By Dr M Madhavi Latha
Any variation in monthly bleeding is called menstrual disorder, a common problem in general female population. Women harbour undue anxiety over these, which could be only minor aberrations, and only in few cases sinister.
What is normal mensturation?
In a normal healthy woman, menarche occurs between age group of 10-16 (mean 12.5) years and ends around 40 to 45 years. During the period in between, which is called the reproductive period, she gets her menses or periods normally with a monthly rhythm of 28+/- 5 days with blood flow of 80-100 ml lasting for 4-6 days. Any change in rhythm or flow is called disorderly menstruation. Some of those encountered in routine practice are:
Amenorrhea or absence of bleeding: This could be Primary Amenorrhea where no menarche occurs even after16 years though there may be presence of secondary sexual characteristics (ie development of breast, pubic and axillary hairs and the female contour of body with rounded shoulders and broad hips). In contrast, Secondary Amenorrhea denotes absence of menses for more than six months in previously normally menstruating woman.
Oligomenorrhea: Infrequent bleeding which occurs more than 35 days apart.
Polymenorrhea: Menses occurring in less than 21 days.
Menorrhagia: Timely menses but with excess of 80-100ml bleed, wetting more than seven to eight pads per day.
Hypo menorrhea: Scanty bleeding may be even just spotting on one pad.
Dysmenorrhea: Painful bleeding mostly on the first day of bleeding or it may extend to all five days.
Other forms like inter-menstrual, post-coital, and precocious bleed (menarche occurring before age of 10 years) may also happen.
Incidence
It varies from 1-5% for Amenorrhea, 15-20% for Menorrhagia, 50% for Dysmenorrhea.
What are the causes?
Uterus or womb is the main organ from which debris of its lining is thrown out as menses. So anything which increases its surface area like fibroids, polyps, or adenomyosis (hypertrophy of its walls) can cause Menorrhagia.
A non-patent vagina (passage from uterus to outside) or absent uterus or vagina or genetic abnormalities may cause Primary Amenorrhea.
Tumours or infection of ovaries (which secrete hormones estrogen and progesterone) may cause excess, less or irregular bleeding depending on excess, less or irregular secretion of hormones.
The pituitary and hypothalamus in brain secrete releasing hormones for ovarian hormones. They can play havoc with menses, when deranged by disease or tumours
Other than these, some simple factors like stress, impending exams, change of place, job or relationship can also affect menses through sensitive hypothalamus.
Prolonged use of antidepressants, anti-epileptics and other drugs, excess or too less weight, anaemia, tuberculosis, thyroid, renal and liver diseases also may cause menstrual disorders.
Post-coital bleeding which means bleeding or spotting after intercourse definitely requires examination of cervix because most of the cancers arise from this part of uterus. Fortunately, this is most easily visible to naked eye under good light with least discomfort to woman. Hence, women should come forward to let themselves be checked by a gynaecologist.
What does a gynaecologist do?
A good gynecologist takes a detailed history to determine the kind of bleeding-whether it is continuous/intermittent/scanty/heavy/frequent/painful/or post-coital.
A local examination of vulva (external part), vagina and cervix (which is the opening of uterus into vagina) is done under good light to exclude local causes.
This is followed by a bimanual internal exam to feel uterus and ovaries
A good ultrasound with preferably Doppler is done to rule out uterine or ovarian masses or other pathology. In addition, simple hormonal tests like FSH, LH, prolactin and thyroid, in addition to routine tests, can point out the culprit.
What is the treatment?
Medical or surgical treatments give definite results, but the foremost thing to do is to take good 5-10 minutes to counsel the apprehensive woman, to scientifically identify the problem and approach it as any other disease like fever ,which have a cause, a pathology, diagnosis and treatment.
Medical treatment
After a number of pathologies are ruled out and if all the organs are normal, the gynecologist prescribes 3 to 6 months cyclical hormonal therapy to set right the menstrual cycle.
The gynecologist may also prescribe analgesics, antispasmodics and vitamin E, and primrose to alleviate dysmenorrhoea. Thyroid hormone, hematinics and other drugs too are prescribed as per the case.
Surgical treatment
In case of obvious pathology, different procedures like myomectomy for fibroid uterus, polypectomy for polyps, outflow tract surgeries, laparotomy for removal of ovarian masses, adhesions and puncture of cysts etc are done.
Many times simple ablative techniques are used to remove uterine lining. They range from simple Dilation and Curettage (D&C) to hysteroscopic endometrial ablation by resectoscope, loop, roller ball, laser coagulation to third generation techniques like radio frequency induced thermal ablation, microwave endometrial ablation, impedance ablation etc, these are simple, safe and quick procedures in expert hands.
Conclusion
Menstrual disorder, though it could be only due to a mild variation in hormones , still mandates thorough investigation of every patient so as to not miss any sinister causes.
l (Dr M Madhavi Latha is a consultant gynecologist at
Aster Medical Centre in Al Khor)