Menstruation Abnormalities

Problems that interfere with a woman’s regular menstrual cycle are known as menstrual disorders. They include uncomfortable cramping throughout the period, unusually heavy bleeding, or no bleeding at all.

Between puberty and menopause, menstruation takes place. The monthly flow of blood from the uterus through the cervix and out through the vagina is known as menstruation, often known as “menses” or a “period.”

Some Abnormalities are:

Dysmenorrhea

Dysmenorrhea is the medical term for painful menstrual periods which are caused by uterine contractions.

Types of dysmenorrhea

• Primary dysmenorrhea -refers to recurrent pain,
• while secondary dysmenorrhea results from reproductive system disorders
• Both can be treated

Primary dysmenorrhea

• Is the name for common menstrual cramps that come back over and over again (recurrent) and aren’t due to other diseases
• Pain usually begins one or two days before you get your period or when bleeding actual starts
• You may feel pain ranging from mild to severe in the lower abdomen, back or thighs
• Pain can typically last 12 to 72 hours
• Other associated symptoms-nausea, vomiting, fatigue, diarrhea
• may become less painful as you get older and may stop entirely if you have a baby

Secondary dysmenorrhea

• Is the name for painful periods because of a disorder or an infection in your female reproductive organs
• Pain from secondary dysmenorrhea usually begins earlier in the menstrual cycle and lasts longer than common menstrual cramps
• usually don’t have nausea, vomiting, fatigue or diarrhea

What causes painful menstrual cramps?

Menstrual cramps happen when a chemical called prostaglandin makes the uterus contract (tighten up). The uterus, the muscular organ where a fetus grows, contracts throughout your menstrual cycle. During menstruation, the uterus contracts more strongly. If the uterus contracts too strongly, it can press against nearby blood vessels, cutting off the supply of oxygen to muscle tissue. You feel pain when part of the muscle briefly loses its supply of oxygen.

How does secondary dysmenorrhea cause menstrual cramps?

Menstrual pain from secondary dysmenorrhea is a result of problems with the reproductive organs. Conditions that can cause cramping include:

• Endometriosis: A condition in which the tissue lining the uterus (the endometrium) is found outside of the uterus. Because these pieces of tissue bleed during your period, they can cause swelling, scarring and pain
• Adenomyosis: A condition where the lining of the uterus grows into the muscle of the uterus. This condition can cause the uterus to get much bigger than it should be, along with abnormal bleeding and pain
• Pelvic inflammatory disease (PID): An infection caused by bacteria that starts in the uterus and can spread to other reproductive organs. PID can cause pain in the stomach or pain during sex
• Cervical stenosis: Narrowing of the cervix, or the opening to the uterus
• Fibroids (benign tumors): Growths on the inside, outside or in the walls of the uterus

What are the symptoms of menstrual cramps?

If you have painful periods, you may have:

• Aching pain in the abdomen (pain may be severe at times)
• Feeling of pressure in the abdomen
• Pain in the hips, lower back and inner thighs

How can you relieve mild menstrual cramps?

• Place a heating pad or hot water bottle on your lower back or abdomen
• Rest when needed
• Avoid foods that contain caffeine
• Avoid smoking and drinking alcohol
• Massage your lower back and abdomen
• Exercise daily
• Pain-killer
• Oral contraceptive pills

For relieving secondary dysmenorrhea –

• oral contraceptives
• other types of medications
• surgery

What types of alternative therapies might help with menstrual cramping?

• Yoga
• Massage
• Acupuncture and acupressure
• Relaxation or breathing exercises

Premenstrual syndrome (PMS)

Premenstrual syndrome (PMS) is a combination of symptoms that many women get about a week or two before their period.

PMS is a combination of physical and emotional symptoms that many women get after ovulation and before the start of their menstrual period. Researchers think that PMS happens in the days after ovulation because estrogen and progesterone levels begin falling dramatically if you are not pregnant. PMS symptoms go away within a few days after a woman’s period starts as hormone levels begin rising again. PMS symptoms are different for every woman. You may get physical symptoms, such as bloating or gassiness, or emotional symptoms, such as sadness, or both. Your symptoms may also change throughout your life.

Physical symptoms of PMS can include:

• Swollen or tender breasts
• Constipation or diarrhoea
• Bloating or a gassy feeling
• Cramping
• Headache or backache
• Leg pain
• Lower tolerance for noise or light

Emotional or mental symptoms of PMS include:

• Irritability or hostile behaviour
• Feeling tired
• Sleep problems (sleeping too much or too little)
• Appetite changes or food cravings
• Trouble with concentration or memory
• Tension or anxiety
• Depression, feelings of sadness, or crying spells
• Mood swings
• Less interest in sex

These tips will help you be healthier in general, and may relieve some of your PMS symptoms.

• Get regular aerobic physical activity throughout the month. Exercise can help with symptoms such as depression, difficulty concentrating, and fatigue.
• Choose healthy foods most of the time. Avoiding foods and drinks with caffeine, salt, and sugar in the two weeks before your period may lessen many PMS symptoms.
• Get enough sleep. Try to get about eight hours of sleep each night. Lack of sleep is linked to depression and anxiety and can make PMS symptoms such as moodiness worse.
• Find healthy ways to cope with stress. Talk to your friends or write in a journal. Some women also find yoga, massage, or meditation helpful.
• Don’t smoke. In one large study, women who smoked reported more PMS symptoms and worse PMS symptoms than women who did not smoke.
• Over-the-counter pain relievers may help lessen physical symptoms, such as cramps, headaches, backaches, and breast tenderness.
• Prescription medicines may help if over-the-counter pain medicines don’t work:
• Hormonal
• Antidepressants Diuretics
• Anti-anxiety medicine may help reduce feelings of anxiousness.

All medicines have risks. Talk to your doctor about the benefits and risks.

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Menorrhagia

Heavy menstrual bleeding (formerly known as menorrhagia) is a common disorder among people who menstruate. It refers to bleeding lasting longer than seven days and involves more blood flow sometimes with clots than is typical during menstruation.

Menstrual bleeding that's so heavy that it interferes with your daily life is never normal.

How common are heavy periods?

Heavy period bleeding is common, affecting anywhere from 27% to 54% of people who menstruate.

Is heavy menstrual bleeding serious?

Heavy menstrual bleeding can be serious if you lose so much blood that you show signs of  anemia . Anemia is a condition arising from having too little iron in your body. Anemia can be life-threatening without treatment.

Also, some of the conditions that can cause heavy period bleeding, like cancer, require early medical intervention.

What are the signs and symptoms of heavy menstrual bleeding?

Signs of heavy menstrual bleeding include:

• Abdominal pain.
• Periods lasting longer than seven days.
• Passing blood clots that are the size of a quarter or bigger. The blood may appear red, pink, brown, or even rust-like.
• Bleeding through 1 or more tampons or pads each hour for more than two consecutive hours.
• Losing more than 80 milliliters of blood during your period instead of what is typical, 35-40 milliliters.
• Anemia symptoms, like feeling exhausted, tired or short of breath.
• With anemia, you may also notice signs of a condition called pica. Pica symptoms include hair loss, pale skin, and the urge to eat non- food items (paper, hair, dirt, etc.).

See your provider if have these symptoms.

How do you know if you have heavy menstrual bleeding?

Heavy menstrual bleeding interferes with your quality of life. Many people with heavy periods assume that periods are supposed to be inconvenient and uncomfortable. They may have watched people in their families live with heavy periods without seeking care and followed their example. But periods should never cause you to restrict activities or accept inconvenience.

During your period, you should be able to:

• Wear a standard pad or tampon every three to four hours without changing it.
• Wear a single menstrual product without having to double-up (wearing two pads or two tampons at the same time) at any point.
• Leave your home without having to pack extra bags of pads or clothing changes.
• Live your life as usual, without missing work, avoiding going out in public, or skipping activities you enjoy.

If your periods are disrupting your life, it's time to see your provider.

How long does heavy menstrual bleeding last?

Heavy menstrual bleeding is a period that lasts longer than seven days. How long you bleed depends on what's causing your bleeding.

Hormone imbalances

The hormones that your body produces, like estrogen and progesterone, help regulate your menstrual cycle, including how heavy your periods are. Having a condition that causes your hormones to become imbalanced can lead to heavy period bleeding. Causes include

• Anovulation.
• Thyroid disease.
• Polycystic ovary syndrome (PCOS).

Weighing more than your ideal body weight can interfere with your body's hormone production and lead to heavy menstrual bleeding, too.

Non-cancerous growths in your uterus

Benign growths in your uterus and conditions that cause cells in your uterus to grow improperly can cause heavy menstrual bleeding, too. Causes include:

• Polyps.
• Fibroids.
• Adenomyosis.

Cancerous growths in your uterus

Conditions that increase your risk of getting cancer, including endometrial hyperplasia, as well as cancers that affect your reproductive system, can cause heavy menstrual bleeding. These include:

• Uterine cancer.
• Cervical cancer.

Infection

Infections, including sexually transmitted infections (STIs) can cause heavy bleeding. These include:

• Trichomoniasis.
• Gonorrhea.
• Chlamydia.
• Chronic endometritis.

Pregnancy complications

Heavy bleeding can be a warning sign of pregnancy complications, such as:

• Miscarriage.
• Ectopic pregnancy.
• C-Section niche. High numbers of cesarean sections can lead to a scar that creates a pocket in your uterus. That pocket can collect blood, which you can later bleed.

Other medical conditions

Heavy menstrual bleeding is a symptom associated with various conditions, including bleeding disorders and non-bleeding disorders. Some common medical conditions that can lead to heavy bleeding are:

• Von Willebrand disease.
• Liver disease.
• Kidney disease.
• Pelvic inflammatory disease (PID).
• Leukemia or platelet disorders.

Medications

Certain medicines can cause heavy menstrual bleeding, too. These include:

• Blood thinners and aspirin.
• Hormone replacement therapy.
• Tamoxifen (breast cancer drug).
• Intrauterine devices (IUDs).
• Birth control pills and injectables (NuvaRing®, Depo-Provera®, Implanon®).

Failing to remove contraceptive devices when needed can also cause abnormal uterine bleeding.

Diagnosis and Tests

How is heavy menstrual bleeding diagnosed?

Your healthcare provider will ask a series of questions about your medical history and menstrual cycle to diagnose heavy menstrual bleeding.

Your provider may ask about:

• Your age when you got your first period.
• The number of days your period lasts.
• The number of days your period is heavy.
• Family members with a history of heavy menstrual bleeding.
• Your pregnancy history and current birth control methods.
• Current medications you're taking, including over-the-counter ones.

Come prepared to talk about your quality of life, too. Your provider needs to know if you've been doubling up on menstrual products, avoiding activities or placing restrictions on your life in any way because of heavy periods.

What tests will be done to diagnose heavy menstrual bleeding?

Your provider will do a physical exam and a pelvic exam. Many non-invasive procedures are available that can help your provider diagnose what's causing your bleeding, such as:

• A sonohysterogram (saline-infusion sonography) to check for problems in the lining of your uterus. A sonohysterogram allows your provider to see the inside of your uterus while it's filled with saline. It offers higher accuracy and sensitivity when detecting abnormalities in your uterine cavity than an ultrasound without saline.
• A hysteroscopy to check for polyps, fibroids or other irregular tissue in your uterus. Hysteroscopy allows your provider to inspect your vagina, cervix and uterus. Your provider can remove growths that may be causing your bleeding, like fibroids or polyps, during a hysteroscopy.

You may have other tests, depending on your age and how severe your symptoms are. Other tests may include:

• A blood test to check for signs of anemia, clotting issues, or thyroid disease.
• A Pap smear to study cells from your cervix for changes that may indicate cancer.
• An endometrial biopsy to check uterine tissue for cancer cells or other irregularities.
• Transvaginal ultrasound to check the appearance of the organs and tissues in your pelvis.
• Magnetic resonance imaging (MRI) to check for abnormal structures inside your uterus when an ultrasound doesn't provide enough information.
• A cervical culture to test for infection, as indicated by your medical history and the results of your physical exam

Management and Treatment

How is heavy menstrual bleeding treated?

Treatment depends on what's causing your bleeding, how severe your bleeding is, your health, age and medical history. Also, treatment depends on your response to certain medicines and your preferences. For instance, you may not want to have a period at all, or you may want to reduce your bleeding. In addition, your plans to get pregnant will affect your treatment options.

Talk with your provider about your health concerns and your goals for treatment.

Medications used to treat heavy menstrual bleeding

• Iron supplements improve your iron stores.
• Nonsteroidal Anti-inflammatory Drugs (NSAIDs) like Ibuprofen® or Aspirin® can ease your cramps and reduce your bleeding.
• Birth control (pills, vaginal ring, patch, IUDs) may help make your periods more regular and lighten your blood flow.
• Hormone therapy (HT) can help balance the amount of estrogen and progesterone in your body so that your menstrual flow isn't as heavy. IT is often recommended for heavy menstrual bleeding associated with perimenopause but comes with risks that you should discuss with your provider.
• Gonadotropin-releasing hormone (GnRH) agonists can temporarily stop or reduce bleeding by preventing ovulation.
• Gonadotropin-releasing hormone (GnRH) antagonists (elagolix®) can manage heavy period bleeding related to fibroids.
• Desmopressin nasal spray can stop bleeding associated with von Willebrand disease by helping your blood clot.
• Antifibrinolytic medicines, like tranexamic acid, prevent clots from breaking down and causing excessive bleeding.

Procedures used to treat heavy period bleeding

Hysteroscopy is often used to diagnose and treat heavy period bleeding. With an operative hysteroscopy, your provider inserts a thin, lighted tube into your vagina that allows them to inspect your uterine cavity. The hysteroscope acts as a precise surgical instrument, too, and can help your provider remove any growths that may be causing your bleeding.

Other procedures include:

• Myomectomy. A procedure that removes fibroids from your uterus.
• Uterine artery embolization (UAE). A procedure that restricts the blood flow from fibroids and tumors.
• Endometrial ablation. A procedure that destroys all or part of the lining of your uterus. Often, your provider will recommend sterilization afterward. Endometrial ablation puts a fetus at risk of serious complications if you become pregnant.
• Hysterectomy. Surgery that removes your uterus and prevents you from having periods or getting pregnant.

How is heavy period bleeding managed?

Treatment may begin with medication and then progress to minor procedures and surgical options. Speak with your provider to decide which options work best for your health

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Metrorrhagia

Metrorrhagia is abnormal bleeding between regular menstrual periods, prolonged bleeding or an extremely heavy period.

What causes abnormal uterine bleeding?

Abnormal uterine bleeding can have many causes, including a variety of medical conditions and even stress:

Hormone imbalances

• Anovulation.
• Thyroid disease.
• Polycystic ovary syndrome (PCOS).

Weighing more than your ideal body weight can lead to hormone imbalances that may cause abnormal uterine bleeding too.

Structural abnormalities in your uterus

• Polyps.
• Fibroids.
• Adenomyosis.

Precancer and cancer

• Uterine cancer.
• Cervical cancer.
• Vaginal cancer.
• Ovarian cancer.
• Endometrial hyperplasia.

Infections

• Trichomoniasis.
• Cervicitis.
• Chlamydia.
• Gonorrhoea.
• Endometritis.
• Vaginitis.

Other medical conditions

• Von Willebrand disease.
• Liver disease.
• Kidney disease.
• Pelvic inflammatory disease (PID).
• Leukemia or platelet disorders.

Medications

• Blood thinners and aspirin.
• Hormone replacement therapy.
• Tamoxifen (breast cancer drug).
• Intrauterine devices (IUDs).
• Birth control pills and injectables Retained foreign bodies and trauma

Forgetting to remove an IUD can lead to infection and abnormal bleeding. Trauma to your uterus, caused by an injury, can also cause bleeding

How is abnormal uterine bleeding diagnosed?

• A pelvic exam.
• A cervical exam.
• A Pap smear (Pap test).
• A pregnancy test. A miscarriage causes heavy bleeding.
• Blood tests.
• A thyroid test.
• Hormone levels test.
• hysteroscopic exam of your uterus lining (endometrium). This test checks for fibroids, polyps or signs of cancer.
• A pelvic ultrasound.
• A biopsy of your endometrium.

How is abnormal uterine bleeding treated?

Your treatment depends on what’s causing your bleeding. Medications and surgical options are available to manage your bleeding or treat what’s causing it. Medications

Medications used to treat abnormal uterine bleeding include:

• Birth control pills.
• Progestin (can be given by a shot, implant or device placed in your uterus called an IUD).
• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen.
• Gonadotropin-releasing hormone (GnRH) agonists can temporarily stop or reduce bleeding by preventing ovulation.
• Gonadotropin-releasing hormone (GnRH) antagonists can manage heavy period bleeding related to fibroids.
Surgery
• Hysteroscopy. A procedure where your provider removes atypical structures in your uterus, like fibroids and polyps.
• Uterine artery embolization. Stops blood flow to fibroids, causing them to shrink.
• Myomectomy. Removes fibroids while keeping your uterus intact and preserving your ability to get pregnant and have children.
• Endometrial ablation. Destroys your uterus lining through the use of a laser, heat, electricity, microwave energy or freezing. You shouldn't have this procedure if you want to get pregnant and have children.
• Hysterectomy. Removes your uterus. Hysterectomy is often used to treat cancer or cancerous changes in your endometrium. Advanced stages of cancer may need radiation or chemotherapy.

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Amenorrhea

Amenorrhea is the absence of menstruation, often defined as missing one or more menstrual periods. Primary amenorrhea refers to the absence of menstruation in someone who has not had a period by age 15.

The most common causes of primary amenorrhea relate to hormone levels, although anatomical problems also can cause amenorrhea

Secondary amenorrhea refers to the absence of three or more periods in a row by someone who has had periods in the past. Pregnancy is the most common cause of secondary amenorrhea, although problems with hormones also can cause secondary amenorrhea.

Treatment of amenorrhea depends on the underlying cause.

Medications

Certain medications can cause menstrual periods to stop, including some types of:

• Antipsychotics
• Cancer chemotherapy
• Antidepressants
• Blood pressure drugs
• Allergy medications

Lifestyle factors

Sometimes lifestyle factors contribute to amenorrhea, for instance:

• Low body weight. Excessively low body weight — about 10% under normal weight — interrupts many hormonal functions in the body, potentially halting ovulation. Women who have an eating disorder, such as anorexia or bulimia, often stop having periods because of these abnormal hormonal changes.
• Excessive exercise. Women who participate in activities that require rigorous training, such as ballet, may find their menstrual cycles interrupted. Several factors combine to contribute to the loss of periods in athletes, including low body fat, stress and high energy expenditure.
• Stress. Mental stress can temporarily alter the functioning of your hypothalamus — an area of your brain that controls the hormones that regulate your menstrual cycle. Ovulation and menstruation may stop as a result. Regular menstrual periods usually resume after your stress decreases.

Hormonal imbalance

Many types of medical problems can cause hormonal imbalance, including:

• Polycystic ovary syndrome (PCOS). PCOS causes relatively high and sustained levels of hormones, rather than the fluctuating levels seen in the normal menstrual cycle.
• Thyroid malfunction. An overactive thyroid gland (hyperthyroidism) or underactive thyroid gland (hypothyroidism) can cause menstrual irregularities, including amenorrhea.
• Pituitary tumor. A noncancerous (benign) tumor in your pituitary gland can interfere with the hormonal regulation of menstruation.
• Premature menopause. Menopause usually begins around age 50. But, for some women, the ovarian supply of eggs diminishes before age 40 and menstruation stops.

Structural problems

Problems with the sexual organs themselves also can cause amenorrhea. Examples include:

• Uterine scarring. Asherman's syndrome, a condition in which scar tissue builds up in the lining of the uterus, can sometimes occur after a dilation and curettage (D&C), cesarean section or treatment for uterine fibroids. Uterine scarring prevents the normal buildup and shedding of the uterine lining.
• Lack of reproductive organs. Sometimes problems arise during fetal development that lead to missing parts of the reproductive system, such as the uterus, cervix or vagina. Because the reproductive system didn't develop fully, menstrual cycles aren't possible later in life.
• Structural abnormality of the vagina. An obstruction of the vagina may prevent visible menstrual bleeding. A membrane or wall may be present in the vagina that blocks the outflow of blood from the uterus and cervix.

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Oligomenorrhea

Oligomenorrhea is defined as irregular and inconsistent menstrual blood flow in a woman. Some change in menstrual flow is normal at menarche, postpartum, or in the perimenopausal period.

What are the signs and symptoms of oligomenorrhea?

Missed and delayed periods are the most common sign of oligomenorrhea, but you may experience other symptoms depending on what’s causing your periods to be unpredictable. Symptoms include:

• Acne.
• Headaches.
• Hot flashes.
• Abdominal pain.
• Vaginal discharge.
• Impaired vision.
• Excess hair growth on your face and body.

What causes oligomenorrhea?

Conditions that cause hormone imbalances in your body are often to blame for infrequent period

Causes of oligomenorrhea include:

• PCOS
• Androgen-secreting tumors
• Cushing’s syndrome
• Prolactinoma
• primary ovarian syndrome
• hyperthyroidism
• congenital adrenal hyperplasia
• Pelvic inflammatory disease (PID):
• Asherman’s syndrome (endometrial adhesions)
• diabetes
• Eating disorders:
• Extreme physical activity:

Certain medications can lead to infrequent periods, including:

• Hormonal contraceptives, like birth control pills.
• Antipsychotics.
• Antiepileptics.

How is oligomenorrhea diagnosed?

Medical history

• What a normal period’s like for you: Your provider will want to know how many days pass between periods, how heavy your periods are, etc. Understanding what a typical period means for you helps your provider understand the severity of your issue.
• Your family’s medical history: Having a family member with a condition that causes oligomenorrhea (ex. PCOS) may increase the likelihood that you’ll have it, too.
• Your habits & lifestyle: Your provider may ask about your diet and exercise habits to see if your routine may be causing infrequent periods. They may also ask about whether you’re having unprotected sex, to rule out whether an STI may be causing your period irregularities.
• Medications you’re taking: Hormonal contraceptives, antipsychotics, antiepileptics and steroids have all been linked to oligomenorrhea.

Exams

Examinations include:

• Physical Exam: Your provider inspects your face, neck, breasts and abdomen to check for signs of conditions that are causing oligomenorrhea.
• Rectovaginal exam: Your provider inserts one gloved finger into your vagina and another into your rectum to feel for any masses inside your body.
• Vaginal speculum exam: An instrument called a speculum widens your vagina so that your provider can check your vagina and cervix for signs of bleeding, inflammation or scar tissue that may be causing issues. Your provider may order a cervical swab to test for an infection.
• Abdominal exam: Your provider feels for masses and tender spots in your abdomen.

Imaging

Imaging procedures include:

• CT scans: Detect masses that may be causing bleeding.
• Pelvic and abdominal ultrasounds: show signs of inflammation and PCOS.
• Magnetic resonance imaging (MRI): can confirm a prolactinoma diagnosis.

What tests will be done to diagnose oligomenorrhea?

Blood tests can help your provider check your hormone levels and blood sugar. Your provider may test your levels of:

• Thyroid-stimulating hormone (TSH): Decreased levels may indicate hypothyroidism.
• Follicle-stimulating hormone (FSH): Increased levels may indicate primary ovarian insufficiency.
• Luteinizing hormone (LH): Increased levels of LH in relation to FSH can help your provider diagnose PCOS.
• Prolactin: Increased prolactin levels may indicate prolactinoma.
• 17-OHP: Your levels of 17-OHP can help your provider diagnose congenital adrenal hyperplasia.
• Blood sugar: A HbA1c test can help your provider diagnose diabetes.

Management and Treatment

How is oligomenorrhea treated?

Treatment for oligomenorrhea depends on the cause.

• Hormone therapy: Your provider may prescribe birth control pills or other hormone treatments if your oligomenorrhea is caused by a hormone imbalance.
• Surgery: Your provider may remove tumors that are producing excess androgens.
• Lifestyle changes: You may need to make adjustments to your diet and physical activity if nutritional deficiencies or strenuous activities are causing your issues.

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