but it’s not always something to worry about. If the amount of blood present exceeds the speed at which your body can make these anticoagulants you may experience clots, which can escape through your cervix, which softens slightly to allow the blood to escape. Clots tend to be small, usually no bigger than the size of a fifty-pence coin. However, larger clots, and lots of them, are a sign that there’s heavy bleeding going on, so it’s worth visiting your GP to check it’s not causing anaemia, to consider treatment and whether there’s an underlying reason, many of which are covered in Chapter 5.
While you’ve been busy concentrating on the outward manifestations of your period, you may not have realised that your brain has been busy making hormones: GnRH (gonadotrophin-releasing hormone), LH (luteinising hormone) and FSH (follicle-stimulating hormone). GnRH is produced first by the hypothalamus and then signals to the anterior pituitary to release LH and FSH, which then stimulate the ovary to prepare an egg for release (ovulation) and to produce oestrogen, which starts to rebuild the endometrium, in preparation for the hope of a pregnancy during this new cycle. Eventually, there is a massive surge in LH release, which triggers ovulation. LH is what you are trying to detect with the ovulation sticks that you can buy if you’re trying to get pregnant and want to work out when you’re ovulating. A patient once proudly told me that she usually ovulates about three times per month because her ovulation sticks told her so. You cannot ovulate more than once during a single menstrual cycle, although you can release more than one egg, which is how you get non-identical twins. This is one of the quirks of ovulation sticks; they tell you when you have had an LH surge, which can happen several times in one cycle, but they don’t confirm you popped out an egg.
Luteal phase: eggs and shells
Eggs live in sacs called ‘follicles’ which undergo several months of maturation before they can get to the stage of being released. Ovulation marks the start of the luteal phase and is like a Hollywood audition; at the start of your cycle there may be ten eager, willing candidates, but as time goes on, only one is selected to go forward and become the ‘dominant follicle’, which grows and grows, forming a cyst which pops on about Day 12–16 of the cycle, throwing it on to the main stage in the hope of being fertilised. It’s not unusual to get a bit of pain at this point. Ovulation itself is an inflammatory process and the ovary producing the ‘star egg of the show’ can get slightly enlarged which itself causes pain; then, when the cyst bursts, it leaks a little bit of fluid into your pelvis which can be uncomfortable. This ovulation pain (also called ‘mittelschmerz’, German for ‘middle pain’) can be sharp or like toothache, really low down near your hip bone on one side, but it usually lasts only twelve to twenty-four hours. Many women are quite anxious about this kind of pain and are horrified by the idea of a cyst bursting in their tummies. But it’s a positive sign that their bodies are working the way they should, which reassures most people. There may also be a little bit of bleeding at this time; ovulation bleeding only happens in about 3 per cent of cycles,2 but it’s certainly nothing abnormal that you need to worry about. It happens due to a momentary drop in oestrogen.
After the egg is released, a shell of the original follicle, called the ‘corpus luteum’ is left behind in the ovary, which starts to release progesterone – the pro-pregnancy hormone. One of its main roles is to ensure the lining is fully preened and plumped up for the arrival of a fertilised egg. Progesterone levels are at their highest seven days after ovulation, and if fertilisation has not occurred, the corpus luteum eventually throws its hands up in the air and says, ‘I can’t do this any more. I’m bored of pumping out all this progesterone to no avail. I’m out of here!’ It then slowly starts to degrade, and this causes a drop in both oestrogen and progesterone, which means the growth of the endometrium is no longer supported, so it begins to fall away. This is your period and the cycle starts again.
Variations in cycle length
It’s normal for there to be some variation in the length of your menstrual cycle on a month-to-month basis.
A lot of mums of teenage girls contact me online, worried that there is something wrong with their daughters because they are only having periods every two or three months. But this is quite common when your periods start because the hormone cycles are still synchronising, and also coming up to the menopause when you have fewer eggs left, meaning you’re less likely to ovulate as easily. Cycles are typically shortest and most regular in your twenties and thirties. Any variation in the length of the cycle at any age will be due to changes in the follicular phase because the length of the luteal phase is pretty standard being dictated by the lifespan of the corpus luteum.3 (See Chapter 4 for other factors affecting cycle length besides age.)
Menstrual cups, tampons, pads … ?
There are an overwhelming number of ‘menstrual-hygiene’ products on the market; I’m not hugely keen on the term because I think it perpetuates the myth of periods being ‘dirty’.
Menstrual cups, tampons, pads … I’m constantly asked which are ‘the best’, and, to be honest, from a health point of view there is no shining star – so I’d advise you to use whichever makes you feel most comfortable.
Menstrual cups
There may be a few furrowed brows at the mention of ‘menstrual cups’. If you are wondering, they are small and egg-cup-shaped and made of a soft silicone, which you insert into your vagina, where they sit collecting blood as it comes out of the cervix. There’s only one small study that has ever compared tampons and cups head to head and actually found greater satisfaction with cups compared to tampons, but it didn’t find any difference in terms of infections4 and there don’t appear to be any clear health benefits. The main advantage is that they are probably better for the environment and will definitely save you money in the long run. But don’t feel you have to use them. I don’t recommend them for the squeamish, as you have to be quite cool about putting your fingers into your vagina to insert them (they don’t come with an applicator like tampons), and it takes a bit of patience to learn how to remove them. After writing an Instagram post on menstrual cups I received a flurry of messages from women sharing the horror stories and proud moments of their first time. The most common initial problem seems to be difficulty removing it. Do not underestimate the strength of the vacuum that a menstrual cup can make with the cervix. However, you’ll quickly learn how to break the vacuum and remove it like a pro.
I’m frequently asked if it’s OK to use them with a contraceptive coil. Different manufacturers have different ideas on this, some saying it’s OK, others saying it should be avoided. This is because theoretically you could dislodge your coil with the aforementioned vacuum effect – something that has, in fact, been confirmed by several women who have contacted me via social media saying they managed to suction out their coil: ‘Anita, I’ve saved my coil, can you put it back in?’ was one SOS message I recently received from a friend. But while I’m all for recycling, you can’t reuse a coil, so I promptly replied, ‘Sorry, darling, you need a fresh one!’ If you do choose to use a cup with a coil, I would advise checking the strings at the end of your period. If you feel they are lower than normal, you can feel the rod of the coil or you can’t feel any strings at all, I would use condoms until you’ve had it checked by a doctor to ensure it’s still in the right place to give you full contraceptive protection.
Tampons
Just as menstrual cups may not be for everyone, the same goes for tampons. Some women just don’t feel comfortable putting something inside themselves. Others find it too painful. This may be due to tight pelvic-floor muscles or not being relaxed enough or, in my experience, endometriosis, probably due to inflammation and scarring in the pelvis. One study suggested that tampon use is protective
