Reproductive health

Menstruation, often called ‘periods’, is the regular discharge of blood and mucosal tissue (known as menses) from the inner lining of the uterus through the vagina. The first period usually begins between 12 and 15 years of age, a point in time known as menarche.

Usually, menarche happens around the age of 12 or 13, but it can start as early as 8 or 9 or as late as 15 or 16. As the body matures during puberty, the ovaries start to release the hormones estrogen and progesterone. These hormones cause the lining of the uterus to build up. The built-up lining is our body’s way to get ready for a fertilized egg to attach to and start developing (that is, a pregnancy). If there is no fertilized egg, the lining breaks down and bleeds. This same process happens all over again.

It usually takes about a month for the lining to build up, then break down. That is why most people get their periods around once a month.

Usually, only one egg is released per month, but sometimes more than one can be released. The egg then travels down the fallopian tube to the uterus. At this time, hormones send a signal to the uterus, telling it to start growing a lining (the endometrium). The reason it does this is so that the uterus can provide nutrients and a place for a fertilized egg to grow into an embryo. The extra uterine lining will eventually shed once the body realizes it doesn’t need it to nurture an embryo. This shedding is the period – which is usually a mix of normal vaginal discharge and blood. The blood can range from brown-ish to a bright red colour, thick or thin, and sometimes comes in clots.

There are three phases of the menstrual cycle. Let’s break it down:

The follicular phase (day 1-14, approximately, with day 1 being the day a period starts):

These two weeks start when bleeding starts, and last for the duration of your period (usually from 2-7 days) and for around a week after that, as the ovaries prepare to ovulate again. As your ovaries get ready to ovulate again, they release a hormone called follicle stimulating hormone (FSH) which causes several bumps filled with fluid, each holding an egg, to rise from the ovary. Usually, one of these follicles will take the lead and reach maturity, meaning the egg is ready to be released away from the ovaries and launched towards the fallopian tube. The other follicles will then usually shrink back down, but if two or more follicles reach maturity at the same time, this can lead to two or more eggs being released. If fertilization occurs, this is when someone might get pregnant with fraternal twins – identical twins are when one single fertilized egg splits in two. During this time, hormones are changing, and estrogen is increasing, which prompts the lining of the uterus (endometrium) to get thicker. This is because your body is sending extra blood to make a sort of nest in case an egg is fertilized once it is released.

Ovulatory Phase: Day 14:

This is when the mature egg is released from the ovary, where it travels into the fallopian tubes and down towards the uterus. It enters the fallopian tube where fertilization can take place if vaginal sex with penetration and ejaculation happens around that time. Otherwise, the egg disintegrates within around 24 hours. Pregnancy most commonly happens during the three days before ovulation and the day of, since the egg is present to be fertilized if it is met by sperm.

That’s because the egg survives for 12 to 48 hours. People are potentially fertile for up to seven days, and maybe up to 10 days because sperm can survive up to five days in the female reproductive tract. That said, the chances of getting pregnant at the far end of the fertile window is very low.

For those who want to get pregnant, it is recommended to have sex (or insert sperm) one to two days before they ovulate.

Luteal Phase: Day 14-28: 

This is after the egg is released and when there is an increase in the hormone progesterone. Progesterone keeps the uterine lining thickened in case it needs to provide a nurturing environment for a fertilized egg. When an egg is fertilized, it will embed in this thickened lining and receive nutrients to help it continue to grow – this is the beginning of a pregnancy. If fertilization doesn’t happen, progesterone level drops, and this signals to the body that it’s time to lose the extra endometrial lining since it’s not needed. That means it’s time to start the cycle all over again, starting with a period.

Everyone’s period is different, from the age we’re at when we get our first period, to how heavy (aka how much blood comes out in our period) it is. While it is common to get a period every 28 or so days, how frequent and predictable periods are can vary for a few reasons. For the first couple years of someone getting their period, it might not happen regularly. The same goes when someone is approaching menopause – periods can become less predictable and the length of time between periods may change. How long and how often we get our periods can also be changed by being on hormonal contraception (e.g. the pill or an Intra-Uterine System like the Mirena), by drug use, by eating disorders, intense physical training, and many other things that change our body’s chemistry.

It can be helpful to track your cycle to start figuring out what is normal for you – lots of great phone apps exist for this, or a calendar works just fine too.

Knowing how to track your cycle to understand what is normal for you and how your cycle impacts you is an important part of sexual health and wellness. Lots of people talk about tracking their cycle when they’re either trying to get pregnant, or to avoid getting pregnant, but it can be a great way to get to know our bodies better and notice (and even start to predict) changes in your mood, energy level, and vaginal discharge, as well as detect potential health issues.

Make a quick note in your calendar of when you get your period. It can be great to predict when you’re most likely to be ovulating (approximately 14 days after your period starts) so, if you’re having sex, you can be aware of when it is most likely that pregnancy will happen. If you’re having uncomfortable symptoms each time you have a period, like migraines or intense cramps, make note of when these are taking place. This information can be really helpful if you need to seek out medical advice.

Premenstrual syndrome (PMS) is a combination of symptoms that many menstruating people get about a week or two before their period. Over 90% of people who menstruate experience symptoms like bloating, headaches, and moodiness. For some, these symptoms may be so severe that they miss work or school (see PMDD or endometriosis below), but most experience milder symptoms. On average, those in their thirties are most likely to have PMS.

I’m in pain – help!

While hormonal fluctuations cause a normal range of symptoms, it might be time to check-in with a health care provider if these emotional or bodily symptoms interfere with your day to day to life. It can be normal to feel irritable, bloated, grumpy, or sad in the few days before or right as your period starts. Taking an over-the-country medication like ibuprofen or naproxen can help a lot with cramps. But if your cramping and bleeding is so heavy or painful that you often need to stay home from school or work, or if you’re feeling deeply depressed around your period, it’s a good idea to see a doctor. While a range of these symptoms are very normal, some medical conditions can amplify these symptoms, and treatments exist to help ease your symptoms. You deserve to be well!

Premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) refers to experiencing severe depressive symptoms, irritability and tension before your period begins. This is more severe than premenstrual syndrome, which can cause mood changes. With PMDD, mood changes are much more pronounced and interfere with one’s day to day life. Usually, symptoms start around 5 to 11 days before your period and stop shortly after your period starts. Treatments in the form of antidepressants can be prescribed to help ease these symptoms.

Polycystic ovary syndrome (PCOS) is a hormonal disorder that is relatively common among people who have uteruses, particularly those who are of reproductive age. While the exact cause is unknown, the most common symptoms include irregular periods (infrequent, irregular, or prolonged) and elevated levels of androgens (commonly referred to as male hormones) that can cause increased facial and body hair, acne, or baldness. Typically, PCOS causes ovaries to be enlarged which can make them function differently. Treatment will depend on the symptoms you are having and can involve a combination of medication and lifestyle changes. While PCOS can be one of the causes of infertility, it does not mean you can’t get pregnant.

Endometriosis is a painful disorder where the tissue that grows inside your uterus, the endometrium, grows beyond the uterus into the fallopian tubes and sometimes into the tissue lining your pelvis or beyond. Like your uterine lining, it thickens, break downs, and bleeds with each period. But because of the location of this extra tissue, it can get trapped and cause pain, scar tissue, or fibrous tissues to develop. This causes painful periods (which may include lower back or abdominal pain), and can cause pain during sex, bowel movements, or urination. Sometimes, it can cause infertility and some people might first find out they have endometriosis when they’re trying to get pregnant. A good health care provider can help you manage your symptoms. Treatments include using birth control pills or over-the-counter pain medications to ease the pain. For more advanced endometriosis, hormone therapy or surgery to remove the scar tissue (called excision) might be recommended by your doctor.

For those who have been on hormonal birth control for the majority of their reproductive years, sometimes, the moment we go off birth control is when we first experience the symptoms of endometriosis such as flare ups of pain during different parts of your menstrual cycle, or lower abdominal bloating. If you experience these symptoms, it is important to see a health care provider for a referral to an OBGYN who can assess your symptoms and if needed, discuss treatments with you.

Perimenopause is not a reproductive disorder – it’s the time when someone start transitioning towards menopause. It's the time when the ovaries start to make less and less estrogen. It usually starts in people’s forties but can start in their thirties. The average length of perimenopause is four years, but for some people this stage may last only a few months or continue for 10 years. Perimenopause ends when a person has gone 12 months without having their period.

During perimenopause, people will experience a range of symptoms like hot flashes, vaginal dryness, mood swings, fatigue, difficulty sleeping, and irregular periods. Periods that may have been regular might get longer or shorter, or more time will pass between periods.

While it’s true every person’s menopause experience is different, physical, mental, and emotional changes that accompany this stage of life can be frustrating and isolating. It is for this reason self-care during this time is so important. For some, this means increased dedication to adequate sleep, exercise, and managing stress. For others, it is dietary changes, hormone replacement therapy, or anti-depressants. For all, keeping lines of communication open with family, friends, and health care providers help figure out what is most helpful during a big transition.

Menopause

Menopause is the time when menstrual periods stop permanently, and you can no longer get pregnant. After menopause, your body makes much less of the hormones estrogen and progesterone. Very low estrogen levels after menopause can affect health and cause symptoms such as hot flashes and so, it can bring some lifestyle changes, including the introduction of important routine tests, to relieve symptoms and ensure good health and wellness. While the list of possible symptoms can feel disheartening, some of the physical changes caused by reduced female hormone levels may be welcomed (e.g. fibroids shrinking, no more hormonal headaches, no more PMS) and for some, the emotional and social changes can feel energizing.

People choose to use contraception, most commonly referred to as birth control, for lots of different reasons. There is no “right” reason to use it. Even though the purpose of birth control is to prevent pregnancy, people choose to use contraception for many other purposes. For example, some hormonal birth control methods may help regulate periods, address period related mood disorders, reduce acne, and lower endometriosis related pain. Other methods can suppress menstruation, which can help with gender dysphoria (a term that describes a wide range of feelings that may occur if our gender is different than the sex we’re assigned at birth or the gender we’re assumed to identify with). Some people experience dysphoria related to their periods depending on their gender identity.

People become pregnant at many different ages and stages of life. Everyone is different, faces different circumstances and wants different things. What to do next may or may not be an easy decision for you. You can more find information on your three options: abortion, adoption, and parenting here. 

The information is intended for people who are pregnant, but it can also be useful information when it comes to supporting a partner, friend or family member who is pregnant. One of the biggest predictors of whether someone will have a good outcome regardless of the choice they make is whether they have emotional support from family, friends and/or their partner(s).

None of the three options is better than the other. Every person needs to make the decision that is right for them. If you have mixed feelings about being pregnant and about the choices available to you, making a decision can feel difficult. It is helpful to know your feelings, to name them and to examine them. You may find it helpful to think about how the idea of having an abortion, arranging for an adoption or becoming a parent makes you feel and why.

Many people continue to have conflicting feelings about each choice. You may find that whatever decision you make, it won’t feel like the perfect decision. We can make what we know is that best decision for us and be sad, angry or scared about some aspects of that decision. It is natural for many of us to have some mixed feelings. If you can’t decide what to do, you may need to get more information about your choices or talk with someone you trust – not to decide for you, but to help you pull out what factors in your life and circumstances might help you decide what you think will be best for yourself.

I just can’t decide! Who can I talk to?

It can be helpful to weigh your options by talking with people you trust, like a family member, friend, or partner. However, not everyone has this kind of support, while others still require additional support. Everyone deserves to have this help! Options counselling can be a great resource and is available in many locations for free and over the phone. To be connected with reputable options counsellor, call our Access Line at 1-888-642-2725.

Planning a family is not just about having children or not. It’s also about who we want to make a family with, how to space our children (if we have or want them), where and how we wish to raise them, and more. Families come in different shapes and they all deserve respect and recognition.

Family means so many different things: biological families, nuclear families, adoptive families, families with same-sex parents, queer families, polyamorous families, step-families, blended families, families that share co-parenting relationships with multiple people, foster families, extended families, immediate families, single-parent families, childfree families, multi-generational cohabitating families, divorced families, and so much more. People can create their families through adoption, foster care, choosing family friends to become family, assistive reproductive technologies, sperm and/or egg donors, surrogacy, cohabitating, taking care of one another, etc.

Despite that, almost all representation of families we see in the media and in books (including kids’ books) are heterosexual two-parent families. It is important for health care providers, media, authors, artists, educators, and policy makers to defy that lack of representation because all families deserve to be seen, respected, and celebrated.

While many people make big decisions around when (and if) they would like to become pregnant or start a family, some people have their choices constrained by partners or family members when it comes to choosing whether or not to become pregnant, or whether or not to continue a pregnancy. Reproductive coercion is a form of intimate partner violence where one partner uses aspects of the other person’s reproductive health (like contraceptive use and pregnancy) to maintain power, control, and domination. The most common forms of reproductive coercion include sabotage of contraceptive methods, pregnancy coercion, and pregnancy pressure.

Sabotage of contraceptive methods means actively interfering with a partner’s contraception to make them pregnant. Examples include hiding, withholding, or destroying a partner’s oral contraceptives; breaking or poking holes in a condom on purpose or removing a condom during sex without consent (often referred to as “stealthing”); not withdrawing when that was agreed upon; and removing vaginal rings, contraceptive patches, or intrauterine devices (IUDs). A large study undertaken in the United States showed that 1 in 7 women between the age of 16 and 29 had experienced birth control sabotage in their lives, 1 in 5 had been pressured by their partner to become pregnant, and 1 in 3 women who reported intimate partner violence also reported reproductive coercion. Reproductive coercion was also reported by 1 in 8 people who had not experienced other forms of relationship violence, meaning it happens in relationships that don’t otherwise seem abusive.

Pregnancy pressure means pressuring a partner to become pregnant when they do not wish to become pregnant. Pregnancy coercion involves coercive behaviour like forced sex (sexual assault and rape), threats, or violent actions toward a partner who does not comply with their partner’s wishes regarding the decision to terminate or continue a pregnancy. Examples of pregnancy pressure and coercion include threatening to hurt a partner who does not agree to become pregnant, forcing a partner to carry a pregnancy to term against their wishes through threats or acts of violence, forcing a partner to terminate a pregnancy when they do not want to, or injuring a partner in a way that may cause a miscarriage.

Reproductive coercion does not always just involve partners but can also be perpetrated by family. For instance, young people who experience an unplanned pregnancy may be pressured by family members into making certain decisions about whether to continue or terminate the pregnancy. While it’s normal to discuss things like pregnancy or family-making goals within in the context of our families and relationships, and very normal for people to have different desires and goals, pressuring someone to continue or terminate a pregnancy against their will, or tampering with their contraception, is always wrong. We all have the right to make our own decisions about our bodies and reproduction, even when those choices don’t align with those of our partners, peers, or family.

Click here for more information and resources on reproductive coercion.

Trying to conceive, navigating infertility, or being involuntarily childless are all important reproductive health issues that can have significant impacts on our mental health and well-being. We deserve the support of our loved ones, community, and health care team when we face those particular moments in our lives or challenges.

If you are trying to get pregnant, there is a lot of information available to figure out what is the best time for sex to conceive, what medical technologies can help to get a person pregnant, what supports 2SLGBTQ+ families can seek out, when age starts to impact fertility, when to seek medical help when you’ve been trying for a while, etc.

For some, conceiving will not be challenging but for others, it might take longer or be more difficult than anticipated. Those of us who face difficulties conceiving can feel alone and like they are the only ones facing setbacks.

Talking with your trusted friends and family as well as your health care team is important to get the support you need to make sense of a lot of medical information, navigate potential medical systems like fertility clinics, and deal with the anticipation and stress this big life event can bring.

Infertility is more common than we may think, even though many of us received fear-based messages throughout our younger years about how easy it is to “accidentally” get pregnant (which, while true for some is untrue for others). In Canada, one in six people wanting to be pregnant experience infertility when trying to conceive their first child or after a successful pregnancy (referred to as secondary infertility). Secondary infertility refers to parents who have failed to conceive after 12 months of trying to get pregnant or who have experienced recurrent miscarriages.

If you are having fertility problems, there are options and medical help available. It is important to seek support for the medical side of infertility but also for the emotional impacts it can have. Having to adjust our expectations of what we thought our lives would look like can bring up grief and sadness. Similarly, going through fertility treatments can bring a lot of stress on our bodies, our minds, and our relationships. Talking about it often means we can connect with others who have been through this experience and this can be helpful to many of us.

While many of us will be successful in using treatment for fertility challenges, some of us will remain involuntarily childless. There isn’t much information available on involuntary childlessness and this can mean that those of us who face this situation get little social support. It is harder to deal with physical and mental health problems such as anxiety and depression that can arise when dealing with grief if you don’t have proper support. If you are finding yourself involuntarily childless, know that you are not alone, it is a serious issue, and you deserve support and care. Your health care team can play a role in making sure you are receiving the attention you deserve.

Miscarriages are common and they happen in about 15 to 20% of pregnancies. Most of the time, they happen during the first eight weeks of pregnancy. We usually don’t know the cause of miscarriages. While it can be tempting to blame ourselves when a miscarriage happens, it’s important to remember that it is not your fault.

When pregnant, it is important we take any vaginal bleeding seriously and seek medical help if it happens. About 20% of people who are pregnant will have some bleeding before the 20th week and about half of those pregnancies will continue without any other issues. But sometimes it can be a symptom of a miscarriage. If you are experiencing bleeding during pregnancy, medical help will be needed to monitor and, if necessary, manage the miscarriage.

Despite how common this experience is, we don’t talk about it enough. Many people feel quite alone in their experience. It can also bring about changes in our relationships, as we start to have to shift our expectations around building our families or experience the grief of losing a pregnancy that we had already started connecting with. Some of us experience deep grief when losing a wanted pregnancy and it can take time to recover and move through this difficult experience. Your loved ones, community, and health care team can all be sources of support when you are facing such an experience.

Stillbirth and infant loss

While it is rare, people can lose their babies later in their pregnancy. Some babies are born too soon, with a serious illness, or with problems their healthcare team did not expect. In those rare cases, some babies die either late in the pregnancy, shortly before birth, during birth, or shortly after.

Experiencing a stillbirth or infant loss is devastating and compassionate care is crucial. Stillbirth and infant loss not only bring about grief, but they can bring about changes in our partnerships and relationships as we try to make sense of our grief. The Pregnancy and Infant Loss Network has helpful resources for those experiencing infant loss and bereavement. It includes a section for health care providers to build their capacity to provide skilled and compassionate care for those who experience infant loss.

If you have experienced miscarriage, stillbirth or infant loss, there are grief groups in many areas (as well as virtual groups) where you can meet with others and talk openly about your experience. This can be helpful for some people in processing grief, though there is no single way to grieve. It can be helpful to search online for “pregnancy and infant loss support groups near me” to find these groups.

When you choose to pursue a pregnancy, pregnancy care is important for your own health and the health of your pregnancy. Pregnancy care consists of prenatal (before birth) and postpartum (after birth) health care for people who are pregnant. This includes getting important information, tests, treatments, and care to help decrease risks during pregnancy and increase the chance of a safe and healthy delivery. Regular prenatal visits can help health care providers monitor pregnancies and identify any problems or complications before or if they become serious.

While a lot of the information available on pregnancy focuses on prenatal care, postpartum care is also very important. The postpartum period lasts six to eight weeks, beginning right after the baby is born. During this period, someone who has just given birth will go through many physical and emotional changes while learning how to care for a newborn and experiencing sleep deprivation. Postpartum care involves monitoring the postpartum person’s health to identify any possible complications from labour and delivery, getting proper rest, nutrition, lactation support if necessary, vaginal care, and mental health support when needed.

Obstetric violence refers to poor treatment and abuse experienced by individuals in reproductive healthcare settings, typically during the childbirth process. This can range from non-consensual medical treatments or interventions (for example, the use of episiotomy or instruments like forceps without consent) to coercive sterilizations or C-sections, denial of care (including denial of pain management), shaming and stigma from healthcare providers, being threatened with the involvement of the Children’s Aid System (particularly for Indigenous and racialized women who disproportionately have their children seized at higher rates), and overt violence during labour (physical violence, verbal humiliation and harassment, sexual assault, or coercive vaginal exams).The impact of experiencing obstetric violence can be devastating and include health complications, severe psychological distress, trauma, and in some cases death due to neglect.

While most people will have positive and affirming reproductive healthcare experiences, many people experience mistreatment during birth and their postpartum care, a reality that is more and more openly acknowledged and discussed. This is particularly true for those impacted by racism, colonialism, and poverty, as well as people who use drugs. Inaccurate stereotypes around who constitutes a “proper parent” and who is seen as knowledgeable and competent are often to blame.

Birth support workers, including doulas and midwives, can be an excellent support to help mitigate potential violent experiences in reproductive care settings. Unfortunately, doulas and midwives are not always available due to restrictive policies around midwifery and doula care as well as prohibitive costs. Others may not choose to have a doula or midwife as part of their birthing team.

For more information on obstetric violence, please visit the page of the Obstetric Justice Project, a patient advocacy initiative aimed at exposing mistreatment and abuse in reproductive healthcare across Canada.

In Canada, maternal mortality rates are low due to access to high quality health care. However, this number has risen slightly in recent years, from 6 deaths per 100,000 in 1990 to 12 in 2010. This increase is most likely due to an increase in caesarian sections, IVF births, pre-existing health conditions, and people choosing to carry out pregnancies at later ages.

Due to inequities and structural racism within the health care system, this rate is disproportionately higher for Black, Indigenous, and People of Colour (BIPOC) in Canada. Some explanations of this are due to different health conditions that disproportionately impact BIPOC communities, due to having a lack of access to preventative health care, or chronic stress due to experiencing racism, as well as structural forces like the placement of grocery stores and the availability of nutritious food. Other explanations look at health care access, and how BIPOC individuals may avoid accessing health care due to previously stigmatizing or racist experiences. Additionally, recent research has been looking at the differential treatment of BIPOC individuals within health care settings and how often, health care providers are not trained in challenging their own internalized assumptions, or in identifying how health symptoms present differently from person to person.

Your birth team (for example, your OB-GYN, midwife, doula, etc.) can help answer your questions and prepare you for what to expect during childbirth, as well as help you with strategies to cope with any anxiety you may be feeling around childbirth.

For more on why maternal mortality disproportionately impacts Black communities, read this Harvard’s report.