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Not All Bleeds are Periods


Period trackers are everywhere these days. From apps like Clue to the cycle tracking app on your smartwatch, it’s easy for you to mark the days that you bleed each cycle. 


But what is that information ACTUALLY telling you?


Unfortunately, not much.


By tracking your period on a typical period tracking app (where you input the days that you bleed as well as possibly the amount that you bleed), all that you are recording is:


  1. How often you bleed

  2. How much you bleed


This information is better than having nothing at all. But unfortunately it isn’t as  helpful as you may have been led to believe.. This is because. . .


Not. All. Bleeds. Are. Periods. 


Stay with me here.


In scientific terms, a period is a bleed following ovulation. 


Menstruation (having a period) may be defined as:


“necrosis and expulsion of the proliferated endometrium after the failure of implantation of a viable, fertilised ovum” (1)


The weird but accurately worded phrase “necrosis and expulsion of the proliferated endometrium” refers to a bleed. The phrase “failure of implantation of a viable, fertilised ovum” refers to ovulation. Bleed following ovulation.


In the Encyclopedia of Reproduction, we again see menstruation defined as a bleed following ovulation. Here, menstruation is defined as “the process whereby most of the superficial or functionalis layer of the endometrium that lines the uterine cavity, disintegrates and is expelled from the uterine lumen at the end of the secretory phase of a nonconception cycle” (2). The disintegration and expulsion of the endometrium refers to the bleed, and the “secretory phase of a nonconception cycle” refers to ovulation. Again, we have a  bleed following ovulation. 


To further illustrate this point, here are some examples of bleeds that you can have that can look, feel, and in all ways be impossible to distinguish from a period, but that are NOT periods because they are NOT bleeds following ovulation. 



Withdrawal Bleed:

  • Experienced by females on hormonal birth control

  • One of the ways that hormonal birth control (pill/IUD/Nuva ring, implant) prevents pregnancy by suppressing ovulation

  • Many females mistakenly believe that a withdrawal bleed is the same as a period (3)

  • Bleed occurs due to the user’s interaction with the synthetic hormones they are taking (for example, females on the pill typically take a 1 week break to allow a bleed to happen)


Breakthrough Bleed:

  • Refers to erratic, irregular, unexpected bleeding experienced by users of hormonal birth control

  • Often attributed to insufficient oestrogens in individual’s hormonal birth control, and can be managed by altering dose of hormones and/or type (4)


Anovulatory Bleed:

  • A bleed experienced by someone who is not on hormonal birth control, but is not ovulating for some reason

  • Frequently experienced by  females who have been diagnosed with Polycystic Ovarian Syndrome

  • Can resemble a period in every way (colour, volume, cramping etc.)

  • Medical investigations (such as progesterone blood testing and medical imaging) and symptothermal cycle charting can help to determine whether ot not a bleed is anovulatory (5,6,7)


References


  1. Hedayat, K. M., & Lapraz, J. C. (2019). The Theory of Endobiogeny: Volume 3: Advanced Concepts for the Treatment of Complex Clinical Conditions. Academic Press.

  2. Salamonsen, L. A., & Evans, J. (2018). Menstruation and endometrial repair. In Encyclopedia of Reproduction (pp. 320-325). Academic Press.

  3. Rutter W, Knight C, Vizzard J, Mira M, Abraham S. Women's attitudes to withdrawal bleeding and their knowledge and beliefs about the oral contraceptive pill. Med J Aust. 1988;149(8):417-419.

  4. Breakthrough Bleeding. (n.d.) Segen's Medical Dictionary. (2011). Retrieved August 28 2020 from https://medical-dictionary.thefreedictionary.com/breakthrough+bleeding

  5. Fraser, I. S., Hickey, M., & Song, J. Y. (1996). A comparison of mechanisms underlying disturbances of bleeding caused by spontaneous dysfunctional uterine bleeding or hormonal contraception. Human reproduction (Oxford, England), 11 Suppl 2, 165–178.

  6. Jones K, Sung S. Anovulatory Bleeding. [Updated 2020 Jun 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549773/

  7. Horowitz, E., & Weissman, A. (2020). The stair-step approach in treatment of anovulatory PCOS patients. Therapeutic advances in reproductive health, 14, 2633494120908818. https://doi.org/10.1177/2633494120908818


As an Osteopath, Alex routinely works with patients to help them achieve their optimum health. For female patients, this requires having an in-depth knowledge of female-specific health, and how hormonal dysregulation can have a widespread negative impact on wellbeing. Her keen interest in female-specific health began during her time as a competitive swimmer, when Alex was committing wholeheartedly to her training but not seeing the results. As Alex developed as a clinician, she learned about the critical role that the menstrual cycle plays in female health, and how instead of working with her body she had unknowingly spent years working against it. Alex now routinely works with female patients to address their health concerns and develop individualised treatment plans. She empowers them by teaching them how to read their fertility biomarkers, and how to use their unique cycle to inform their training and lifestyle. 

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