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What a Menstrual Problem Could Mean

here's as much variation in menstruation as there is in women. One sister has her first period at 11, the second at 14. One woman is “as regular as clockwork,” another's cycles fall randomly across the calendar.

There seems to be no rhyme or reason to it. Yet in most cases, this is all perfectly normal.

But when any menstrual symptom — pain, heavy bleeding, spotting, missed periods — begins to interfere with your life, it's time to seek medical attention. Most problems are relatively uncomplicated and respond well to medication or simple surgical procedures. Others could have more dangerous consequences if the underlying cause is not treated promptly. If you have any doubts about your menstrual problems, see your doctor.

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The Menstrual Cycle
Most women begin to menstruate between 11 and 13 years of age and continue until they reach menopause some 40 years later. Although the “normal” cycle is 28 days, there is no cause for concern if periods are spaced 25 to 34 days apart, since precise regularity is rare. During the “typical” 3-to-5 day menstrual period, the average woman loses less than 2 ounces of blood.

The first menstrual period separates childhood from adolescence. Along with breast enlargement and the growth of pubic hair, it signals a young woman's sexual maturity. This monthly vaginal discharge of blood, secretions, and cells from the surface of the uterus is the final step in a complex cycle that prepares the body to conceive a child.

Each cycle begins when, responding to a cascade of hormones, a dormant egg cell within one of the ovaries begins to ripen. Cells around the maturing egg release the female hormone estrogen, prompting the lining of the uterus (the endometrium) to thicken in preparation for receipt of a fertilized egg.

When it reaches maturity, the developing egg bursts from the ovary and begins its trip down the fallopian tube to the uterus in a process called ovulation. The supporting cells left behind after ovulation then begin to manufacture another hormone, progesterone, in addition to estrogen. This second hormone fosters further growth in the lining of the uterus.

If fertilization does not take place, the ovum dies and production of estrogen and progesterone stops. Robbed of its sustaining hormones, the thickened lining of the uterus begins to break down. The dead endometrial cells, along with a little blood, are then discharged in the menstrual flow.

Normal menstruation depends on the delicate orchestration of the hormones that govern development of the egg. The menstrual cycle can also be affected by disease, diet, emotions, and defective development of the reproductive organs.

Major Menstrual Disorders
Many women experience discomfort (sore, swollen breasts, minor pain in the lower abdomen, nervousness) before their periods. They may also have mild cramps when the menstrual flow starts. In most cases, these symptoms do not interfere with their normal activities and can be alleviated by diuretics (“water pills”) and salt reduction to reduce bloating; plus pain relievers such as aspirin, acetaminophen (Tylenol) and ibuprofen (Advil, Motrin).

For some women, however, symptoms can be more severe, signaling a condition that needs medical attention. These problems include:

Premenstrual irritability and mood swings (PMS)
Very painful periods
Heavy bleeding
Unusually short or long cycles
Failure to menstruate
Early menstruation
Toxic shock syndrome
Should you or your daughter experience any of these menstrual abnormalities, consult your doctor. He or she will take a complete medical history, perform a thorough physical examination, and conduct tests to diagnose the cause of the menstrual problems and determine the best course of treatment.

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Premenstrual Syndrome
Between 70 and 90 percent of menstruating women experience some degree of physical and mental changes before their periods, but only 10 to 20 percent suffer from Premenstrual Syndrome (PMS), a condition that seriously affects their home life, job performance, and personal relationships.

Most PMS sufferers have mood swings, irritability, and bursts of temper four to five days before menstruating, during or following ovulation, or from ovulation through the first days of their period. Other signs of PMS include bloating, sore breasts, weight gain, extreme depression, confusion, and insomnia. These symptoms usually disappear with the onset of the menstrual flow.

There is no agreement on the cause of PMS. Physicians usually concentrate on alleviating the most severe symptoms. Your doctor will probably recommend eliminating or reducing the salt and sugar in your diet and tell you to get regular exercise. If necessary, he or she will prescribe a diuretic for water retention and an analgesic for pain and headache. Tranquilizers and antidepressant medications can help alleviate mood swings and depression. For more about PMS, see chapter 3.

Painful Periods
The medical term for this problem is dysmenorrhea. It's a common complaint, especially among young women who have never borne children. Fifty percent of menstruating women have pelvic pain before or during their period, and 10 percent of them have cramps severe enough to incapacitate them one to three days each month. In the United States dysmenorrhea sufferers lose 140 million working hours each year. There are two types of dysmenorrhea, primary and secondary.

HOW HORMONES TRIGGER YOUR PERIOD

In a slow, steady, 4-week cycle repeated over and over between pregnancies, a woman's body gradually prepares for conception, then discards its work and begins again.

For most of the cycle, the lining of the uterus, (the endometrium, shown here at the bottom of the 28-day chart) grows steadily richer and thicker in preparation for the advent of a fertilized egg. This growth is spurred by increasing levels of estrogen, a hormone produced as an egg ripens to maturity. Once the egg is released (see center of chart), a second hormone, progesterone, kicks in to boost the endometrium to full readiness.

If conception doesn't occur, production of both hormones drops simultaneously (see days 21 to 28 of the chart). The enriched lining then breaks down and sloughs off, exiting the body in the monthly menstrual flow. Cued by this end-of-cycle trough in estrogen and progesterone levels, the body then begins the process anew. (For more information on the monthly ebb and flow of hormones, turn to chapter 17, “How the Reproductive System Works”.)


Primary Dysmenorrhea
In this form of the problem, there is no underlying physical abnormality. Symptoms may include sharp cramps in the lower abdomen immediately before the menstrual period or when bleeding begins. The pain, which is sometimes accompanied by nausea, vomiting, diarrhea, dizziness, headaches, a feeling of tension, and occasionally fainting, may spread to the upper legs and lower back.

The majority of women who suffer from primary dymenorrhea do not experience severe pain until the beginning of ovulation. Their menstrual cycles are usually regular, and a pelvic exam reveals no physical problems. Laboratory tests, however, usually show high levels of prostaglandins, substances which can cause both painful cramps and uterine contractions.

To relieve the cramps, most doctors prescribe prostaglandin-inhibiting medications. Aspirin is the weakest of these drugs. Motrin, Naprosyn, Anaprox, and Ponstel have proved more effective. Oral contraceptives are another alternative. By stopping ovulation and decreasing prostaglandin levels they can usually be relied on to eliminate cramps. In addition, recent research both in the United States and abroad has shown that magnesium, and even electrical nerve stimulation may reduce prostaglandin-induced menstrual pain.

Secondary Dysmenorrhea
This form of the condition usually occurs in older women. It is caused by physical disorders such as fibroid tumors of the uterus, or a condition called endometriosis, in which tissue from the uterine lining (endometrium) is found in the ovaries and other locations outside the uterus. Invasion of the wall of the uterus by endometrial tissue (a condition called adenomyosis) also may be at fault. Endometrial polyps are sometimes to blame. Pelvic inflammatory disease is another potential culprit. And occassionally, the problem is due to narrowing of the opening from the cervix into the vagina.

To identify the source of the problem, your doctor will take a case history and perform a pelvic exam using a variety of instruments and techniques, possible including x-ray and ultrasound. The doctor also may perform dilation and curettage, also called D&C, a minor procedure in which the cervix is opened so that a sample of endometrial tissue can be removed from the uterus for microscopic examination.

Endometriosis is the most common cause of secondary dysmenorrhea, especially in women over 37 years old who have had no babies for five years. For a full discussion of this disorder, turn to the chapter on “Keeping Endometriosis at Bay” later in this section.

If the problem is adenomyosis, surgical removal of the uterus (hysterectomy) may be necessary, though prostaglandin inhibiting drugs can alleviate the pain.

If fibroid tumors or endometrial polyps are at fault, surgery may be needed. (For more on this, see chapter 7, “Your Treatment Options for Fibroids,” later in this section.) In milder cases, prostaglandin inhibitors may suffice. If pelvic inflammatory disease turns out to be the culprit, antibiotics may provide a cure. (See chapter 6, “The Dangers of Pelvic Inflammatory Disease”). Narrowing of the cervix requires corrective surgery. Occasionally, an IUD may be the cause. If so, the doctor may prescribe prostaglandin inhibitors, or, if necessary, recommend removing the device and using another form of birth control.

Slight bleeding from the ovary during ovulation causes some women to experience light pain for a few days in the middle of the menstrual cycle. In contrast to most forms of secondary dysmenorrhea, this pain is rarely severe enough to require medical attention. In extreme cases the doctor may prescribe birth control pills to stop ovulation.

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Heavy Bleeding
Occasionally menstrual flow seems heavier than usual, or a period lasts longer than normal. In general, there is little cause for concern unless you find it necessary to use at least two extra sanitary pads or tampons a day. That means you have lost almost 3 ounces of blood over the course of a period. You should also see your doctor if a period lasts more than seven days, or two periods are spaced less than 21 days apart. Heavy or lengthy uterine bleeding occurring at regular intervals is usually a sign of an underlying physical problem.

When you go to the doctor, he or she will want to know about the frequency and amount of the bleeding, whether it's accompanied by pain or blood clots, what type of contraception you use, and whether you bruise easily or bleed often from places other than the uterus. The doctor will also do a number of tests. Urine and stool testing can detect possible problems in the urinary tract, stomach, and intestines that might cause the bleeding. If you are in your childbearing years, you should also have a pregnancy test, a Pap smear (if you haven't had one in 12 months), a biopsy of the endometrium, and a test for ovulation. If you are not ovulating, the doctor will usually perform a D&C of the endometrium .

In addition, if the physician suspects the bleeding stems from inflammation of the vagina, cervix, endometrium, or fallopian tubes, he or she will perform an internal exam, take a blood count, and may take tests for sexually transmitted diseases.

Causes and Cures
Tumors of the pelvic organs could be at fault. Fibroid tumors in the uterus are rarely cancerous but may cause heavy periods. Although small fibroids usually need no special treatment, your doctor may want to remove them. Removal of the entire uterus may be necessary if the fibroids are large or rapidly growing.

Endometrial cancer is another possible cause. Although this disease usually strikes after menopause, every women over 35 with heavy bleeding should be tested. If the test is positive, a complete hysterectomy (removal of the uterus, ovaries, and fallopian tubes) followed by radiation is the usual treatment.

Polyps, small growths attached to the wall of the uterus, can also cause excessive bleeding. Because there is a slight risk that the polyps will become malignant, especially after menopause, they are often removed.

Excessive estrogen production, combined with lack of progesterone, can cause continuous stimulation and overdevelopment of the endometrium, leading to heavy bleeding in both adolescence and the premenopausal years. To correct the condition, your doctor may prescribe progesterone to stop the bleeding. When periods become normal, one or two weeks on Provera each month for two or three months should promote shedding of the endometrium. If the problem stems from imbalance of other hormones, such as those in the thyroid, pituitary, or adrenal glands, the doctor will correct it with medication.

There are several other diseases that could be at fault. Both underactivity of the thyroid (hypothyroidism) and advanced liver disease can cause heavy bleeding. Women with leukemia (cancer of the white blood cells) and certain other blood disorders may also develop the problem.

Some medications can promote heavy bleeding. Among the offending drugs are steroids, digitalis (Digitoxin, Digoxin), and blood thinners such as Coumadin. Withdrawal of estrogen or progesterone medication can also be a cause.

A woman who menstruates normally loses little iron during her period, but if you bleed heavily, you may develop anemia (iron deficiency). In that case, the doctor will usually stop the bleeding with hormones and advise you to take an oral iron preparation.

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Unusually Long or Short Cycles
Although few women menstruate exactly every 28 days, extremely short (under 25 days) or long (over 34 days) cycles can be a cause for concern, especially if you plan to have children.

Short cycles often signal low levels of estrogen and progesterone in the system, possibly resulting from an undersupply of certain precursors. Lacking these hormones, the endometrium cannot develop properly, and infertility may result. Short cycles also develop as some women approach menopause. They can also result from over- or underactivity of the thyroid gland.

Irregular periods can be a sign of appproaching menopause. But they can also arise from an increase in the number of cells in a section of the endometrium. Endometrial hyperplasias are caused when too much estrogen is produced by a women who does not ovulate. To diagnose the problem, your doctor will probably perform a D&C, scraping cells from the endometrium and doing a biopsy. Mild hyperplasias are usually treated with monthly doses of progesterone. More serious hyperplasias require long-term progesterone therapy or even removal of the uterus.

Long cycles are not necessarily a problem. Many women with long cycles produce eggs and are fertile. Their ovaries are normal, and the eggs just take a long time to mature. By far the most common cause of an unexpectedly long cycle is simply pregnancy! However, some women with regular periods two to five months apart may have ovarian cysts. Also, when a very long cycle is accompanied by a sudden increase in body hair, a decrease in breast size, and enlargement of the clitoris; and menstruation eventually stops altogether, the problem could be a growth or tumor of the adrenal gland. To make a diagnosis, the doctor will take urine, glucose tolerance and other tests. A CT scan or Magnetic Resonance Imaging (MRI) might also be ordered.

Long cycles can also develop from over or underproduction of thyroid hormone.

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Failure to Menstruate
When periods fail to start by the age of 16 or 17, a young woman has the condition that doctors call primary amenorrhea. For most of these girls, the problem is nothing more serious than an unusual delay. But for a few, there may be a more important underlying cause. Doctors divide young women with a significant problem into four groups.

Group 1: Girls in this group have flat enlarged breasts and an undeveloped uterus. Sometimes they have no uterus at all. Causes of their lack of menstruation range from low hormonal levels to diseases like tuberculosis, meningitis, and encephalitis. If the girl has some development of the uterus, treatment with gonadotrophic releasing hormone may make future pregnancy possible. If no pregnancy is desired, the doctor will prescribe estrogen to promote breast development. A few girls in this group are genetically male, and require other more specialized therapy.

Group 2: These young women have normal breast development but no uterus; and some may have testes (male sperm-producing organs). Although these girls can never have children, there are measures the doctor can take to correct other problems. If testes are present, they can be surgically removed after puberty and the doctor can prescribe estrogen. If the girl has a short vagina, it can be surgically lengthened to allow for intercourse.

Group 3: There are few girls with neither a uterus nor breast development Available treatments are similar to those recommended for girls in Group 2. Estrogen is prescribed to promote breast development.

Group 4: If a girl has both breast development and a uterus, the failure to menstruate may be due to an imbalance in hormone secretion. Treatment is similar to that for amenorrhea developed later in life.

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If Menstruation Stops
When periods stop in a sexually active, regularly menstruating woman, the first thing that comes to mind is a possible pregnancy. If she is past 40, menopause may be the cause. But when the doctor has ruled out both pregnancy and menopause, it's time to look for other reasons.

This condition bears the medical name secondary amenorrhea. It is defined as the lack of a period either for six months or for at least three times as long as the length of a menstruating woman's normal cycle. Causes range from tumors and cysts to weight gain or loss, and emotional factors.

Chronic failure to ovulate is one of most common causes. A lack of ovulation is normal during the first couple of years after menstruation begins and again before menopause. But at other times it may be due to low levels of a key reproductive hormone called GnRH (gonadotrophic releasing hormone). Levels of this hormone often drop when a woman is under stress, has been on a “crash” diet, has had a head injury or serious infection such as encephalitis or meningitis, or has stopped using birth control pills.

If the doctor suspects that lack of ovulation is the culprit, he or she will ask you to record your temperature upon waking . The doctor will study samples of your cervical mucus and vaginal secretions and examine a piece of tissue from the endometrium. He or she may also need to determine whether your progesterone level rises over the course of a month.

If failure to ovulate is indeed the problem and you don't want to become pregnant, the doctor will prescribe estrogen and progesterone or an oral contraceptive. This promotes shedding of the endometrium and discourages development of growths in the uterus that can occur when estrogen levels remain high for a long period of time. If you do want to have a baby, a medication called Clomid is usually prescribed.

Several problems with the ovaries can also cause periods to stop. To check the ovaries, your doctor may ask you to begin taking progesterone. If you fail to menstruate after seven days it's an indication of inadequate estrogen levels, a possible pregnancy, or a disruption in the ovarian cycle. The doctor may also study vaginal secretions, which can show whether the ovaries are wasting away, hardened, or are able to function normally. Other tests can tell whether development of the ovaries is normal and whether they are producing estrogen properly.

Often, ovarian cysts are at fault. Together with a thickened endometrium, they are the hallmark of a condition called the Stein-Leventhal syndrome. Women with this problem fail to menstruate, may fail to ovulate (or ovulate only occasionally), have a great deal of facial and/or body hair, and may have episodes of heavy bleeding between bouts of amenorrhea. Many of these women have increased levels of testosterone, a male sex hormone normally present in small quantities in the female as well.

To diagnose the problem, the doctor will determine the levels of androgen and estrogen through laboratory tests. He or she will also examine the pelvic area to see whether the ovaries are enlarged due to the presence of cysts.

If the doctor finds a number of cysts, and you do not want to become pregnant, he or she will prescribe Provera, or birth control pills to cause the endometrium to shed. A combination of estrogen and progesterone will suppress ovarian function, and thus decrease the risk of cancer of the endometrium. If you want to conceive, the doctor may give you Clomid or Pergonal to induce ovulation.

Problems in the uterus and fallopian tubes may be to blame for amenorrhea. In some cases the lining of the uterus continues to grow unchecked for many weeks or years. Women with this condition may have one or two months without a period preceded and followed by excessive bleeding. A D&C (scraping of the uterus) and biopsy of the lining may be necessary for diagnosis. To treat the problem, the doctor will prescribe Provera or estrogen-progesterone therapy.

Malfunctioning adrenal glands that secrete excessively high or low levels of adrenal hormone can also lead to amenorrhea. Tumors, steriod therapy, and even weight loss can all affect adrenal performance. Prednisone, dexamethasone, and hydrocortisone can often clear up the problem. Girls who are born with malfunctioning adrenals must have lifelong treatment. In most other cases, the condition clears up and treatment can be discontinued after several months.

Other glandular disorders can also be at fault. Cysts, tumors, serious infection, and eating disorders can disrupt the pituitary gland and lead to amenorrhea.

Overactivity or underactivity of the thyroid gland can cause the problem, too. To correct specific glandular imbalances, there are a number of medications your doctor can prescribe.

Anorexia nervosa, the loss of more than 25 percent of one's ideal body weight, is another potential cause of amenorrhea—as well as other serious physical and emotional problems. Almost all anorexic women stop menstruating, and many have glandular disorders leading to low levels of estrogen. If anorexia is the culprit, you'll need treatment for the underlying problem as well as the lack of periods.

Breastfeeding women may fail to menstruate for 10 or more months. Their high levels of prolactin, a hormone necessary to produce breast milk, may suppress the hormones that trigger the menstrual cycle. Since ovulation is still a possibility, all breastfeeding women should use “barrier” birth control such as a diaphragm or vaginal sponge if they want to prevent conception.

There is no substantial proof that either prolonged use of an oral contraceptive (the “Pill,”) or use at an early age causes amenorrhea. Close to 95 percent of nonmenstruating users of oral contraceptives resume normal cycles spontaneously after discontinuing the medication. The one percent who fail to menstruate for more than six months after stopping the pill generally have a glandular or ovarian disorders.

Some women stop menstruating permanently before they reach the age of 35 and begin to experience the typical symptoms of menopause. Their ovaries secrete insufficient estrogen to maintain the menstrual cycle and become small and wasted away. There is no effective treatment for this condition. Progesterone will not cause a return of menstruation, and in all but a few instances, drug therapy will not restart ovulation.

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Early Menstruation
Although the average age for the beginning of menstruation is between 11 and 13, a few girls develop breasts before they are eight or have their first period by nine. This condition is called precocious puberty.

About 90 percent of girls who menstruate early have “true” precocious puberty, that is, their reproductive system functions exactly like that of an adult. These youngsters secrete the hormones necessary for menstruation. They ovulate, are fertile, and have secondary sex characteristics. Most become short women because their higher-than-normal estrogen level stops their growth at an early age. The underlying cause is an abnormality in the brain.

Girls with “pseudo” precocious puberty do have increased estrogen levels, but do not produce the other reproductive hormones as adults do. Because of the increased estrogen, they develop secondary sex characteristics, but they are not fertile. Causes range from ovarian or adrenal tumors that produce estrogen, to an underactive thyroid, or use of certian cosmetics and estrogen-containing foods and medications.

To make a diagnosis, the doctor will check estrogen levels, inquire about birth injuries or a family history of brain disease and perform various other tests. Treatment focuses on medications which prevent the release of reproductive hormones such as GnRH. Injections of the birth-control drug Depo-Provera reduce the amount of estrogen, stop menstruation, decrease breast development, and allow growth to develop normally. However, its long-term effects may be serious. Girls who menstruate early may also need psychological counseling.

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Toxic Shock Syndrome
In 1978 medical journals reported that a small number of menstruating women were developing an illness characterized by high fever, sore throat, headache, a sunburn-like rash, vomiting, nausea, diarrhea, extremely low blood pressure, fainting, peeling skin, muscle pain, kidney or liver problems, disorientation, and even shock. They named the new disease “toxic shock syndrome” (TSS).

By 1980 they had pinpointed the major culprit: superabsorbent tampons—although in a few cases, staph infection following an injury, or trauma was given the blame.

TSS is caused by toxin-producing staphylococcus bacteria. According to one theory, inserting a tampon into the vagina can produce small tears or ulcerations that allow the bacteria to enter the rest of the body. A second theory holds that extra-large tampons contain more air spaces than small sizes, and that these pockets provide the oxygen that the bacteria need to multiply.

If you suspect you are developing TSS, you should remove your tampon immediately. In eight out of ten tampon-related cases, this will stop the growth of the bacteria. Your doctor will check for the presence of staph by testing blood samples and vaginal and cervical smears. If the bacteria are at fault, antibiotics such as erythromycin will usually clear up the problem.

Superabsorbant tampons such as Rely were taken off the market soon after they were implicated in toxic shock syndrome. Since then, the number of cases has dropped dramatically. However, it's still wise to change tampons frequently, alternate tampons with sanitary napkins, especially at night, and wash your hands before inserting a tampon.

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Exercise And Menstrual Problems
Controversy surrounds the role of exercise in the development of menstrual problems. Researchers have noted that more female athletes have amenorrhea, prolonged cycles, or delayed menstrual onset than do other women, but there is no general agreement on the reasons.

According to one theory, the lack of menstruation among athletic women stems from loss of weight and body fat. Glandular problems have also been blamed. Low estrogen levels, vitamin deficiency, and the stress of rigorous training and competition are other proposed causes.

On the positive side, many athletes do have regular menstrual cycles — and they have milder cramps, less PMS, shorter-lasting periods, and fewer headaches than their sedentary sisters. On balance, most doctors recommend regular, reasonable exercise.

Dr Mohans Diabets
American Diabetes Association
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