in the week before menses worsens PMSMaintain exercise — don't skip due to luteal fatigue; moderate aerobic 30 min improves mood + reduces bloating
🌙 7-10 days pre-period (luteal phase — dysmenorrhea prevention + PMS buffering)
Prophylactic NSAIDs (history of dysmenorrhea + moderate-to-severe pain) — start 1-2 days before the expected period, not after pain begins (PGs already released)Ibuprofen 400 mg q6h × 2-3 daysNaproxen 250-500 mg q8-12h × 2-3 daysWith food + don't exceed OTC ceilingMg 200-400 mg/day (citrate / glycinate) — smooth-muscle relaxation + NMDA modulation + migraine reduction (Peikert 1996 RCT); from luteal phase through cycle day 2B1 (thiamine) 100 mg/day — Gokhale 1996 large RCT: significant dysmenorrhea improvementB6 50-100 mg/day — Wyatt 1999 BMJ Cochrane: overall PMS improvement; do not chronically exceed 100 mg/day (peripheral neuropathy risk, see vitamin-b6 island)Omega-3 EPA + DHA 1-2 g/day — Rahbar 2012 RCT + Pattanittum 2016 Cochrane: dysmenorrhea + inflammatory PG modulation (atlas fats-omega-3 + fish-oil)Ginger (Zingiber officinale) 250 mg × 4/day — start 3 days pre-menses + first 3 days of period, Ozgoli 2009 RCT: equivalent to mefenamic acid + ibuprofenCa 1000-1200 mg/day (food-first) + adequate vitamin D — Bertone-Johnson 2005 NHS II: PMS risk significantly ↓Reduce sodium + alcohol + caffeine (luteal phase) — reduces edema + breast tenderness + irritabilityAdequate sleep + reduce blue-light exposure — sleep loss in the week before menses worsens PMSMaintain exercise — don't skip due to luteal fatigue; moderate aerobic 30 min improves mood + reduces bloating
Days 1-3: active management
🩸 Period days 1-3 (peak dysmenorrhea, active management)NSAID already started (1-2 days pre-menses) → continue on schedule — the single most important interventionHeat therapy (40-44 °C, 4-6 h, 1-2 times/day) — Akin 2001 RCT: equivalent to mefenamic acid; synergistic with NSAIDsHot water bottle / heat pad / heated trousers (worth it for recurrent users)Beware low-temperature burns (especially while sleeping)Adequate water + moderate exercise (low-to-moderate intensity) > complete bed restArmour 2019 Cochrane (Level B): moderate exercise 30 min × 4 weeks/week → significant dysmenorrhea reduction"No exercise during menses" is wrong — it should be "avoid maximal effort + stop if uncomfortable," not "no exercise at all"Walking / yoga / stretching / moderate aerobic all OKIron + vitamin C (HMB / anemic) — start 1-2 days after the period; 30-60 mg iron/day + 50-100 mg vitamin C concurrent (atlas iron + vitamin-c/iron L4)Alternate-day iron (Stoffel 2017) improves total absorption in mild-to-moderate deficiency (hepcidin reset)Gentle, easily-digestible diet — PGE2 increases gut motility, some women have menstrual diarrhea → reduce spicy + caffeine + ensure fiber"Be gentle with yourself" is not superstition — late luteal + first 2 days of menses have weakened cortisol regulation + heightened pain sensitivity; reducing high-stakes decisions + big arguments + extreme social load is reasonable
Post-period + supplement truth table
🌱 1-2 weeks post-period (follicular phase — repair + strength)Iron repair: HMB / deficient individuals supplement iron + vitamin C, but avoid taking with Ca / tea / coffee / dairy / antacids (at least 2 hours apart)Strength-training peak window — follicular estrogen rise → strength + recovery better than luteal (Wikström-Frisén 2017, etc.)Want a strength PR / HIIT / heavy intensity? This is the windowAdequate protein 1.2-1.6 g/kg/day — for endometrial rebuilding + systemic repair (atlas protein/muscle)Diary review + adjust next cycle's strategy — record this cycle's peak pain / blood volume / red flags, decide whether next cycle's NSAID should start 24 or 48 hours earlierChronic-disease check / ferritin recheck — recurrent HMB → check ferritin + hemoglobin every 6 months; catch and treat early
Truth table for common "period supplements"
Brown-sugar water (widespread Chinese custom): mostly sugar + very little iron (~ 0.5 mg/100 g); essentially useless for iron repletion; subjective "warming" comes from the hot water itself. Not harmful but do not let it replace real iron sourcesDonkey-hide gelatin (e-jiao) / red dates (TCM "blood-tonics"): e-jiao has extremely low iron (~ 0.2 mg/g), protein is mostly collagen; red dates have ~ 2 mg iron/100 g, food-grade is fine but not a therapeutic dose"Period detox teas" / "period-regulating pills" / "brown-sugar ginger teas": no evidence; some products contain irregular ingredients (laxatives / herbal hormonal compounds)Chocolate / dark chocolate (≥ 70%): Mg + polyphenols + endorphin induction → subjective relaxation; some evidence support, but not a therapeutic tool"Womb-warming patches" (a Chinese consumer product): primarily iron-powder exothermic oxidation, physically equivalent to a hot water bottle (40-44 °C), not "TCM energy." The heat effect is genuinely effective, the name is misleading but the product isn't necessarily bad
Atlas connections
fats-omega-3 + fish-oil — PG pathway + EPA/DHA sources + form choicemagnesium + magnesium/relax L4 — uterine smooth-muscle relaxation + NMDA + migraine (Peikert 1996)vitamin-b6 — Wyatt 1999 PMS + upper-limit warningvitamin-b1 — Gokhale 1996 dysmenorrheavitamin-d + calcium — Bertone-Johnson 2005 PMSiron + vitamin-c/iron L4 — HMB → iron repletion + alternate-day + Stoffel 2017protein/muscle L4 — protein for post-menses repair + endometrial rebuilding
Period exercise: yes or no?
"Can I exercise during my period?" is one of the most misreported health questions. Let's answer with evidence, then provide an executable template.Core answer: yes, and for most women it is beneficial
Armour 2019 Cochrane meta: moderate exercise (30 min × 3-4 times/week) → significant reduction in dysmenorrhea severity + durationDaley 2009 meta: aerobic exercise improves PMS + dysmenorrheaFaramarzi 2017 RCT: 8 weeks of yoga → improved both dysmenorrhea + PMS
How to train? — stratified by intensity
OK during periods (most people)
Walking / jogging: 30-45 min at 50-70% max HRYoga / Pilates: emphasise stretching + breath, avoid extreme inversions (theoretically harmless but some women feel uncomfortable subjectively)Swimming: use a menstrual cup / tampon; does not contaminate pool water (water pressure prevents leakage)Dance / low-intensity HIIT intervals: as toleratedRegular strength training: pay attention to feel, may reduce load 5-10%
Adjust as tolerated
Heavy strength PRs / high-intensity HIIT: women with severe day-1-2 dysmenorrhea can delay to day 3Long-distance running (15+ km): depends on anemia + painCrossFit / extreme training: as tolerated
Not recommended short-term (severe dysmenorrhea)
If severe dysmenorrhea cannot be controlled with NSAIDs, don't tough it outDeep inversion postures (headstand, shoulderstand) feel uncomfortable for some women on days 1-2Excessive dehydration + hot environments (hot yoga + sauna): menses already lose water + narrowed thermoregulation, caution
Key principles
1. Listen to the body, not slogans — if tired, scale back; no need to insist on a "period PR"
2. Full warm-up + hygiene products ready — menstrual cups / tampons suit heavy activity better than pads
3. Hydration + electrolytes — period water loss + sweating, supplement Na/K as appropriate
4. Avoid very cold showers post-exercise — not superstition; peripheral vascular reactivity is slightly elevated during menses, no need to stress it
"Complete bed rest during your period" is a wrong tradition
Long sitting / bed rest → pelvic congestion ↑ → dysmenorrhea worseLight-to-moderate exercise = ↑ uterine blood flow + endorphin release → subjectively better than analgesics (in some women)Restriction should apply only to severe dysmenorrhea + red flags + heavy bleeding with anemia
Menses + high-level athletes (RED-S, low energy availability)
Female Athlete Triad → RED-S (Relative Energy Deficiency in Sport): low energy intake → functional hypothalamic amenorrhea (FHA) + ↓ bone density + stress fracturesSerious training + cycle disturbance / amenorrhea / very light periods → not "training is going well" but an energy-deficit warningManagement: more calories + lower training volume + nutrition counselling + gynaecology / endocrinology as needed
Bottom line: period exercise is individual, but the default should be keep moving rather than "lie down to recover"; intensity = listen to the body + plan equipment ahead + don't be tied to the slogan "periods need rest."
Chapter 6
Myths debunked + escalate
Myths debunked + escalate
Most "period taboos" passed down on Chinese internet and from elders lack evidence, but like all folk wisdom a few of them really do hold. Let's put each one on the table.
🚫 No evidence (safely ignore)
"No hair-washing during periods" — no study supports this; modern bathrooms with warm water + a hairdryer have no causal link to "headache" or "head-wind." The taboo arose in an era without water heaters or hairdryers, where "avoid getting chilled" was reasonable, but it doesn't apply now"No cold water / cold food during periods" — "the uterus catches cold" is not a medical concept; the uterus does not directly contact GI contents; cold food is warmed to body temperature before reaching the intestine; no direct causal link to dysmenorrhea. Small observational studies fail to confirm cold food/dysmenorrhea association (although warm water beats cold water subjectively + increases hydration, a real benefit, but not from the taboo)"No swimming during periods" — use menstrual cup / tampon to prevent leakage; water pressure prevents outflow; chlorine disinfection + showering afterwards eliminates hygiene concerns"No sex during periods" — medically not forbidden, comfort + personal choice; contraception still needed (menstrual conception is rare but possible) + STI protection (cervical os slightly open, theoretical infection-risk slightly elevated, practical difference minimal)"No dental work / surgery during periods" — emergencies proceed; elective major surgery routinely avoids menses, but the rationale is "reduce bleeding interference + patient comfort," not "harms vital energy""Periods detoxify / menstrual blood is dirty" — menstrual fluid = endometrial tissue + blood + mucus, no "toxins""Red dates / e-jiao / brown sugar replenish blood" — see the truth table; cultural symbols, not therapeutic iron doses"Eating fruit / vegetables / cold dishes = cold" — no evidence"No photos + no ancestor worship + no temples during periods" — cultural / taboo topics, unrelated to physiology
🚫 No evidence (safely ignore)
"No hair-washing during periods" — no study supports this; modern bathrooms with warm water + a hairdryer have no causal link to "headache" or "head-wind." The taboo arose in an era without water heaters or hairdryers, where "avoid getting chilled" was reasonable, but it doesn't apply now"No cold water / cold food during periods" — "the uterus catches cold" is not a medical concept; the uterus does not directly contact GI contents; cold food is warmed to body temperature before reaching the intestine; no direct causal link to dysmenorrhea. Small observational studies fail to confirm cold food/dysmenorrhea association (although warm water beats cold water subjectively + increases hydration, a real benefit, but not from the taboo)"No swimming during periods" — use menstrual cup / tampon to prevent leakage; water pressure prevents outflow; chlorine disinfection + showering afterwards eliminates hygiene concerns"No sex during periods" — medically not forbidden, comfort + personal choice; contraception still needed (menstrual conception is rare but possible) + STI protection (cervical os slightly open, theoretical infection-risk slightly elevated, practical difference minimal)"No dental work / surgery during periods" — emergencies proceed; elective major surgery routinely avoids menses, but the rationale is "reduce bleeding interference + patient comfort," not "harms vital energy""Periods detoxify / menstrual blood is dirty" — menstrual fluid = endometrial tissue + blood + mucus, no "toxins""Red dates / e-jiao / brown sugar replenish blood" — see the truth table; cultural symbols, not therapeutic iron doses"Eating fruit / vegetables / cold dishes = cold" — no evidence"No photos + no ancestor worship + no temples during periods" — cultural / taboo topics, unrelated to physiology
Partly true + genuinely true
🤔 Partially true (the mechanism is not as in legend)"Keep warm during periods" — partly true: abdominal + lumbar warmth (40-44 °C × 4-6 h) is effective non-pharmacologic analgesia (Akin 2001 RCT); but you don't need to "avoid all cold," just targeted heat + appropriate ambient warmth"No intense exercise during periods" — see the prior scene: partly true, but it's "as tolerated," not "no exercise""Lower immunity during periods" — partly true: subtle luteal-phase immune modulation (slight T-helper 2 shift) + HSV / some infections more likely to recur the week before, but not "severely immunocompromised"; no special isolation needed"Heightened emotional sensitivity during periods" — see PMS/PMDD above; real neuroscience, not "melodrama"
✅ Genuinely true
Adequate sleep + reduce caffeine + alcohol (the week before) — sleep loss premenstrually worsens both PMS + dysmenorrhea (data + mechanism both support)Adequate water + warm drinks — not "avoid cold" but compensating for fluid loss + subjective comfortNSAID + heat combination + start 1-2 days early — the evidence-based gold combination for pain controlHMB → early ferritin + iron supplementation — not "heavy periods are normal" but the most common reversible cause of iron-deficiency anemia
Escalation: when to see a doctor / ER
⬆️ When to escalate to medical care?Period management can be 70-80% covered by NSAIDs + heat + lifestyle, but several clear escalation triggers apply:
Escalate to OTC + nutritional intervention (no clinic needed)
Moderate dysmenorrhea + 1-2 day work impactRegular cycle + normal volume + no red flags
Escalate to gynaecology outpatient (this month)
NSAIDs ineffective / contraindicated → gynaecology assessment of COC / LNG-IUDHMB (PBAC > 100 or subjective "1 hr saturation") → gynaecology + iron statusPersistent dysmenorrhea ≥ 6 months + progressively worsening → endometriosis work-upPersistent cycle abnormality (< 21 or > 35 days for ≥ 3 cycles) → endocrinology + gynaecologyPeriods + easy bruising / nosebleeds → coagulopathy screen (vWD)PMS severely impacting work / suicidal ideation → joint psychiatry + gynaecology evaluation for PMDD
Escalate to ER (today)
Heavy bleeding + dizziness / tachycardia / pallorSevere abdominal pain + positive pregnancy test (ectopic risk)Any postmenopausal vaginal bleedingHigh fever + abnormal discharge (PID)
Medical treatment tools (under gynaecology guidance)
COC: suppresses ovulation + thins endometrium → dysmenorrhea ↓ 70-90% + HMB ↓; simultaneously contraceptiveRisk: VTE (especially smokers + 35+ + aura migraine)Suited to: dysmenorrhea + needing contraception + endometriosis + PCOSLNG-IUD (Mirena / Kyleena etc.): local progestin release → thins endometrium → HMB ↓ 70-95% + dysmenorrhea ↓ + 5-year contraceptionSuited to: HMB + dysmenorrhea + endometriosis + adenomyosis; first-choice for manyProgestin only: situationalGnRH antagonists (elagolix / relugolix): moderate-severe endometriosis / fibroids, short-term estrogen suppression + add-back to protect boneTranexamic acid: HMB acute relief (taken in the first 5 days of menses) → menstrual blood loss ↓ 30-50%; does not affect the cycleSurgery: only for the most severe endometriosis / large fibroid / adenomyosis / refractory HMB; hysterectomy is terminal
Tools, privacy + for everyone
Period-tracking tools (privacy first)Apps: Clue / Flo / Apple Health (prefer local storage) / Garmin Health syncPrivacy warning: post-Roe v. Wade some US states have seen "menstrual data subpoenaed by courts" → prefer apps with local storage + end-to-end encryption + non-US serversRequired, long-term usable: cycle start date / length / volume / pain / abnormal bleeding / PMS scoreA 3-6 month log = more informative than any single hormone draw, and the strongest leverage at the gynaecology visit
For non-women readers
Menstruation is not "a women's matter" — it is everyone's health literacyPartners / fathers / friends / colleagues understanding the basics + recognising red flags = sparing her from carrying information asymmetry alone"Just endure it" + "normal period pain" are the two phrases this generation of women has heard the most — the atlas hopes to make those phrases occur a few fewer times
Bottom line: periods are not a taboo subject, they are a health topic that is quantifiable, optimisable, escalable. "Endure" is history's cost; understanding + tools + early checking is now's option.