By Prof. Oladapo Ashiru
The regular menstrual cycle is supposed to be 21 to 35 days. That is, the woman is supposed to have her period every 21 to 35 days. When the period comes more frequently than this, it is referred to as Abnormal Uterine Bleeding.
In 2011, the International Federation of Gynaecology and Obstetrics developed a lucid classification of abnormal uterine causes and their causes. Abnormal uterine bleeding when cyclical/ovulatory is called heavy menstrual bleeding; however, it occurs with anovulation called Abnormal uterine bleeding with ovulatory dysfunction (AUB-O).
AUB-O and its causes can be a significant cause of infertility. If the woman is constantly bleeding, it can cause infertility simply because the couple will not have sex because of the bleeding. For example, I had a patient whose period lasted a full 17 days. Even though the period was not heavy, it created a problem because it made it impossible for her and her husband to have intercourse. The period would go on for days, clear up for a few days only for the spotting to start again. They were married for six years without getting pregnant. About 70% of women who do not release an egg during the menstrual cycle have Dysfunctional Uterine bleeding. Their irregular periods are due to a hormonal imbalance between estrogen and progesterone. It is a very significant cause of infertility, making up to 10% of infertility causes.
The American Society for Reproductive Medicine’s 2019 scientific congress on October 16th, 2019; held a focus group discussion on irregular periods. Some of the observations are discussed here.
Dr. Wang and his team showed that in terms of the typical menstrual cycle characteristic, irregularity and extra-long cycle length are associated with a higher risk of mortality, according to a study presented at the American Society for Reproductive Medicine’s 75th Scientific Congress and Expo. In a prospective cohort study, researchers from Harvard and Tongji Medical College in China teamed up to analyze data on 93,775 women, followed for the years 1991 to 2013 as part of the Nurses Health Study II.
Participants described the history of their menstrual cycles for the study, reporting the usual length and regularity at ages 14 to 17, 18-22, and 28-48. The women had no history of cancer, diabetes, or cardiovascular disease at enrolment.
Researchers used statistical methods to determine associations between cycle characteristics and mortality, accounting for relevant confounders, including BMI, race/ethnicity, physical activity, and lifestyle factors.
During 1,729,410 person-years of follow-up, 1679 deaths were recorded, including 828 from cancer and 166 from cardiovascular disease.
Women whose menstrual cycles were always irregular between the ages of 14 and 17 and 18 to 22 were 21% and 34%, respectively, more likely to die from any cause than women reporting very regular menstrual cycles in the same age ranges. A similar association is in women with irregular menstrual cycles from age 28 to 48. Women reporting cycle lengths of 32-39 days, or more than 40 days, were also at higher risk of death during follow-up than women whose usual cycles lasted 26-31 days.
ASRM Vice President Hugh Taylor, MD, observed, “Irregular cycling could be evidence of an underlying health condition. But these clues are subtle and may not, in themselves, cause much worry. Patients who experience menstrual irregularity should maintain a healthy lifestyle and be alert to health changes.”
The above-quoted study serves as a warning to people who have irregular periods or long cycles to seek immediate medical attention since such processes may be due to underlying conditions.
Regular menstrual periods typically last for five days but can vary between two to eight days. When menstruation first starts, it can take up to 2 years to establish a regular ovulatory cycle. After puberty, most women’s menstruation becomes regular. The length of time between each period is similar, and a cycle is about 28 days on average but can range from 21 days to 35 days.
Menstruation is said to be abnormal if there is an alteration in the time between periods and the volume of the menstruum for example –
●
Less than 21 days or more than 35 days apart,
●
missing three or more periods in a row,
●
The menstrual flow is much heavier or lighter than usual.
●
Periods that last longer than eight days
●
Periods that are accompanied by pain, cramping, nausea, or vomiting
●
Bleeding or spotting that happens between periods, after menopause, or the following sex.
A woman’s menstrual cycle is controlled by two hormones, estrogen, and progesterone. The levels of these two hormones vary during the month. During the first half of the month, estrogen is high to stimulate the uterine lining’s growth, called the Endometrium, and to recruit eggs to grow in the OvaryOvary. When the egg is ready to be released from the OvaryOvary (ovulation) for fertilization around the 14th day, progesterone rises and causes changes in the endometrial lining of the uterus prepare it for pregnancy. However, if the egg is not fertilized, the progesterone level falls, and the thickened prepared Endometrium is shed as the monthly menses. If estrogen levels are abnormal, there will be no recruitment and growth of eggs. It will also disturb the production of progesterone, and therefore, the periods will be irregular. In irregular periods, even when a couple has intercourse during the times that the woman should usually be fertile, there may be no fertilized eggs. She is not growing any eggs that can be released. Therefore, irregular periods are the first sign that there may be problems with a woman’s reproductive system. Abnormal Uterine Bleeding is also caused by many other factors such as Polycystic Ovary Syndrome, which are multiple cysts in the ovaries, usually with a peripheral distribution in the ovarian cortex. Women who are on dialysis may also have heavy or prolonged periods. So do some women who use an intrauterine device (especially the copper device) for birth control.
Most young girls will have irregular periods when they first start menstruating. But by the time they are 20 years old, their periods should have settled down to the average 28 to 30-day cycle. By the time most women are 45 years old and are nearing menopause, they will also have irregular periods (climacteric phase) until their period finally stops when they are about 55years old. Many women approaching menopause may not produce any eggs even when they have their periods because of the irregular rise and fall of the two hormones, estrogen and progesterone. For some women, this dysfunctional bleeding occurs when they have just gotten married. It, of course, will be a big problem, as most newly married couples will be trying to get pregnant.
What causes abnormal menstruation (periods)?
There are many causes of abnormal periods, ranging from stress to more serious underlying medical conditions:
●
Stress and lifestyle factors. Significant weight gain or loss, dieting, extreme exercise, travel, illness, or other changes in a woman’s daily routine can have affected the menstrual cycle.
●
Medications:
· Blood thinners such as anticoagulant medications
· Birth Control Pills -contain mostly a combination of the hormones estrogenic and progestin (some contain progestin alone). The pills prevent pregnancy by keeping the ovaries from releasing eggs. Going on or off birth control pills can affect menstruation. Irregular or missed periods for up to six months may occur after stopping birth control pills. Progestin-only medication may cause bleeding between periods.
· Steroids
● Non-malignant gynecological conditions
· Uterine polyps or fibroids- Uterine polyps are small benign (noncancerous) growths in the uterine lining, while fibroids are non-malignant tumors attached to the muscle of the uterus(womb). There may be one or more fibroids that may cause heavy bleeding and pain during periods. If the fibroids are large, they might put pressure on the bladder or rectum, causing discomfort
· Endometriosis- The endometrial tissue that lines the uterus breaks down every month and is discharged with the menstrual flow. Endometriosis occurs when the endometrial tissue starts to grow outside the uterus. Often, the endometrial tissue attaches itself majorly to the ovaries or fallopian tubes; or other body areas. Endometriosis may cause abnormal bleeding, cramps, or pain before and during periods, and painful intercourse.
●
Pelvic inflammatory disease. Pelvic inflammatory disease (PID) is an inflammation and infection of the upper female genital tract. The condition may result via the vagina during sexual contact and then spread to the uterus and upper genital tract. Gynecologic procedures, childbirth, miscarriage, or abortion can also predispose to PID. PID symptoms include a heavy vaginal discharge with an unpleasant odor, irregular periods, pelvic and lower abdominal pains, fever, nausea, vomiting, or diarrhea.
Polycystic Ovarian Syndrome (PCOS) -the ovaries make large androgens, which are male hormones. Small fluid-filled sacs (cysts) may form in the ovaries. The hormonal changes can prevent eggs from maturing, and so ovulation may not take place consistently. Sometimes a woman with polycystic ovary syndrome will have irregular periods or stop menstruating altogether. The condition is associated with obesity, infertility, and hirsutism (excessive hair growth and acne). This condition may be caused by a hormonal imbalance, although the exact cause is unknown.
●
Premature ovarian insufficiency. This condition occurs in women who are less than 40 years with a malfunction in the ovaries. Their menstrual cycle usually stops like menopause. Women treated for cancer with chemotherapy and radiation, family history of premature ovarian insufficiency, or specific chromosomal abnormalities may have it.
● Non-malignant medical conditions
· Thyroid abnormality (Hypothyroidism, hyperthyroidism)
· Bleeding disorders such as low platelets count
Overactive thyroid or underactive thyroid can cause anovulation and coagulation disorders with associated menstrual irregularities.
Other causes of abnormal menstruation include:
●
Cancers of the uterus, cervix, Ovary, or vagina
Treatment options
Treatment can also depend on the woman’s age, heavy bleeding, thickened endometrial lining, and whether the woman plans to have children. It might not be safe to get pregnant after some treatments, while others can make it impossible. A wait-and-see approach may be adopted for perimenopausal women because the symptoms may get better on their own. It’s also advisable to rule out chronic illnesses or a blood disorder.
Medical treatment- Drugs are the first line of treatment.
1. Hormones. Birth control pills and other hormone treatments may give you regular menstrual cycles and lighter periods.
2. Gonadotropin-releasing hormone agonists (GnRHa). stop your body from making specific hormones. They can shrink fibroids for a while, but they’re usually used along with other treatments.
3. NSAIDs-ibuprofen or naproxen taken for a few days before the period starts may help lighten the bleeding.
4. Tranexamic acid- This is a pill that helps with blood clotting and can control heavy uterine bleeding.
5. For some women, an intrauterine device that releases progestin hormone can stop heavy bleeding. Some women may not get their period at all.
6. Antibiotics to treat infections, if any.
Surgical management:
Sometimes surgery can be needed to stop the bleeding
1. Endometrial ablation. The procedure uses heat, cold, electricity, or a laser to destroy the uterus’ lining. It may end the periods entirely and reduce the chances of pregnancy. Birth control pills are recommended until menopause.
2. Myomectomy or uterine artery embolization-doctor may take the fibroids out or cut off the vessels that supply them with blood.
3. Hysterectomy- taking out the uterus. It may be needed for huge fibroids, endometrial or uterine cancer. Otherwise, it’s the last resort when other treatments haven’t worked
