REVIEW ARTICLE
Biological and lifestyle determinants of menstrual health
P. S Karthika*, Jesmitha Jalal, S.S Shifana, G. L. Aarsha
Post-Graduate and Research Department of Zoology, Government College for Women,
Thiruvananthapuram, Kerala, India
Corresponding author: P.S. Karthika, E-mail: karthikakathu2003@gmail.com
Journal of Experimental Biology and Zoological Studies. 1(2): p 94-101, Jul-Dec 2025.
Received: 08/06/2025; Revised: 18/06/2025; Accepted: 25/06/2025; Published: 01/07/2025
__________________________________________________________________________________________
Abstract
The menstrual cycle is a reproductive process that prepares the uterus for a potential pregnancy,
occurring regularly during a woman's reproductive years. Menstruation, marked by vaginal bleeding, is
a part of this cycle and happens when pregnancy does not take place. While hormonal control, primarily
involving the hypothalamic-pituitary-ovarian axis, plays a central role in orchestrating the menstrual
cycle, the process itself is far more intricate. It is shaped not only by biological mechanisms but also by
an array of psychological, environmental, and socio-cultural factors, all of which contribute to
individual variability in menstrual experiences. This comprehensive review delves into the diverse
internal and external factors that influence key aspects of menstruation, including the timing of onset
(menarche), cycle regularity, duration, frequency, menstrual bleeding, and associated indicators. A
deeper understanding of the contributing factors associated with menstruation may be useful as it
enables more informed healthcare decision-making, supports the development of personalized
approaches to menstrual health management, and contributes to broader efforts in education and public
health policy related to reproductive well-being.
Keywords: Menstrual health, menstrual stress, hormonal imbalance, endocrine disruptors, amenorrhea,
anovulation, menorrhagia, menarche, PCOS, lactational amenorrhea.
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Introduction
Menstruation or period is characterized by the cyclical shedding of the endometrium leading to the
vaginal discharge of blood and mucosal tissue which take place during the reproductively active phase
of a woman. The cyclical events associated with menstruation is referred to as menstrual cycle. The
menstrual cycle is only one aspect of the cyclic reproductive activity in a woman’s reproductive life
and is closely synchronized with changes in the ovary, collectively known as the ovarian cycle. [1,2]
Ovarian cycle
The ovarian cycle refers to the recurring changes within the ovary, including the development of ovarian
follicles, ovulation and the formation of the corpus luteum. These processes prepare the endometrium
for the implantation of a fertilized ovum and support early pregnancy. The ovarian hormones, oestrogen
and follicle-stimulating hormone (FSH) play key roles in the development and maturation of ovarian
follicles. Luteinizing hormone (LH), secreted by the anterior pituitary gland, triggers ovulation through
a surge in its levels. The ovarian cycle is divided into two phases: the follicular phase (before ovulation)
and the luteal phase (after ovulation). In healthy women, ovulation typically occurs around day 14 of
the cycle. The follicular phase is dominated by oestrogen and FSH, while the luteal phase is primarily
influenced by progesterone secreted by the corpus luteum. If fertilization and pregnancy do not occur,
the corpus luteum degenerates and forms a scar-like structure called the corpus albicans. [1,2]
Menstruation and the uterine cycle
Menstruation is initiated primarily by the falling levels of progesterone, along with the release of
prostaglandins.[2] These hormonal changes cause constriction of the spiral arteries and spasms in the
endometrial tissue. As a result, the blood supply to the endometrium is cut off, leading to oxygen
deprivation and tissue death. The upper layer of the endometrium then breaks down, capillaries rupture,
and the discarded tissue along with blood flows out through the vagina. This process is known as
menstruation. An enzyme called plasmin breaks down blood clots in the menstrual fluid, helping to ease
the flow of blood and broken-down lining from the uterus. Menstrual discharge typically continues for
26 days. Approximately 3060 ml of blood lost during menstruation. Menstruation is a sign that
pregnancy has not occurred.[1]
The next phase of the uterine cycle, known as the proliferative phase, follows menstruation. This phase
is characterized by a gradual increase in oestrogen secretion, which stimulates the growth and
regeneration of the uterine lining. The latter part of the follicular phase of the ovarian cycle corresponds
to the proliferative phase. As ovarian follicles mature, they secrete increasing amounts of oestradiol, a
form of oestrogen. This hormone initiates the formation of a new endometrial layer and the development
of spiral arterioles within it.[1]
The final phase of the uterine cycle is the secretory phase, which overlaps with the luteal phase of the
ovarian cycle. During this phase, the corpus luteum secretes progesterone, which causes further
thickening of the endometrium and cervical mucus. These changes prepare the uterus for implantation
of a fertilized egg, which by this stage has developed into a blastocyst. In early pregnancy, progesterone
also increases blood flow to the endometrium and reduces uterine smooth muscle contractility to support
successful implantation and maintain pregnancy. If pregnancy does not occur, both the ovarian and
uterine cycles start over again.[2]
The menstrual cycle is a tightly regulated, cyclical process orchestrated by hormonal interactions within
the hypothalamicpituitaryovarian (HPO) axis. It is the overt manifestation of a complex
neuroendocrine dialogue. This interaction reflects a person’s overall health, including metabolic,
physiological, and environmental conditions. In the context of rapid urbanization and global health
transitions, the menstrual cycle increasingly reflects the cumulative impact of modern life. The
epidemiological shift from infectious to chronic disease, combined with significant lifestyle changes,
has contributed to a rising prevalence of menstrual irregularities, dysmenorrhea, and amenorrhea. This
review aims to interrogate the multifaceted influences that act upon the menstrual cycle ranging from
hormonal imbalance to lifestyle factors. By synthesizing insights from reproductive physiology and
behavioural science, this review discusses some of the common factors that can disrupt the normal
reproductive cycle in human females.
Hormonal imbalance
Hormonal balance plays a crucial role in regulating the menstrual cycle, controlling follicle maturation,
ovulation, and preparation of the uterine lining through a complex interplay of hormones like oestrogen,
FSH and LH. Common imbalances include oestrogen dominance, which causes heavy periods, breast
tenderness and mood swings; low progesterone levels, which lead to irregular periods and spotting,
typically caused by chronic stress, age-related hormonal shifts, and PCOS (polycystic ovary syndrome)
characterized by excess androgens which disrupts ovulation, causing irregular cycles and fertility issues.
Additionally, thyroid hormone imbalances, such as hypothyroidism or hyperthyroidism can cause
menstrual irregularities.[3] Factors that trigger the balance include lifestyle choices such as a poor diet,
inadequate exercise, irregular sleep patterns, and exposure to endocrine-disrupting chemicals. Chronic
stress can also disrupt hormone balance by elevating cortisol levels and affecting secretion of
reproductive hormones. Other factors such as excessive caffeine and high alcohol consumption can
interfere with oestrogen and progesterone balance. Likewise, certain medications can alter natural
hormone levels, causing changes in menstrual cycles. Women in their late 40s or early 50s may
experience hormonal fluctuations during perimenopause and menopause, leading to irregular cycles and
mood swings and other hormonal disorders. Menstrual disorders related to hormone imbalance include
amenorrhea (absence of menstruation), dysmenorrhea (painful menstruation), menorrhagia (heavy or
prolonged bleeding), oligomenorrhea (infrequent menstruation), premenstrual syndrome (PMS) and
premenstrual dysphoric disorder (PMDD) characterized by emotional and physical symptoms before
menstruation. The treatment depends on the cause and there are a variety of treatments used to balance
hormone levels such as hormone therapy and medication. By understanding the impact of hormonal
imbalances on menstrual cycles and making simple yet effective lifestyle changes, women can manage
their reproductive health and alleviate symptoms. By prioritizing self-care, balanced diet, and stress
management, it is possible to maintain hormonal balance and reproductive health, thereby improving
menstrual cycle. [3]
Endocrine disruptors
Endocrine-disrupting chemicals (EDCs) are substances that can interfere with the body's endocrine
system, which regulates hormones essential for various bodily functions. Due to its structural similarity
with endogenous hormones, it can interfere hormone production and its function. So, they can mimic,
block or alter production of certain hormones such as oestrogen, leading to a range of health issues. [4]
Some of the common EDCs include bisphenol A (BPA), phthalates, polychlorinated biphenyls (PCBs),
dioxins and heavy metals, which can be found in various everyday products. BPA, phthalates and
parabens are found in food packaging, cosmetics and feminine hygiene products. It can disrupt female
reproductive health, causing menstrual irregularities, hormonal imbalances, delayed puberty, breast
cancer, infertility and potentially reducing fecundability. [5] High exposure poses significant health risks
to women, particularly in relation to premenstrual syndrome (PMS). Exposure to these chemicals has
been linked to menstrual irregularities, changes in cycle length, and potential fertility issues,
highlighting the importance of understanding the effects of EDCs on women's health. [4,5]
Menstrual stress nexus
Stress can lead to many different changes in our body, that may affect mental as well physical health.
The complex interplay between stress and hormones can disrupt menstrual cycle, leading to
irregularities and changes in period duration and intensity. One may experience spotting, menorrhagia,
dysmenorrhea, amenorrhea, PMS etc due to stress.[6] The hypothalamic-pituitary-adrenal (HPA) axis
is responsible for adjusting the balance of hormones in response to stress. In a stressful situation,
hypothalamus releases corticotropin-releasing hormone (CRH). It then triggers HPA axis stress
response leading to the production of the stress hormone cortisol. A high level of stress leads to an
increase in secretion of cortisol which, in turn, decreases gonadotropin-releasing hormone (GnRH)
production, leading to changes in oestrogen and progesterone levels. Fluctuating progesterone levels
can affect the luteal phase of the ovarian cycle, leading to variations in menstrual cycle length. Stress-
induced delays in ovulation can also contribute to prolonged periods. The interplay between HPA axis
and hypothalamic-pituitary-ovarian axis plays a crucial role in these changes, highlighting the complex
relationship between stress and menstrual health. Understanding the impact of stress on menstrual
cycles highlights the importance of stress management for reproductive health. Stress can be reduced
to some extent through practices such as yoga, regular exercise, and maintaining a balanced diet. [7]
Weight fluctuations and nutrition
Obesity and high body mass index (BMI) are known risk factors for anovulation and infertility. Studies
suggest that obesity may contribute to infertility by shortening the luteal phase, causing irregular
periods, amenorrhea, and miscarriages. [8] Obesity during puberty is also linked to irregular periods and
conditions like PCOS which can cause missed periods, heavy bleeding and higher levels of testosterone
and insulin. [9] Leptin, a protein hormone primarily produced by fat cells (adipocytes), plays a regulatory
role in maintaining long-term energy balance and body weight. Leptin regulates the gonadotropin surge,
which initiates the development of pubertal stages. [10, 11] Kisspeptins are peptides that regulate the
hypothalamic-pituitary-gonadal (HPG) axis and are involved in the onset of puberty, sex hormone-
mediated gonadotropin secretion, and fertility. They stimulate gonadotropin-releasing hormone
(GnRH) neurons, leading to the secretion of GnRH and the subsequent release of gonadotropins and
sex steroid hormones. Insulin also has a crucial role in both childhood obesity and reproductive health.
In children, insulin resistance can increase the risk of type 2 diabetes and contribute to obesity and
impaired growth. In women, insulin resistance can lead to PCOS, which may affect menstrual cycles
and fertility. Together, leptin, kisspeptin, and insulin influence childhood obesity and the early onset of
puberty by acting through the hypothalamic-pituitary-ovarian (HPO) axis. Even if obese women have
regular periods, they tend to have lower levels of certain reproductive hormones such as gonadotropins,
oestradiol and inhibin during the first part of their cycle. This suggests that obesity itself may reduce
hormone production. [12] Questionnaire data from 1,012 women (aged between 17 and 53) suggest that
obese women are more than twice as likely to experience heavy menstrual bleeding compared to women
of normal weight, while underweight women are less likely to experience heavy bleeding. [13] Women
with a normal BMI, especially around 20 kg/m², have the lowest risk and better reproductive health [14].
Excessive exercise
There is varying evidence that increased physical activity may help lower the risk of breast cancer in
both premenopausal and postmenopausal women, as exercise can reduce oestrogen levels in the
body.[15] However, exercise related menstrual dysfunction may include problems like short luteal phase,
anovulation, oligomenorrhoea, amenorrhoea and delayed menarche. These issues have many causes,
but its main reason is hypothalamic inhibition with suppression of gonadotrophin releasing hormone
pulsatility i.e., the frequency at which pulses of the hormone are released by the hypothalamus. [16]
During the luteal phase, women often perceive exercise as more difficult, even when performing their
usual workout. Continuous high-intensity exercise during this phase can lead to increased physical
stress and more negative psychological responses. [17]
Medical condition
Menstruation can be affected by various medical conditions that disrupt hormonal balance or damage
reproductive organs. In the first few years after menarche, the most common cause of menstrual
irregularities is anovulation resulting from the immaturity of the hypothalamic-pituitary-ovarian axis.
Women with type 2 diabetes tend to have significantly longer menstrual cycles and the incidence of
oligomenorrhea in their 20s is nearly twice as high compared to non-diabetic controls.[18] Thyroid
dysfunction is a significant underlying cause of menstrual irregularities. Subclinical hypothyroidism
has been linked to mild menstrual disturbances such as occult menorrhagia, while in women of
reproductive age hyperthyroidism is most commonly associated with oligomenorrhea and amenorrhea.
[19] Endometriosis is a common condition affecting about 10% of women. The most frequently reported
symptom is dysmenorrhea which may be accompanied by nausea, vomiting, mood swings, lower back
pain, and fatigue; over time, this can progress into chronic pain. Dyschezia (difficult or painful
defecation), especially when it follows a cyclical pattern with menstruation, can also indicate
endometriosis.[20] Cushing's syndrome can cause menstrual disturbances due to hypogonadotropic
hypogonadism and shares several features with PCOS, including amenorrhea or oligomenorrhea,
obesity, hirsutism, an exaggerated response to GnRH, low levels of sex hormone-binding globulin, and
elevated blood androgen levels [21]. Valproate, a widely used antiepileptic medication, may increase the
risk of developing PCOS in girls with epilepsy or bipolar disorder, possibly due to the immaturity of
the hypothalamic-pituitary-ovarian axis. [22]
Antipsychotics, which are widely used to treat adolescents with bipolar disorder, psychotic conditions,
and behavioural disturbances, can cause hyperprolactinemia in some cases, potentially leading to
oligomenorrhea or amenorrhea.[22] Antidepressants such as paroxetine, sertraline, venlafaxine, and their
combination with mirtazapine are linked to a higher risk of menstrual disturbances in women of
reproductive age.[23] Isotretinoin used for the treatment of severe acne, is found to have menstruation-
related side effects such as amenorrhea, dysmenorrhea and oligomenorrhea.[24] Progestogen-only
hormonal contraceptives such as progestin-only pills (POPs), Depo-Provera (DMPA), and implanon
are commonly associated with disturbances in bleeding patterns among users. Progestogen-only pills
can cause various bleeding irregularities, including amenorrhea, irregular spotting, or prolonged
bleeding, with amenorrhea and unscheduled light bleeding being particularly common in Depo-Provera
(DMPA) users. Irregular vaginal bleeding is the most common side effect of newer hormonal
contraceptives. [25] Hormone therapies like the levonorgestrel intrauterine system, subdermal implant
and other progesterone-based therapies can reduce blood loss and may cause amenorrhea. Drugs that
inhibit prostaglandin synthesis, such as NSAIDs include aspirin, ibuprofen and naproxen sodium reduce
uterine contractility in dysmenorrheic women. Oral progestins such as norethindrone acetate and
dienogest, target the progesterone receptor. It is known that dienogest reduces dysmenorrhea in women
with endometriosis. Abnormal vaginal bleeding was observed significantly more often in women of
reproductive age treated with edoxaban compared to those receiving warfarin. [26] Certain cancer
therapies can negatively impact the reproductive system, potentially leading to secondary amenorrhea.
Individuals diagnosed at older ages are more likely to experience prolonged amenorrhea and early onset
of menopause. [27]
Age and life changes
There is a significant effect of age on menstruation as it influences the menstrual cycle onset, pattern as
well as eventual cessation. The average menstrual cycle length increases from age 15 to 23, decreases
until around age 45, and then increases again. [28] During childhood because of the inactivity of
hypothalamic-pituitary-ovarian axis, the hormone levels are low and no mature eggs are produced by
the ovaries. Hence no menstruation occurs. [29] Following puberty there is an irregularity in menstrual
cycles as the body adjusts to hormone changes. As a result, ovulation may not occur with every cycle
initially. [30] The age of 15-40 is considered as the reproductive age during which period the menstrual
cycle becomes regular and ovulation occurs monthly. Here the average cycle ranges up to 28 days.
Fertility is at its peak between the ages of 20 and the late 30s.[31] Mid-late 40s are accompanied with
hormonal fluctuations, shorter, longer or irregular cycle, heavier or lighter bleeding and increased PMS
syndrome due to declining ovarian functions.[32] Menopause is defined as the permanent absence of
menstrual periods (amenorrhea) for 12 consecutive months. It marks the end of reproductive years and
is characterized by a drop in oestrogen and progesterone levels, cessation of ovulation, and symptoms
such as hot flashes and sleep disturbances. [33] No menstrual bleeding should occur during post-
menopausal stage. Any occurrence of post-menopausal bleeding is regarded as abnormal and must be
diagnosed. [34]
Pregnancy
Menstruation halts entirely during the stage of pregnancy, mainly due to the increased levels of
oestrogen and progesterone which maintains the uterine lining to support the developing foetus. Human
Chorionic Gonadotropin (hCG) produced during post-implantation assist corpus luteum, thereby
ensuring continued progesterone production which in turn maintains the uterine lining. Oestrogen and
progesterone levels steadily increase during pregnancy, which inhibits follicle development and
ovulation by suppressing the hypothalamic-pituitary-ovarian axis. [35] During pregnancy, the placenta
itself acts as an endocrine organ, secreting progesterone. [2] In fact, progesterone predominates during
pregnancy and is often referred to as the pregnancy hormone. Postpartum menstrual changes are
accompanied by a decline in pregnancy-associated hormone secretion, gradually creating conditions
favourable for the resumption of the menstrual cycle.[1]
Lactational Amenorrhea
Lactational Amenorrhea is a natural infertility period caused especially by exclusive breast feeding.[1]
This happens due to the release of prolactin, which in turn suppresses the GnRH secretion, leading to
reduced LH and FSH levels, which inhibits ovulation and menstruation. The release of prolactin is
stimulated by suckling. When the frequency of breast-feeding decreases or supplemental feeding is
introduced, there will be a decline in prolactin levels and this causes resumption of menstrual cycle. [36]
Lifestyle factors
The endocrine system is interfered by nicotine and other chemicals in tobacco. Hence smoking causes
fluctuations in oestrogen and progesterone levels, which are very essential for regulating the menstrual
cycle. Heavy smoking is associated with shorter menstrual cycles, variability in cycle and menses
lengths, and a higher risk of anovulation. [37]
Alcohol interferes with the metabolism of oestrogen and progesterone, leading to heavy menstrual
bleeding and irregular cycles. Excessive alcohol consumption disrupts liver enzymes responsible for
hormone breakdown, contributing to menstrual disturbances. It can also cause anovulation, which may
result in infertility. Regular intake of large amounts of alcohol can elevate levels of reproductive
hormones such as oestradiol and luteinising hormone (LH), further disrupting the menstrual cycle. [38]
Altogether stoppage of periods may occur due to poor nutrition or food habits. Maintenance of essential
body fat is very important for the production of sex hormones. Menstrual regularity and flow are
affected by the deficiency of dietary iron and zinc. Amenorrhea is common in underweight individuals.
Skipping meals, particularly breakfast and consuming junk food are linked to increased menstrual
cramps and mood instability. [39]
Conclusion
The menstrual cycle, traditionally defined by its endocrine foundations, is a complex biological process
influenced by an interplay of physiological, psychological, environmental, and socio-cultural factors.
These influences are multifaceted and interdependent, extending beyond the classical hypothalamic-
pituitary-ovarian axis to include nutritional status, psychological stress, circadian rhythm disruptions,
endocrine-disrupting exposures, and genetic predispositions. Raising awareness and promoting
education can empower women to take a more proactive role in their reproductive health, while
encouraging healthcare systems to adopt more personalized care approaches. As we move towards a
more integrative model of medicine and women’s health, it is essential to reframe menstrual health as
a multidisciplinary concern; one that calls for collaborative insights from endocrinology, psychiatry,
nutrition, public health and other fields. Adopting this holistic perspective is crucial not only for
optimizing reproductive care but also for recognizing the menstrual cycle as a key indicator of overall
health and resilience.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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