Menstrual Dysfunction

Menstrual periods (periods or menstruation) denote the regular shedding of the lining of the womb that occurs in women of childbearing age. It is a natural process and indicates normal functioning of the body.

Menarche

The very first period in a woman’s life is known as ‘menarche’ and the average age of the menarche in the UK now is 11 years. There usually is a short phase of irregularity of periods after the menarche before it eventually settles to a regular pattern.

Menopause

The very last period in a woman’s life is known as ‘menopause’. The average age of the menopause in the UK now is 51 years. There usually is a variable phase of irregularity of periods before the menopause.

Normal menstrual patterns

Periods vary in duration and amount of blood loss over time in the same woman as well as between different women. We accept as normal periods that last between 2 and 7 days. The amount of loss is a subjective one and so we rely on women to tell us what they perceive their loss to be (whether light, average or heavy). The interval from one period to another is called the ‘menstrual cycle’ and its length varies from one woman to another and even from cycle to cycle in the same woman. We accept as normal cycle lengths that range from 21 to 35 days and that do not vary by more than 7 days. Cycle lengths do not always remain the same and can change with advancing years; this is not abnormal and should not cause concern.

Care during periods

A few lifestyle changes may be necessary during periods. It is advisable for women to have regular showers rather than baths and to avoid swimming during this period. Various forms of sanitary pads and tampons that cater for all patterns of menstrual loss are readily available for use during periods. They all come with their manufacturer’s information detailing their good and bad points, and woman need to consult these to decide which best suit their circumstances. Pads and tampons need to be changed regularly, the number of times depending on individual circumstances (for instance amount of blood loss). There is no medical reason why a pad and tampon cannot be used at the same time so long as advice regarding both is adhered to, but a need for this may indicate excessive blood loss. Wearing a tampon for longer than is advised can lead to sores and infections in the vagina, as well as a potentially life-threatening illness called ‘toxic shock syndrome’. Any woman who experiences ill health (especially fever and a rash) while using a tampon needs to see her doctor urgently to find out why.

Myths about periods

Women are not unclean during a period! The material that is lost during a period is a mix of blood, broken down tissues from the lining of the womb and body water, and is mostly clean before passing out of the womb. There is no medical reason why a woman cannot have sex during a period so long as both partners appreciate the aesthetic aspects of this. During a period is in fact the safest time in the cycle to avoid getting pregnant. Women are however more likely to acquire or transmit sexually transmitted infections if they have unprotected sex during a period.

Heavy periods (menorrhagia)

Menorrhagia means menstrual blood loss that is heavier than normal and this might relate to the duration and/or flow. Menstrual blood loss varies enormously and what one woman considers excessive might be normal to another. It is therefore difficult to establish a standard for normality and so we rely on women to tell us what they perceive their loss to be. Any period that lasts longer than 7 days or during which greater than 80mls of blood is lost is generally regarded as heavy. For practical purposes however, doctors will investigate and treat any woman who reports her periods are heavy. The magnitude of this problem is reflected by the fact that 2 in 5 women visit a gynaecologist because of period problems (mostly heavy).

What causes heavy periods?

Periods may naturally be heavy in some women and this may run in some families. Many women with heavy periods have no disease of the womb or ovaries (a condition known as ‘dysfunctional uterine bleeding’). Causes of heavy periods can be placed in categories for convenience:

Women who do not make this connection may thus complain of sudden onset of heavier periods. Some women also complain of heavier periods following sterilisation although most of this effect is due to their coming off the pill.

Problems of heavy periods

Heavy periods may cause anaemia increasing the need for blood transfusion. Association of heavy periods with cancer of the womb or cervix makes it important that the cause is found and treated. Besides these, heavy periods mainly have a nuisance factor.

How we investigate heavy periods

We sometimes use a picture chart to monitor the number of pads and/or tampons used throughout the period. Blood tests are done to check for anaemia, other blood disorders and to determine hormone levels. Ultrasound scans of the pelvis are used to look for tumours. We sometimes inspect the inside of the womb with a telescope passed through the neck of the womb (hysteroscope) and take a scrape (biopsy) from the womb to check for cancer. How we treat heavy periods

In many cases explanation and reassurance may be all that is required. Treatment of the underlying cause usually sorts the problem. Where no cause is found (dysfunctional uterine bleeding) treatment will depend on the woman’s age and future fertility plans. The available treatment options include:

Painful periods (dysmenorrhoea)

Painful menstrual periods are also simply known as dysmenorrhoea. Women’s perceptions of period pains vary as much perhaps as their individual pain thresholds. Therefore what one woman considers painful another might accept as just another fact of life. Also, while some women may wish for completely pain-free periods others may consider some degree of pain acceptable. Dysmenorrhoea may start with a woman’s first few menstrual periods (primary) or it may start after the woman has had pain-free periods for some time (secondary). The nature and intensity of the pain experienced with each type varies considerably:

What causes dysmenorrhoea?

Primary dysmenorrhoea usually has no underlying cause. The hormonal fluctuations that occur in cycles where ovulation (release of an egg) has taken place are thought to increase the levels of a substance called prostaglandin in the womb. This substance leads to very intense contractions of the womb muscles giving rise to the intense pain of primary dysmenorrhoea. Secondary dysmenorrhoea is usually due to an underlying cause although this is not always detectable. Causes include endometriosis, swellings of the womb (fibroids and adenomyosis), polyps in the lining of the womb and pelvic infections. Heavy periods may lead to secondary dysmenorrhoea by causing blood clots to form in the womb.

Problems of dysmenorrhoea

Dysmenorrhoea can be a devastating condition with the potential to disrupt the family, social and work life of the woman.

How we investigate dysmenorrhoea

We will normally investigate and treat any woman who finds painful periods a problem. The history and examination are crucial to making a correct diagnosis. We take genital tract swabs to exclude infection and perform an ultrasound scan of the pelvis and sometimes day case laparoscopy (keyhole inspection of the pelvis).

How we treat dysmenorrhoea

Treatment of primary dysmenorrhoea is primarily relief of pain. This is achieved with mild to moderate strength painkillers and anti-inflammatory medicines. The combined oral contraceptive pill is also useful in relieving this pain because it prevents ovulation, a necessary event for primary dysmenorrhoea to occur. Occasionally, we offer to place a Mirena coil in the womb under local or general anaesthesia. Treatment of secondary dysmenorrhoea is treatment of the underlying cause. Endometriosis can be treated by medicines to suppress the disease or surgery to remove the deposits in the pelvis. Antibiotics are used to treat pelvic infections and surgery may be used to deal severe complications like pelvic pus collection. Polyps of the womb can be removed by surgery. Treatment of fibroids and adenomyosis depends on the woman’s wishes regarding future fertility; medicines are used to reduce the size of the womb and relieve pain until the fibroids can be removed by surgery (myomectomy). Ultimately, removal of the womb (hysterectomy) is an option for women who have no wish for future fertility.

Absence of Periods (amenorrhoea)

Amenorrhoea refers to the continuous absence of menstrual periods for a period of six months or more.

Causes of amenorrhoea

There are several causes of amenorrhoea that we can place in categories for convenience:

Is amenorrhoea harmful?

It depends on the underlying cause. Absence of periods is not on its own harmful, but harm may come from lack of the hormone oestrogen. Amenorrhoea that persists for longer than six months increases the risk of osteoporosis and sometimes pre-cancer of the lining of the womb. Women with low oestrogen levels (as in anorexia) will be at increased risk of osteoporosis while those with normal or high oestrogen levels (as in polycystic ovary syndrome) will be at increased risk of pre-cancer. Women may experience hot flushes during this period.

How we investigate amenorrhoea?

This depends on what we think is the most likely cause. Common tests include blood tests (for hormones and chromosomes), ultrasound scan of the pelvis and special scans of the brain (CT or MRI scan). We sometimes perform a hormone (progesterone) challenge test by giving hormone tablets for 7-14 days; a positive result is the commencement of a period after the tablets are stopped. Some women will require operative investigations like laparoscopy to inspect the inside of the pelvis.

How we treat amenorrhoea

Treatment depends on what is causing the condition. Simply inducing ovulation may be all that is required in women with fertility problems. Women with low oestrogen levels at risk of osteoporosis will be offered appropriate protective strategies that might include ‘hormone replacement therapy’. We induce periods in women with normal or high oestrogen levels are at risk of pre-cancer of the womb to ensure a minimum of four periods a year. Women with premature ovarian failure will be offered counselling (including discussion about future fertility) and support to help them cope with the problem. They will be offered appropriate protective strategies that might include ‘hormone replacement therapy’. We will discuss egg/embryo donation for IVF treatment if they wish to have children subsequently.

Irregular periods (oligomenorrhoea)

Irregular periods or oligomenorrhoea affect a good number of women with menstrual difficulties and refers to menstrual cycles that last longer than 42 days or occur less than six times a year.

What causes irregular periods?

The causes of oligomenorrhoea are similar to those of amenorrhoea and can be placed into categories:

Problems of oligomenorrhoea

Oligomenorrhoea on its own is not harmful but its underlying cause could be. Women with normal or high blood oestrogen levels are at increased risk of developing pre-cancerous changes of the tissue lining the womb.

How we investigate oligomenorrhoea

The causes of oligomenorrhoea are similar to those of amenorrhoea and the tests done are similar; they depend on what we think is the most likely cause. Common tests include blood tests (for hormones and chromosomes), ultrasound scan of the pelvis and special scans of the brain (CT or MRI scan). Some women will require operative investigations like laparoscopy to inspect the inside of the pelvis.

How we treat oligomenorrhoea

The treatment of oligomenorrhoea depends on its cause. Simply inducing ovulation may be all that is required in women with associated fertility problems. Where there is no cause, treatment will depend on the risks and the woman’s wishes. Periods can be regularised with hormone tablets every 1-2 months. Women with premature ovarian failure will be offered counselling (including discussion about future fertility) and support to help them cope with the problem. They will be offered appropriate protective strategies that might include ‘hormone replacement therapy’. We will discuss egg/embryo donation for IVF treatment if they wish to have children subsequently.

‘women can conceive during periods of oligo/amenorrhoea; so, if you wish to avoid pregnancy use adequate contraception’