The Smart Woman’s Health Assessment 

Knowledge is power. This is especially true when it comes to your own health; that’s why we begin this book with a targeted self-assessment. Being familiar with your own body and the numbers and measurements that reveal your basic health status is both empowering and essential to good self-care. The health assessment you’ll find here is not the standard assessment that you might get from a doctor. It focuses primarily on your behaviors in relation to nutrition, physical activity, and mental health. I’m a big believer in knowing your health numbers—but not just the typical ones that your health care provider will obtain during visits, such as your blood pressure, lipoprotein profile (including cholesterol levels and triglycerides), and fasting blood glucose. These are important, of course, and I include them in other chapters. However, this assessment is aimed at helping you know where you stand on more atypical measures of overall health. I urge you to take the time to complete this health evaluation before you read this book. It consists of eight assessments:

Body mass index

Waist circumference

Vitamin D level

Nutrition and food-related behaviors

Physical fitness and movement-related behaviors

Self-efficacy level

Joy quotient

Family history

Most of these assessments can be completed right now, with just a pen or pencil; some will take time to complete; one will require a visit to your health care provider. Try to finish all of them—within a couple of weeks, if possible. Knowing the results will help you better understand where your health concerns lie and where to best focus your efforts at prevention. Throughout this book, I will refer back to these assessments and discuss ways to help you address the risk areas you identify here.

To complete this health assessment you will need:

A visit to your health care provider to obtain measurement of your serum vitamin D level. If you’ve had it measured already, call for the results. However, chances are good that your health care provider will not have assessed your vitamin D level. When you get this assessment, ask to have your blood pressure taken and your blood lipid and fasting blood glucose levels measured at the same time. You’ll need these later in the book to fully assess your risk for heart disease and diabetes.

A body weight scale

A tape measure to determine your waist circumference and your height

A nearby track or treadmill where you can do a walking test

An exercise mat or towel

A stopwatch or a watch with an easy-to-use second hand

A yardstick

A pen and a calculator 

Some time to talk with relatives

1. BODY MASS INDEX

Body mass index (BMI) is a calculation of your weight in relation to your height. BMI is related to several important health conditions, including heart disease, type 2 diabetes, cancer (especially breast and colon), and osteoarthritis. To calculate your BMI, weigh yourself in the morning with minimal or no clothes to get as close as possible to your true body weight. You should also measure your height in the morning, when you are tallest (as a result of your spine elongating during sleep). Stand with your back against a flat surface and have someone place a ruler on top of your head, parallel with the floor. Mark your height on the wall and then measure with a tape measure. Once you have these measurements, use the chart at right to calculate your BMI.

Body weight = __________ pounds

Height = ______ feet ______ inches

BMI = ______________

 BMI scores are organized into the following categories:

In general, the higher your BMI category, the greater your risk for chronic disease. This is especially true for obese and extremely obese individuals. The overweight category is less clear. Research demonstrates that if you are overweight but fit (see fitness assessments ), you do not have a greater than normal risk. The unfortunate reality, however, is that most overweight women are not fit, and so they are at greater risk for chronic disease. It’s important to note that being below weight is also not healthy. Having a BMI below 18.5 puts you at risk for a number of chronic diseases, especially mental health disorders and cancer. (See Chapter 10 for more detail on body weight and energy balance.)

2. WAIST CIRCUMFERENCE

Abdominal obesity (a large waist) is a risk factor for heart disease and type 2 diabetes. For women, the risk of these two diseases goes up with a waist size that is greater than 35 inches. To measure your waist circumference, stand and place a tape measure next to your skin around your waist, just above your hip bones. Exhale completely and then take the measurement.

Waist circumference = _____________ inches

Generally, if your waist circumference is greater than 35 inches, the only way to decrease it is to lose weight by eating a little less and exercising more.

3. VITAMIN D LEVEL

Vitamin D is an important nutrient obtained by the body primarily through exposure to direct sunlight and food sources such as milk and sardines with bones; low levels are linked to a number of serious health conditions, such as osteoporosis, cancer, cardiovascular disease, diabetes, and poor immune function. At least a third of adults in the United States have deficient or marginal vitamin D status. People who live in the northern part of the country (where your skin can’t make vitamin D in the wintertime) have the lowest levels, on average; those who live in the south tend to have the highest levels. Your blood levels will be given to you in either ng/mL or nmol/mL.

Vitamin D blood (25-hydroxyvitamin D) level = __________ ng/mL

or nmol/mL

These are the newest criteria recommended by experts in the field. They are more stringent than those currently listed in US government guidelines. I expect that within the next several years, these new guidelines will be adopted by the government. If you have a vitamin D level lower than optimal, you should talk with your health care provider about vitamin D supplementation. (See Vitamin D and Calcium.)

4. NUTRITION AND FOOD-RELATED BEHAVIORS

For this assessment, you will need to look at your nutritional intake and behaviors related to food. I encourage you to take the time to do this assessment. Although it provides only a snapshot of what and how you eat, it will give you a general idea of your pattern of eating.

STEP 1 . ASSESSING YOUR FOOD INTAKE

On a piece of paper, list ALL food and drink you consumed yesterday (don’t include measurements, such as ounces, weight, or number of glasses, etc.).

Now score what you’ve consumed by referring to the list below and placing a plus sign, a negative sign, or a zero next to each food or drink. Of course, there are thousands of different foods, and I can’t possibly list them all here, but this overview provides scoring for the general categories into which most foods fall. Use your judgment in scoring foods that do not appear below.

Pluses

Put a + (plus sign) next to any fruit or vegetable without added sugar, low-or fat-free dairy without added sugar (yogurt and milk), fish (not fried), raw or dry-roasted nuts (unsalted), seeds, legumes, beans, non-meat vegetable proteins (e.g., eggs and soy), and 100 percent whole-grain foods, including whole-grain cereals.

Negatives

Next, place a – (minus sign) next to most processed foods, fried foods of any kind, chips, cookies, cakes, candies of all types (though I would love to put chocolate in the plus category, I really can’t), sugar-sweetened beverages, highly sweetened energy and granola bars, ice cream and other frozen dairy desserts, sugar-sweetened yogurts, cuts of meat (beef, pork, lamb, and chicken) that are not lean, refined-grain foods (pancakes, waffles, muffins, etc.), salty, ready-made foods such as pizzas and frozen dinners, high-fat sauces, dips, gravies, dressings, and more than one alcoholic beverage.

Neutrals

Finally, place a 0 (zero) next to all other foods. Most likely these will consist of 100 percent fruit juices, lean meats (beef, pork, lamb, and chicken), most canned soups, pasta, white bread, white rice, low-salt crackers and pretzels, and potatoes and other foods that don’t easily fit into other categories.

Tally the total number of +, –, and 0 signs.

Total + = _____ Total – = _____ Total 0 = _______

STEP 2. ASSESSING YOUR FOOD-RELATED BEHAVIORS

Do you regularly:

For the food intake section, you should have twice as many healthy plus food choices as negatives and zeros. If you don’t, consider shifting your food pattern to include more positives (such as fruits, vegetables, whole grains, low-or nonfat dairy, and fish); even more important, try to include fewer negatives. (See Chapter 26.) It’s fine to have negatives in your usual pattern of eating—in fact, it’s important to enjoy these foods occasionally—but you don’t want them to outnumber the positives. I love my ice cream and chocolate, but I try to make sure that these treats are just that—treats—and that the majority of my eating consists of wholesome food. For the food behavior section, it is healthiest to have as many no’s as possible. These behaviors are linked to excessive calorie intake. If you’ve answered yes to several of these questions, use the suggestions in Chapter 24 to learn new strategies to change your behaviors.

5. PHYSICAL FITNESS AND MOVEMENT-RELATED BEHAVIORS

For this assessment, you will test your fitness and examine your behaviors related to physical activity. It will take some time to complete, but it’s very important.

STEP 1 . AEROBIC FITNESS, MUSCLE STRENGTH, AND FLEXIBILITY

This assessment will measure your fitness level compared with that of other Americans your age. The test was developed by the President’s Council on Physical Fitness and Sports. For full instructions and to submit your results, go to Adultfitnesstest.org.

Aerobic fitness. The first part of the test is the 1-mile walk. To do this test you should be healthy and capable of walking a mile. You will need to find a standard ¼-mile track (often located at schools or parks) where you can complete four laps. Or you can walk on a treadmill (with the incline at zero) for a distance of 1 mile. You will need a stopwatch to time your walk. You also need to be able to take your pulse (by holding the fingers of one hand against the wrist of the other, just at the base of your thumb) to measure your heart rate.

It’s best if you do this test with a partner, who can assist you in timing your results. 

Start the stopwatch at the beginning of the walk and stop it at the finish line. Just after you cross the finish line, have your partner count off 10 seconds while you measure your pulse rate.

If you are a runner, you can run for this test, but time yourself for a 1.5-mile run and then capture your heart rate.

Muscular strength and endurance. Women tend not to think about the importance of their own strength. But muscular strength and endurance are vital, not only for good health and the ability to complete basic household or work tasks, but also for enjoying recreational physical activities, such as tennis, rock climbing, and sailing. Although there are many ways to measure strength and endurance, two fitness tests—the half situp and the modified pushup—are offered at the adult fitness Web site Adultfitnesstest.org. You can find complete instructions for these assessments there.

Flexibility. Maintaining flexibility as we age is critical for many daily activities and for minimizing our risk of injury. A good assessment for flexibility is a sit and reach test using a yardstick for measurement. You can find complete instructions on the adult fitness Web site.

Scoring. For all of the above tests (1-mile walk, half situp, modified pushup, and sit and reach), log in your results at Adultfitnesstest.org to obtain your score. If you rank in the 90th percentile in each of the categories, you’re maintaining an excellent level of fitness. If you fall below this, there is room for improvement. Ideally, you want to be in the 75th percentile or above. If you fall below the 50th percentile, you need to work on your fitness.

I can’t emphasize enough how important it is to know your level of physical fitness. In recent research at Tufts, we have found that women across the country are seriously out of shape. One study published in 2009 demonstrated that midlife women living in the Midwest had such poor cardiovascular fitness that they would actually qualify for a heart transplant. This is why I have included this assessment—it may be the most important one of all.

STEP 2: ASSESSING YOUR MOVEMENT-RELATED BEHAVIORS

Do you regularly:

The behaviors above are related to healthy physical activity habits. The more you answered yes, the better! Also, the more sedentary your work is, the more important it is for you to be active, answering yes to as many of the above questions as possible. These are smart behavior choices that can help lower your risk for serious health conditions and diseases, including heart disease. (See Chapter 27 for a full physical activity program.)

6. SELF-EFFICACY LEVEL

Self-efficacy—the belief in your own abilities, especially to bring about change—strongly influences every aspect of your health and well-being. It’s especially important when you are trying to change behaviors to improve your health. Below are three sets of questions to help you understand your level of self-efficacy in general, and in the areas of nutrition and physical activity in particular.

Use the following scale to answer the questions:

1 = Not at all confident

2 = Slightly confident

3 = Moderately confident

4 = Very confident

5 = Extremely confident

GENERAL SELF-EFFICACY

NUTRITION

In the following situations, how confident are you that you can eat plenty of healthy foods such as fruits, vegetables, and whole grains and avoid sugary, processed, salty, and otherwise unwholesome foods?

PHYSICAL ACTIVITY

In the following situations, how confident are you in your ability to be physically active?

Scoring. A score of 3 or higher in any of the situations described above indicates that you have good self-efficacy (in general or in the particular health behaviors—nutrition and physical activity). If you scored below 3, don’t despair; the information presented in this book will help you boost your self-efficacy. (See Chapter 24, Making Change.) Self-efficacy is very behavior-specific.. You may have excellent self-efficacy in one kind of health behavior, but not in another. If you’re working to change a specific. health behavior such as quitting smoking, you can amend the above questions to better suit that behavior.

7. JOY QUOTIENT

Our mental health is as important, if not more important, than our physical health. Ideally, we want to be sound in both body and mind. Chapter 23 of this book discusses at length the elements of good mental and emotional health, including joy or contentment. The following questions are designed to help you understand this aspect of your mental health: How joyful are you?

Read the following 10 statements and score them on the scale.

If you averaged 7 or above on these statements, your life is most likely very joyful. If you averaged 5 or below, I urge you to find ways to bring more joy into your life. (See Chapter 23, Mental Health.)

8. FAMILY HISTORY

Learn as much as you can about your family’s medical history. Knowing the illnesses experienced by your parents, grandparents, and other blood relatives can help you take action to keep yourself and your family healthy. If you know that close relatives have had cancer or heart disease, for example, then it’s important to be vigilant about getting regular screenings for these diseases and to pay close attention to warning signs.

Not long ago, my close friend Zoe told me a revealing story about her family history. Zoe’s dad, a university professor, died at age 42 while he was running. Both his father and his grandfather had died at an early age from heart disease. But because both of these relatives had smoked and not taken very good care of themselves, Zoe’s dad had believed that they died early because of poor lifestyle habits. He had taken very good care of himself, so he assumed he would be safe. But it turns out that a rare genetic disorder runs in his family, causing very high blood cholesterol levels in family members. If he had known this at an early age, he could have taken medications that may have prevented his premature death.

This is an unusual case, but it does illustrate how important it is to know the details of your family history. You should be aware of any family members who may have been diagnosed with a disease or passed away at an early age. This information will help you and your health care provider decide whether you need genetic testing or counseling or whether you should take precautionary measures, such as getting more frequent health screenings, making lifestyle changes that will help ward off the full development of the condition, or taking medications to help you lead as healthy and long a life as possible.

(If you were adopted or your parents died before you could obtain this information, you most likely won’t have access to it. In that case, you should do what you can with regular assessments.)

To begin chronicling your family’s medical history, record on a separate sheet of paper the following questions about each of your family members, including your parents, grandparents, and siblings. Fill in the answers and give the information to your health care provider during your next physical or checkup.

Family member_________________________________

Current age or age at death____

Alive:  Yes No

If deceased, cause of death _____________________________________

If alive, list chronic conditions and age at onset, if any _______________

Any substance abuse? _________________________________________

If you have completed this health assessment, congratulations! You have accomplished an important step toward taking charge of your own health. You have a much better understanding of the nature of your individual health needs and concerns. Review the results now, and on a separate sheet of paper, jot down a few notes about your specific areas of concern that you’d like to keep in mind as you read this book.

PART I

Sex for Life:

Reproductive and Sexual Well-Being

My interest in women’s health grew out of my fascination during graduate school with how beautifully orchestrated our bodies are. I’m very glad I’m a woman—I think we’re truly amazing creatures. But our reproductive systems and our sexuality are complicated, and it takes some effort to understand how things work. How can I best care for my reproductive organs? How can I prevent disease? How can I fully enjoy being female? Part I is designed to help you understand your female self, how your reproductive system changes as you age, and how to keep it as healthy as possible throughout your lifetime.

As women, we’re much luckier today than we were even just a couple of decades ago. In nearly every aspect of reproductive health, from birth control to health care providers, we have more choices than ever before. There is much more open dialogue about reproduction and about the real risks of unsafe sex. We have more reliable guidance on maintaining a healthy pregnancy. And we’ve come a long way in understanding what many women consider the big hurdle or change of life in reproductive health: menopause. Although there are definite drawbacks to menopause, such as unpleasant physical symptoms and loss of estrogen (the hormone that keeps our bones strong), I speak from experience in saying that there are some advantages. There are also excellent new options available to help minimize menopause-related symptoms and reduce the risk of health problems as we age and our hormones change.

Whatever your stage in life, I urge you to take your reproductive health seriously. Know your choices. And perhaps most important, find an excellent reproductive health expert to guide you.

Part I also explores the nature of a healthy sex life and describes how it can be a potent and positive force to enhance your relationships and your sense of yourself. Views of what makes for satisfying and pleasurable sexual activity differ from woman to woman and often change as you go through the stages of life. It’s a good idea to become an authority on your own body in this realm as in others, to learn what excites you and gives you the most pleasure.

These S.M.A.R.T. behaviors will help you keep your sexual health and reproductive system in top shape:

Be comfortable with your sexual and gender identity.

Find a health care provider you’re comfortable talking with about your sexual and reproductive health.

Be aware of your full range of choices for birth control, fertility issues, menopause symptoms, and other aspects of reproductive health.

Avoid extremes of body weight and exercise.

Know your partner’s sexual history.

Always use condoms to ensure safer sex.

Strive for good communication and frank discussion with your sexual partner.

Enjoy your sexuality.

Understand what is normal for your body so that you know when to seek medical care.

1

Reproduction

The female reproductive system is an intricate and complex set of organs that carry out an amazing variety of tasks, from producing sex hormones to nurturing the miracle of new life. They include internal organs—ovaries, fallopian tubes, uterus, vagina, and accessory glands—and also the vulva, which covers the opening to the vagina. A woman’s main reproductive organs are two ovaries—each about the size and shape of an almond—located on either side of the uterus. Ovaries produce eggs (ova) and sex hormones. Over the course of a lifetime, they produce, store, and release about 450 eggs in a process known as ovulation.

Two slender 4-inch fallopian tubes, or oviducts, connect the ovaries with the uterus. The end of each tube near the ovary is funnel shaped and fringed with fingerlike extensions called fimbriae that draw the egg into the tube. When an egg is released from your ovary, the fimbriae catch it and help push it along the fallopian tube in its 7-day journey to the uterus. Because the egg is only fertile for about a day, fertilization occurs in the fallopian tubes before the egg moves to the uterus.

Your uterus, or womb, provides the fertilized egg with a nurturing, hospitable environment in which to grow. The uterus is a powerful, muscular organ, normally about the size and shape of an upside-down pear. Its 1-inch-thick muscular walls can expand to accommodate a full-term fetus and help push the baby out during labor. The lining of the uterus, known as the endometrium, is where a fertilized egg arriving from the fallopian tube embeds and develops. If the egg is not fertilized, it dries up and, roughly 2 weeks later, exits the body along with menstrual flow consisting of sloughed tissue from the endometrium.

Your uterus opens to your vagina at the cervix, a strong, thick-walled opening normally no wider than a straw but capable of expanding to allow the passage of a baby. Within the cervix are glands that secrete mucus. This mucus varies in consistency from tacky and sticky to thin and clear and either assists or impedes sperm, depending on the time of your cycle.

From the cervix, the vagina runs about 4 inches to the vaginal opening. A hollow, accordion-like muscular tube lined with mucous membranes that keep it moist, the vagina is where the erect penis is inserted during sexual intercourse. It also serves as the birth canal and as a passageway for menstrual flow from the uterus. The vagina expands during sexual arousal and, especially, during childbirth. The lower third of the vagina is laced with many nerve endings and includes the Gräfenberg spot, or G-spot, a sensitive spot roughly the size of a dime, 2 to 3 inches up just past the pubic bone; for some women, it is an area of erotic sensitivity. During sexual arousal, small glands on either side of the vagina known as Bartholin’s glands may also swell and lubricate the passage. The opening to the vagina is known as the introitus; at birth it may be partially covered with a membrane of tissue called the hymen. It was once thought that a torn hymen was evidence of sexual intercourse, but that’s simply not true. A hymen can be easily stretched, abraded, or torn by physical activity, use of tampons, masturbation, and other activities.

Your external genitalia, also known as your vulva or pudendum, include the mons pubis, the fleshy area just above your vaginal opening; the labia majora and labia minora, the two skin flaps surrounding the vaginal opening, which help keep bacteria out of the vestibule of the vagina; and the clitoris, a highly sensitive structure rich in blood supply and nerves, which swells during sexual arousal. Your clitoris is the only part of your body that is designed solely for pleasure.

While your breasts are not strictly necessary for procreation, they are part of your reproductive system and are sensitive to female hormones. Each breast has a raised nipple surrounded by a circular pigmented area called the areola, which contains muscles that make your nipple stand erect in response to touch and, sometimes, to cold. Your nipples contain openings for milk ducts within the breast. Inside, your breasts have lobes of glandular tissue (known as mammary glands) that include the sacs and tubes that make milk. The lobes are separated by protective fat and supported by connective tissue. The shape of your breast is determined by the amount and distribution of fat. The function of your mammary glands is regulated by estrogen and progesterone from your ovaries and, from your brain, prolactin and oxytocin—two hormones involved in breast development and milk production, among other things.

Although we tend not to think of it this way, the brain is a powerful sexual organ, integral to both reproductive and sexual life. The pituitary gland, for instance, a structure about the size of a pea located just beneath the hypothalamus at the base of the brain, sends signals to the ovaries to prepare your eggs for ovulation. Both the hypothalamus and the pituitary gland play an important role in regulating female hormones.

Female Reproductive System

The main organs of the female reproductive system include two ovaries, a pair of fallopian tubes (capped by fimbriae), and the uterus. An ovary releases the egg, which is swept by the fimbriae into the opening of the fallopian tubes, and from there, travels into the uterus.

YOUR REPRODUCTIVE CYCLES

A finely tuned array of interacting sex hormones orchestrates your reproductive cycles. At puberty, the pituitary gland in the brain begins to secrete two key hormones: folliclestimulating hormone (FSH) and luteinizing hormone (LH). These hormones stimulate your ovaries to make other hormones, including estrogen. Toward the end of puberty, your ovaries begin to release eggs—one per month—as part of your monthly menstrual cycle. The cycle has four phases:

Follicular. This phase begins just after menstruation ends and lasts for 6 to 13 days. The pituitary releases FSH and LH, stimulating the growth of a group of egg follicles, only one of which will eventually make a mature egg. Estrogen promotes the thickening of the endometrium in preparation for a fertilized egg.

Ovulatory. On around day 14 of your cycle, a mature egg is released into the fallopian tube—the process called ovulation. At this time of the cycle, your cervical mucus may become clear, copious, and stretchy, a state hospitable to sperm. The cervix opens a little.

Luteal. In this stage, progesterone and estrogen further stimulate the development of the endometrium. If there’s no fertilization, however, the hormone levels drop. At this phase, the endometrium may produce prostaglandins—hormonelike substances that can trigger the cramps, breast tenderness, and mood swings of premenstrual syndrome.

Menstrual. The endometrial buildup, about 2 to 6 tablespoonfuls of blood and tissue, is expelled out of the uterus by uterine contractions. Normal menstrual flow can be light or heavy, regular or irregular, and can last from 3 to 7 days. After this, the endometrium rebuilds itself, and the cycle begins anew.

A girl’s first period, called menarche, may occur anytime between the ages of 9 and 16. Although there are few statistics, it’s widely believed that the age of menarche decreased by 2 to 3 years between 1900 and 1970, most likely due to better nutrition and health care. Today, some 10 percent of American girls reach menarche by age 11 and 90 percent by age 13.75. The average age of menarche in healthy American girls is 12.5, but it’s perfectly normal to start menstruating at either end of the age spectrum. I didn’t get my period until I was 16. At the time, I thought I was abnormal because all of my friends had already begun menstruating. But now I realize I was just at the older end of the age range. Once menarche takes place, most young women will have reached a height within an inch or two of their adult height. Some girls develop body image issues at menarche and during puberty. (This mental health issue is discussed in Chapter 23.)

After menarche, it can take up to 2 years or even more for a young woman to establish regular menstrual cycles. The typical menstrual cycle ranges from 20 to 40 days, with an average of about 28 days. However, there is great variation here, too. Some women experience irregular cycles for much of their premenopausal lives. I had very irregular periods until I got pregnant at the age of 27. Sometimes menstrual irregularities are due to hormone imbalances; consulting a physician can help clarify this.

A woman’s reproductive cycles continue from menarche to menopause, when hormone levels change and reproductive cycles halt—usually in the late forties or early fifties. Cycles often get shorter first and then are erratic. But the pattern varies: Each woman’s body follows its own script.

Women’s Menstrual Cycle

A woman’s menstrual cycle includes a range of interacting events that prepare her body for pregnancy each month. The endometrium thickens; the ovary releases an egg in response to messages sent by the gonadrotropic hormones LH and FSH and the ovarian hormone estrogen. Rising progesterone levels stimulate the building up of the endometrium to provide a healthy environment for a fertilized egg to implant. If fertilization and implantation do not occur, progesterone levels drop, and the endometrium is sloughed off during menstruation. Body temperature rises just after ovulation and stays higher by about 0.4°F for 5 to 10 days, until menstruation.

DISORDERS OF THE MENSTRUAL CYCLE

Menstrual patterns normally change and vary over the course of a lifetime. Flow may shift from light to heavy; monthly cycles may shorten or lengthen. In adolescence and again during perimenopause, women may experience irregular bleeding. After the age of 35, cycles often shorten. However, some menstrual irregularities such as the absence of periods or infrequent, prolonged, or heavy periods may reflect underlying disorders and should be checked out by a women’s health clinician.

Among the common disorders of the menstrual cycle are:

Amenorrhea. Amenorrhea, or the absence of menstruation in a premenopausal woman who is not pregnant, can occur during puberty or later in life. It can be a serious condition that may affect fertility and bone health. (See The Female Athletic Triad.) Primary amenorrhea is not beginning menstruation by age 16. It may be caused by chromosomal abnormalities, problems with the hypothalamus or pituitary gland, structural abnormalities in the reproductive system, or anorexia. Secondary amenorrhea is missing several periods in a row once you have gone through menarche. Amenorrhea can be a normal result of breastfeeding or an intended effect of some kinds of birth control pills or the progesterone-containing IUD. (In these cases, it has none of the implications for fertility and bone health characterized by true secondary amenorrhea.) Or, it can be caused by stress, certain medications such as antidepressants and antipsychotics, polycystic ovary syndrome (PCOS), eating disorders such as anorexia or bulimia, low body weight, thyroid malfunction, premature menopause, and other disorders.

You should consult your health care provider if:

You’re age 16 or older and you’ve never had a menstrual period

You’ve begun menstruating but have missed three or more consecutive periods

Premenstrual syndrome (PMS). Roughly three-quarters of menstruating women experience some kind of premenstrual symptoms, ranging from mood changes to bloating and breast tenderness, especially from their late twenties to early forties. For some women, these symptoms may be so severe that they interfere with daily life. This condition is called premenstrual syndrome. Among the symptoms are severe irritability, tension, anxiety, mood swings, or difficulty concentrating, as well as pronounced physical symptoms such as breast tenderness, abdominal bloating, fatigue, acne, food cravings, and increased appetite. Symptoms most often occur in the second half of the menstrual cycle and resolve within a few days of the onset of menses.

For relief or control of mild PMS symptoms, you can try making lifestyle changes:

Get aerobic exercise—at least 30 minutes three times a week.

Reduce stress through relaxation techniques such as yoga and/or deep breathing.

Get adequate sleep.

Take a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen.

If making these lifestyle changes doesn’t ease your symptoms and they continue to seriously affect your health and well-being, you may wish to consult with your health care provider about taking other medications, such as diuretics or antidepressants. Research suggests that new lines of oral contraceptives show promise in helping with both physical and emotional symptoms.

Dysmenorrhea. Dysmenorrhea, or menstrual pain, affects roughly half of all premenopausal women. There is an increased risk among women who smoke, drink, are overweight, or began menstruating before the age of 11. Other risk factors include stress, excessive caffeine use, and a family history of menstrual pain.

Dysmenorrhea can occur without pelvic disease but can also be a symptom of underlying pelvic disorders, such as endometriosis, uterine fibroids, pelvic inflammatory disease, or ectopic pregnancy.

The more common form is marked by recurrent cramps and lower abdominal pain that may extend to your back and down the back of your legs, and sometimes by headache, nausea, vomiting, and diarrhea. It is thought to be caused by an excess of prostaglandins, which trigger uterine contractions. The pain most often starts within hours of menstrual flow and peaks in the first day or two. It is usually treated with nonsteroidal anti-inflammatory drugs.

The treatment of cramps caused by pelvic disorders may vary, depending on the type of underlying disease.

Menorrhagia. Menorrhagia refers to excessive or prolonged menstrual bleeding. Relatively heavy menstrual bleeding is a common concern, especially for young women in the first year or two after menarche and for older women nearing menopause. Menorrhagia is defined as menstrual flow so heavy it soaks through one or more sanitary pads or tampons every hour for several hours in a row, or flow that lasts longer than 7 days. If you experience these symptoms, you should seek medical help. The cause of menorrhagia can be anatomic (polyps or fibroids, for instance) or hormonal, in which case oral contraceptives can sometimes be used to control bleeding.

Polycystic ovary syndrome (PCOS). PCOS is relatively common, affecting about 1 in 10 women. It is a condition of excess androgens (male hormones—all women have some) and insensitivity to insulin. This causes lack of ovulation and sometimes excess hair growth, especially on the face (hirsutism), and small ovarian cysts. It is also associated with an increased risk for type 2 diabetes. Treatment usually focuses on symptoms. Lifestyle interventions such as exercise and weight loss can be effective, but medications are often used to regulate the cycle, reduce hirsutism, and induce ovulation in those who wish to get pregnant.

THE FEMALE ATHLETIC TRIAD

The link between disordered eating, amenorrhea, and low bone density

When I was a new graduate student in nutrition at Tufts University in 1984, my first research study explored the link between amenorrhea and bone density. Two previous studies had shown that young women who were amenorrheic had lower bone density—probably because of low estrogen levels. To find out more about the link, we recruited a group of young athletic women, half of whom had regular menstrual cycles and half of whom were amenorrheic. Because the laboratory I worked in was part of a nutrition research center, we were interested in finding out whether there were any nutrition issues involved in the association.

The results were surprising. As in the earlier studies, we found that the women who were amenorrheic had lower bone density despite being similar to the other women in weight and activity levels. But our nutrition studies also uncovered something new: The amenorrheic women had disordered eating habits. These women reported eating considerably fewer calories than the women with normal menstrual cycles, despite being similar in weight. In addition, about two-thirds of them were not getting enough protein in their diets. They were also engaging in some atypical eating patterns, skipping meals or eating very tiny meals 20 or 30 times a day. It appeared that this disordered eating and/or calorie restriction,