A Review on Nutritional Requirements During Menstrual Cycle Phases

A normal menstrual cycle is produced by a complex hormonal system and a precisely synchronized axis of the hypothalamus, pituitary, and ovary (HPO). feedback loops that result in ovulation, a dominant follicle's growth, and the endometrial lining's periodic shedding in the case of infertilization [Itriyeva et al., 2022]. One frequent occurrence in the female reproductive system is the menstrual cycle takes place every month from the onset of menstruation during puberty until menopause, playing a crucial role in facilitating conception and pregnancy. The initiation of menstruation signifies the beginning of the typical 28-day cycle, concluding the day preceding the subsequent bleeding episode. Nevertheless, healthy cycles typically last 21–37 days. [schmalenberger et al., 2021]. A fertile period that spans five days prior to ovulation, fertility that is influenced by age and cycle length, and a wide range of cycle durations (26–35 days) are the defining features of women's menstrual cycles. All women experience a rise in FSH at the luteal–follicular transition, which restricts the release of B early on in the follicular phase and encourages a cohort of follicular growth. One week prior to ovulation, the ovulatory dominant follicle (DF), which was chosen during the mid-follicular phase, secretes more oestradiol and inhibin A as it develops. [Mihm et al., 2011].

Normal menstrual physiology

The initial stage of the menstrual cycle, known as the Menstruation marks the beginning of the follicular phase, which typically lasts for4–6 day. The levels of female sex hormones remain consistent and low during this time. The stage of follicular development lasts until the time of ovulation. which the amount of estrogen rises as the egg-containing follicles of the ovaries develop. As the hormone estrogen. levels increase, the release of gonadotropin-releasing hormone also rises, resulting in a sudden surge in lh. When a mature follicle bursts and releases the egg into the uterus, the surge in lh during the late follicular phase signals ovulation. After ovulation, the ruptured follicle transforms into Progesterone and a small quantity of estrogen are secreted by the corpus luteum during the early luteal stage. The progesterone highest point and the second, less significant estrogen peak occur in the mid-luteal phase, preparing the endometrium for a fertilized egg's possible implantation. If a fertilized egg is successfully implanted, pregnancy will conclude the luteal phase. If the egg is not fertilized, the corpus luteum will disintegrate., leading to a decrease in progesterone and estrogen levels in the late luteal phase, preparing the body for a new cycle. Eventually, the uterine lining will separate, allowing menstruation to resume [Carmichael et al., 2021]. For hormone-sensitive people, such as those with premenstrual dysphoric disorder and premenstrual exacerbation (PME) of underlying psychiatric problems, the monthly menstrual cycle can have an impact on their emotional, cognitive, and behavioural functioning, in addition to causing normal physiological changes in women [Schmalenberger et al., 2021]. The hypothalamus's secretion of gonadotropin-releasing hormone (gnrh) is responsible for stimulating normal ovulation and menstruation. The anterior pituitary gland secretes luteinizing hormone (lh) and follicle-stimulating hormone (fsh). The direct interaction between lh and fsh with ovarian cells leads to the production of ovarian androgens [itriyeva et al., 2022]. Alongside genes and estradiol, FSH plays a vital part. in the recruitment and growth of ovarian follicles. Because of well-coordinated feedback loops, In the first part of the menstrual cycle, a dominant follicle develops, and the endome trial lining intensifies; in the middle of the cycle, ovulation occurs; and in the third phase, the endometrium is ready for implantation. Menstruation irregularities, including heavy bleeding and irregular, infrequent, or nonexistent periods, can arise from any aberrations at any level of the HPO axis and from any interruptions to any stage of the painstakingly designed operation [Itriyeva et al., 2022]. The uterine endometrium serves various functions, such as preparing for implantation, sustaining pregnancy if implantation occurs, and triggering menstruation when pregnancy does not take place. Consequently, the uterine lining, or endometrium it is essential in the survival and reproduction of our species. Menstruation and pregnancy are the alternative routes for a progesterone-primed endometrium, and these essential processes are regulated by steroids. The endometrium is a sophisticated tissue composed of multiple cells that undergoes shedding once a month during menstruation when not pregnant. It then swiftly recovers without leaving any scars or losing its functionality [Critchley et al., 2020]. The three stages of a typical ovulatory menstrual cycle are: the ovulatory phase, the luteal (secretory) phase, as well as the proliferative (follicular) phase. Estradiol is the main hormone of the follicular period, whereas progesterone is the main hormone of the phase of luteal development. The loss of the uterine lining marks the beginning of the first stage of the period known as menstruation, which ends with the release of an egg. The main factor influencing the duration of a person's menstrual cycle is the length of time it takes for the cycle to complete, which can range from 7 to 22 days and typically averages 14 days. The anterior pituitary's fsh and lh are secreted as a result of the hypothalamus producing gnrh due to low levels of progesterone and estradiol during the early follicular phase. Lh stimulates ovarian theca cells to produce more androgens, but fsh directly influences ovarian granulosa cells to convert the androgens into estradiol through the action of the enzyme aromatase [itriyeva et al., 2022]. Progesterone levels and the presence of ovulation were evaluated using radioimmunoassay. The most remarkable feature of the menstrual endometrium was its intense survival drive. The signs of this included lipid accumulation, glycoprotein ejection, lysosomal activity, and the uptake of stromal waste by epithelial cells for transit to the uterine cavity. Regression, not cell death, was the primary menstrual event. Despite partial necrosis, the vast majority of the spongiosa's cells survived and underwent remodeling to participate in the new cycle [FLOWERS JR et al.,1978]. FSH is also in charge of recruiting primordial ovarian follicles and promoting their development and maturation,  eventuallyresulting in a dominant follicle's development. The follicle with the dominant position releases more estradiol in the late stage of the follicular cycle, which encourages the growth of the inner lining of the endometrium. When estradiol levels rise, lh and fsh levels decrease as a result of a negative feedback loop [itriyeva et al., 2022]. During this phase, the mid-cycle surge that triggers ovulation is a result of a shift going from a negative circle in the hpo feedback loop from the ovulation to the anterior pituitary gland to a positive loop. After reaching a critical high of approximately 200 pg/ml, diol levels persist for at least 36 hours [itriyeva et al., 2022]. There are two distinct cycles in the menstruation cycle: one that happens in the ovaries and one that happens in the uterine lining. The three stages of the ovarian cycle are the follicular stage, ovulation, and the phase known as luteal. There are three distinct stages of the endometrium cycle: the menstrual, secretory, and proliferation phases. In general, the luteal phase of the ovarian cycle coincides with the secretory phase of the endometrial cycle, whereas the ovarian follicular phase corresponds to the menstruation and proliferation stages of the endometrium. [thiyagarajan et al., 2024]. The mature follicle splits and produces an egg during ovulation; it then transforms starts the luteal phase and enters an organ called the corpus luteum. When luteal development is underway, which lasts an average of 14 days and is longer than the follicular phase, and when LH is present, the lining of the luteum produces progesterone (and less estrogen). When progesterone the inner layer of the endometrium transforms from a proliferative to a secretory lining in preparation of potential implantation when levels are high. Additionally, progesterone boosts body temperature to facilitate conceiving and thickens the mucus in the cervical cavity, which had remained thin and watery during the proliferative and ovulatory phases. [Itriyeva et al., 2022]. Without fertilization, the membrane of the corpus luteum transforms into the corpus albicans, which decreases circulation. lowering levels of estrogen and progesterone. A new cycle begins when the endometrial lining sheds and menstruates as a result of hormonal withdrawal. The establishment of regular, ovulatory menstrual cycles requires the maturation of the HPO axis. This occurs in the months and years that follow menarche, not at the same time. In the first one to two years after menarche, Anovulatory phases occur frequently, and one - six years after menarche, normal ovulatory cycles begin. About 18 to 45% of women experience this within two years of menarche, 45 to 70% do so between two and four years later, and 80% do so within five years. The commencement of the ovulatory cycle in adolescent females varies [Itriyeva et al., 2022].

Dietary energy intake

The follicular phase (beginning on the first day of life) and the stage known as luteal (after ovulation) of menstrual bleeding until ovulation) are the menstrual cycles two normal phases. The four separate hormonal environments that take place within a single cycle are Low levels of progesterone along with reduced estrogen are characteristics of the early follicular period; excessive progesterone and inadequate estrogen are characteristics of the last follicular stages; the medium hormone progesterone and small estrogen are characteristics of the ovulatory phase; and medium progesterone along with elevated estrogen are characteristics of the mid-luteal phase. [Rogan et al., 2023]. These hormonal changes impact various bodily functions beyond reproduction, including the regulation of nutrition. It is believed that estrogen reduces hunger, while progesterone may have the opposite effect when estrogen is present. During exercise, there is a greater preference for using fat as a fuel source, while during rest, there is more glycogen storage in contrast in the luteal stage to the follicular stage. Throughout the cycle, the rates at which fat and carbohydrates are oxidized change. Furthermore, it appears that protein catabolism increases during the luteal phase, which could account for the increased resting metabolic rate during this period [Rogan et al., 2023]. Dietary consumption is influenced by a complicated interaction of environmental, psychological in nature physiological, social, and cultural elements. Regarding the menstrual cycle's function in the complex operations of this system, there is little agreement. Understanding how hormone changes during the period of menstruation effect on calorie consumption is crucial for therapeutic purposes. The energy's accessibility the quantity of accessible Per kilogram of fat-free mass, dietary energy after deducting the energy used for physical activity may be significantly impacted by changes in energy intake, especially for athletes whose It's possible that training quantity won't be modified to take phase-related variations regarding calorie consumption into consideration. Insufficient availability of energy may have detrimental effects on one's health. such as irregular menstruation, weakening bones, endocrinological issues, a decrease in physical performance, and an increased risk of illness or injury. Therefore, if energy intake is reduced during particular menstrual cycle phases, further To provide the best possible energy availability, dietary supplements can be necessary.[Rogan et al., 2023].

• Early-follicular phase: Marked by the least amount of progesterone and estrogen (day 5) and the beginning of bleeding (day 1).
• Late-follicular phase: Higher levels of estrogen compared to earlier stages, while although they are below 6.36 nmol/L, progesterone levels are greater than during the early follicular stage. 14–26 hours before ovulation.
• Ovulatory phase: A positive urine ovulation test (measuring luteinizing hormone) suggests that progesterone levels are elevated compared lower than in previous phases, but closer to the early follicular phase. Compared to the early follicular stage, the amounts of estrogen are higher, although below 6.4 nmol/L within the 24-36-hour timeframe.
• Mid luteal phase: The seven days after ovulation is the mid-luteal phase. confirmation, is characterized by decreased progesterone levels (above 16 nmol/L) and increased estrogen levels compared to the early follicular and ovulatory phases. [Rogan et al., 2023].

Nutritional Practices to Manage Menstrual Cycle Related Symptoms

At least one monthly symptom is reported by up to 80% of women, whereas symptoms related to premenstrual syndrome are thought to be between 10 and 98 percent common globally. Premenstrual symptoms can cause social, professional, and academic absenteeism, lower one's quality of life, and limit one's capacity to work. Primary dysmenorrhea, also referred to as lower abdominal discomfort before or during menstruation without any obvious illness or pathology, is the most prevalent symptom. When compared to the pain-free postmenstrual period, the discomfort of dysmenorrhea can also lower mood and sleep quality. Additional typical symptoms include mood swings, breast soreness, bloating, food cravings, and exhaustion. However, medication avoidance has been linked to the fact that many women do not see a doctor while they are having menstruation symptoms [Brown et al., 2023]. Increased dietary intake has been shown to alleviate menstruation discomfort and premenstrual syndrome. Menstrual discomfort can be alleviated by consuming 50,000 IU of vitamin D supplements once a week for 8 to 9 weeks, 100 mg of thiamine daily for 60 days, 25,000 IU of vitamin E for 5 days starting 2 days before menstruation, and a daily intake of 2 g of omega-3 polyunsaturated fatty acid fish oil supplement. Furthermore, a study conducted on Japanese women found that incorporating fiber into the diet could help reduce menstrual pain. [Naraoka et al., 2023]. Previous studies have shown a correlation between the symptoms and pain of menstruation and lifestyle factors. According to a poll of college students, menstruation pain was reportedly impacted by the use of cola, meat, and alcohol in addition to fruits and beans. Furthermore, a study conducted on junior high school students in Japan found that screen usage, sleep patterns, dietary habits, and involvement in sports groups all affected the prevalence of PMS [Naraoka et al., 2023]. The exact cause of menstrual-related symptoms remains unknown, but various theories propose that hormones produced during ovulation and a diet rich in nutrients may play a role. Imbalances in hormones, such as progesterone and gaba neurotransmitter abnormalities, as well as a family history of medical conditions, can contribute to the development of this disorder. However, because medications like Inflammation have been suggested as a possible cause of menstrual-related symptoms like cramps in the abdomen, which are commonly relieved by non-steroidal anti-inflammatory medications. There is no connection between menstrual headaches and high-sensitivity C-reactive protein, a measure of inflammation in the acute phase, and premenstrual mood, back and abdominal discomfort, breast soreness, abdominal discomfort, gaining weight, and cravings for food. Periods related symptoms can occasionally be lessened by suppressing ovarian hormone secretion, albeit variations in ovarian steroid hormone levels between symptomatic and asymptomatic people have not always been noted [Brown et al., 2023]. Diet appears to be a key moderating role in the reduction and management of various PMS symptoms. The true effects of food and minerals on women with menstrual disorders, however, are not well studied scientifically. Following a healthy eating strategy that prioritizes fresh, unprocessed meals and avoids foods heavy in alcohol, refined fats, carbohydrates, salt, and stimulant drinks is recommended [Siminiuc et al., 2023]. The relationship between menstruation and biological, social, demographic, and behavioural aspects has been recognized. symptoms, and because of the wide range of symptoms and possible causes, symptom alleviation is a major problem with few effective treatments. The symptoms of changing reproductive hormones are commonly managed with hormonal contraceptives (HC). Exogenous steroid hormones known as HC prevent ovulation and cause a steady decrease in endogenous sex hormones. Menstrual-related symptoms have significantly decreased when ovarian hormone release is suppressed. By blocking the hypothalamic gonadotrophin-releasing hormone, HC stops the pituitary from generating luteinizing hormone and follicular stimulating hormone [Brown et al., 2023]. By consistently promoting a negative feedback loop and inhibiting the release of progesterone or endogenous oestrogen, contraceptives provide pharmaceutical authority over the cycle of reproduction. Since they are synthetic, their mechanisms differ from those of hormones produced naturally in the body. These distinctions go outside the female reproductive system and influence how other body systems, like the cardiac and metabolic systems, react and behave, which encompass the inflammatory response and oxidative stress, among other factors. Because of the artificial hormones, their unclear impacts on bodily systems outside of the reproductive system or the fact that the Synthetic hormone that side effects are commonly confused with menstrual-related symptoms. people have been reluctant to use HC even though it may help with menstrual-related symptoms. [Brown et al., 2023]. Supplementing with magnesium is thought to be beneficial in preventing menstrual migraines, PMS, and dysmenorrhea. Magnesium and vitamin B6 combined can dramatically reduce premenstrual stress, and older women's anxiousness can be successfully reduced with vitamin B6. Pyridoxine (B6), folic acid (B9), thiamine (B1), riboflavin (B2), cobalamin (B12), niacin (B3), and pyridoxine (B6) are essential for the production of neurotransmitters that could be implicated in the pathophysiology of PMS. No significant correlations have been found between PMS and dietary consumption of cobalamin, folate, among other pyridoxine, and niacin. Supplemental B vitamin intake was not linked to a decreased risk of PMS. However, women with high dietary intakes of thiamine and riboflavin showed a considerably decreased risk of PMS [Siminiuc et al., 2023]. Maintaining a balanced diet and managing stress, especially by avoiding meals high in refined carbohydrates and consuming fresh, unprocessed foods, helps naturally prevent and treat menstrual-related symptoms. or salt, fats, alcohol, and imitation beverages have been reported. Micronutrients like zinc have been demonstrated to have neurotrophic and anti-inflammatory qualities, despite some research showing no link between macronutrients and menstrual-related symptoms. Inflammation may also be decreased by other dietary interventions, such as consuming more fruits, vegetables, and legumes, which are rich in phytochemicals with anti-inflammatory properties. A number of other nutraceuticals, such as vitamin D, vitamin C, and curcumin, have also been studied as potential remedies for menstrual-related symptoms. There isn't a widely accepted treatment for menstruation-related discomfort at the moment. Considering how simple it is to employ non-pharmaceutical management menstruation symptoms, and dietary modifications may be a good way to stop symptoms from interfering with day-to-day activities. To the best of the writers' knowledge, there is no review available that offers practical advice to practitioners or patients regarding the use of food, supplements, or diet for the management of menstrual cycle symptoms [brown et al., 2023]. During the time leading up to menstruation, it has been recommended that calorie consumption and carbohydrate preference are particularly important because women with premenstrual syndrome (pms) are thought to be more susceptible to fluctuations in hormones or neurotransmitters. The rise in serotonin levels linked to tryptophan explains why mood improves after consuming carbohydrates. which serves as self-medication and relieves a possibly functional serotonin deficiency in the brain. However, the start of PMS is positively correlated with a diet high in sugar, particularly coffee, wine, fried meals, and simple fats. The scientists suggest consuming a diet high in fruits, vegetables, and good fiber to lessen the symptoms of PMS.[Siminiuc et al., 2023].

Nutritional therapies for the management of symptoms associated with menstruation

Calcium and Vitamin D

According to one study from the reviewed literature, self-reported premenstrual symptoms were reduced more effectively by a calcium and vitamin D combination than by a placebo. inadequate intake of vitamin D or calcium. The study did not include assessments to determine the biological process responsible for the observed differences in findings and measures. Additionally, the study did not examine the serum vitamin or mineral levels of individuals to  identify any prior deficiencies before the intervention. However, recent Research has indicated that calcium and vitamin D levels in the blood, which aids in the absorption of calcium, vary throughout the menstrual cycle. The increasing occurrence and severity of menstrual pain have been attributed to disturbances in the regulation of calcium levels [brown et al., 2023]. In the reviewed trials, calcium alone was found to be more helpful than vitamin D when it came to reducing the discomfort associated with primary dysmenorrhea. These results could be explained by a number of processes, as supplements are only given starting on the A study of every group showed that 93% of people were deficient in the calcium and vitamin D group, 86% in the calcium alone group, and 89% in the placebo group; every measurement were reported by themselves, especially the use of a food journal to detect calcium insufficiency; if a person's daily consumption was less than 1000 mg, they were considered inadequate; again, all measurements were self-reported. however, the study did not provide enough mechanistic understanding to make any inferences [Brown et al., 2023]. Two trials that only looked at vitamin D supplementation showed further discrepancies in outcome outcomes (premenstrual symptoms or dysmenorrhea). between duration and dosage. Vitamin D has been demonstrated to have anti-inflammatory properties. It lowers prostaglandin synthesis, which has been linked to a significant a pathophysiological component of dysmenorrhea and PMS. According to earlier studies, vitamin D may affect a number of pathways. associated with PMS and dysmenorrhea, including increased 15 hydroxy prostaglandin dehydrogenase, decreased cyclooxygenase-2 expression and consequently decreased prostaglandin production, lowered pain intensity as a result of enhanced prostaglandin deactivation and controlled prostaglandin the receptor expression. This could highlight the benefits of vitamin D deficiency for women as reported in the reviewed literature, but it could also be limited to this population. [Brown et al., 2023]. In the present evaluation, one research study focused on the calcium use, either by itself or in conjunction with magnesium. Previous studies have demonstrated that serum magnesium plays a crucial role in the balance between electrolyte absorption and excretion, actively metabolizing tissues, and bone stores. Various hormones, such as sex steroids, play a role in regulating these processes. Signs of a deficiency may include muscle cramps, anxiety, and inflammation. Lower levels of prostaglandin f2α, which are associated with pain and inflammation, have been observed. This could potentially have a significant impact on the management of pain related to primary dysmenorrhea. Adding magnesium had a higher effect in reducing the degree of pain, according to one of the studies that looked at The addition of magnesium as well as calcium or calcium alone together. However, information regarding the calcium and magnesium levels of participants before the intervention was not given [Brown et al., 2023].

Zinc

During the menstrual cycle, serum zinc concentrations fluctuate; a zinc shortage can lower these concentrations, which may then result in a decrease in the production of glucocorticoids.
irregular and are linked to dysmenorrhea, as well as neuropsychological symptoms as irritability, sadness, and emotional instability. In contrast to those who got a placebo, women with PMS who took zinc supplements for 12 weeks showed a significant rise in brain-derived neurotrophic factor (BDNF), according to the current study's findings. No previous research has explored how zinc supplementation impacts PMS patients' serum levels of BDNF [Brown et al., 2023]. It is hypothesized that zinc triggers the activation of matrix metalloproteinase, which subsequently triggers the proteinase known as tropomyosin-related kinase. Consequently, pro-bdnf is released and subsequently changes into bdnf. Prior research indicates that bdnf has an influence on women's reproductive system and affects the way sex hormones interact with each other. Recent studies suggest that during the luteal phase, women experiencing premenstrual syndrome (pms) exhibit distinct levels of serum bdnf compared to women without pms. Studies have linked menstrual-related symptoms to both elevated and decreased BDNF levels. However, all studies concur that BDNF levels in the blood are linked to the frequency of symptoms related to PMS and could be involved in the disease's etiology. Brown, N et al., 2023]. Other research indicates that zinc lowers dysmenorrhea by increasing microcirculation, preventing ischemic attacks, deactivating free radicals by raising the dismutase enzyme's concentration, and lowering and controlling the level of inflammatory cytokines and the cyclooxygenase-2 enzyme. Additionally, women's menstrual symptoms are strongly correlated with inflammatory indicators; zinc's anti-inflammatory qualities may reduce the effects of PMS by influencing markers of inflammation like highly sensitive C-reactive protein. [Brown et al., 2023]. Although 50 mg/d is the UK's recommended upper limit for acceptable zinc intake, most multivitamins contain greater than 15–30 mg of zinc supplemented in food. It is advised that women consume 8 mg of elemental zinc daily, exceeding 20 mg daily for an extended duration may pose potential risks. The study that reported taking 50 mg of dofzinc sulphate for four days and the one that reported taking Zinc sulfate tablets containing 220 mg for four days, around when menstrual begins, had a far greater zinc dosage. The present analysis encompasses these investigations. However, this was given every day for 12 weeks. claimed to have used a lower amount of zinc gluconate (30 mg/d) [Brown, N et al., 2023].

Curcumin

Curcumin has a positive effect, according to the findings of the two studies that were part of this systematic review. Following three menstrual cycles and 10 days of 100 mg/12 h of curcumin daily, mean PMS scores were considerably lower and BDNF levels were significantly greater. The suggested processes pertaining to BDNF and its consequent effects on mood and behavior regulation were validated by this investigation [Brown et al., 2023]. Recent studies have shown that curcumin, commonly referred to as turmeric, has anti-inflammatory, health, and therapeutic properties. Research has shown that both physiological and pathological situations may benefit from curcumin. It has been suggested that curcumin has a neuroprotective effect; it works by influencing the release of specific neurotransmitters, including BDNF [Brown et al., 2023]. In each of the investigated studies, Khayat suggested 100 mg/12 h for 10 days, followed by three menstrual cycles, using the identical approach. This plant-based extract has no recommended daily dosage or safe maximum limit; therefore, it might be safe to take as a supplement. Both the methodology and the outcomes were consistent. Similarly, cinnamon was found to reduce the severity of primary dysmenorrhea discomfort, albeit further research is needed to validate the one study that was examined [Brown et al., 2023.

Dietary Management for Menstrual Cycle

Table 1. Essential nutrients and their role in dietary management of the menstrual cycle [pierce et al., 2024].