What are menstrual disorders?

You are said to have a menstrual disorder if your menstrual cycles are abnormal. In adolescents, menstrual disorders may be present as abnormal bleeding from the uterus. These can arise in different forms including: absence of bleeding, irregular bleeding, abnormally heavy periods or bleeding in between periods.

Amenorrhea is the absence of menstruation. It can either be primary or secondary. Amenorrhea is said to be primary when there is a lack of menstruation by the age of 15 years old with an otherwise normal puberty or the lack of secondary sexual characteristics (breast development and pubic hair growth) by the age of 13 years. Amenorrhea is said to be secondary when there is a lack of menstrual periods for 6 months.

Abnormal uterine bleeding is usually determined according to 4 characteristics namely: frequency, regularity, duration and volume. Once a girl has begun to have menstrual periods, there are many disorders affecting the menstrual cycles that can arise. These are often accompanied by painful menses, also known as dysmenorrhea.

What is the normal menstrual cycle?

Menstruation, most commonly known as getting your period, is a normal feature that occurs only in females. It is a process that normally start during puberty. Once you have gone through puberty, you start to experience menstrual bleeding once a month. This occurs after the lining of the uterus has prepared itself for a probable pregnancy by becoming a thicker lining rich in blood vessels. If sexual intercourse occurs during the period of thickening of the lining, fertilization may occur if ovulation has occurred. The fertilized egg then travels to the thick lining of the uterus to get implanted and develop. However, if pregnancy does not occur, the lining is shed, and appears as bleeding from the vagina. This process usually lasts for around 3-8 days. Normally, this is a regular process that can often be predicted based on its pattern of occurrence. The number of days between the first day of one period to the first day of the next period is usually about 21-35 days.

This cycle is controlled by a complex orchestra of hormones. These hormones are produced by two structures located in the brain, including the pituitary gland and the hypothalamus. The events that occur during the menstrual cycle are based on the levels of different hormones at that specific point in time. The cycle of events are as follows:

• Days 1-5: Day 1 is the first day of menstrual bleeding. On average it lasts for 5 days. However, it can vary from 3-5 days among women. Normally, the bleeding is heavier during the first two days, to then gradually decrease until it stops.
• Days 6-14: At that moment, the menstrual bleeding has stopped. The lining of the uterus starts to prepare itself for a possible future pregnancy. It becomes thicker and rich in blood vessels.
• Days 14-25: Around day 14, ovulation occurs. This is the process by which an egg is released from the ovaries and travels down through the fallopian tubes, to the uterus. If sexual intercourse occurs and sperm is present in the fallopian tube, fertilization can occur. The fertilized egg then travels to the uterus to implant into the thickened uterine lining. If pregnancy occurs, the lining of the uterus does not shed and the pregnant woman does not bleed until the baby is born.
• Days 25-28: If no fertilization occurs and no implantation has taken place, hormones are released accordingly to signal the uterus that the lining has to be shed. Once shedding starts, day 1 of the menstrual cycle begins.

What are the causes of menstrual disorders?

Menstrual disorders can occur due to a variety of conditions. Pregnancy and breast feeding are normal causes of absent menstrual periods. Abnormal causes of menstrual irregularities include the following:

• Polycystic ovarian syndrome (PCOS): In this condition, the ovaries are enlarged and contain small areas of collected fluid known as cysts. PCOS is the most common endocrine disorder affecting around 6-10% of women. It is the most common cause if menstrual irregularities or absent menstruations. Women with this condition often have few irregular and sometimes heavy cycles during the year.
• Eating disorder or extreme weight loss: These can cause disruptions in the menstrual cycle.
• Ovulatory dysfunctions: During the first few years of menstruation, the cycles may not be consistent and regular. At that time, this is mostly due to immaturity of the hormonal axis responsible to control the menstrual cycle.
• Premature ovarian failure: This is when your ovaries have lost their normal function before the age of 40 years. This is also known as primary ovarian insufficiency.
• Pelvic inflammatory disease: This is a condition in which the reproductive organs are inflamed and this can result in irregular and painful menstrual bleeding.
• Bleeding disorders: There are disorders that decrease your blood’s ability to clot. If you have bleeding disorders such as Von Willebrand disease, you may have heavy menstrual periods.

• Sexually transmitted infections: Infections such as chlamydia trachomatis, trichomonas vaginalis, herpes simplex virus, human papillomavirus and Neisseria Gonorrhoea, which are transmitted during sexual intercourse with an infected partner may all cause irregular vaginal bleeding in between periods.

What are the signs and symptoms associated with menstrual disorders?

The signs and symptoms vary according to the underlying cause or condition leading to menstrual irregularities. The following signs and symptoms may be present in menstrual disorders:

• Absence of menstrual period
• Bleeding in between periods
• Changes in weight
• Heavy menstruation
• Pelvic pain
• Abdominal pain
• Vaginal discharge
• Painful urination
• Nausea
• Vomiting
• Headaches
• Ecchymoses
• Skin pallor

How is the diagnosis of menstrual disorders made?

To make the diagnosis of a menstrual disorder, your doctor will start by asking a series of questions about your menses, the flow, regularity and other specific characteristics. He/she will also ask other questions to rule out the possibility of any other medical conditions that may be associated with menstrual irregularities. Your doctor will then proceed with a thorough physical examination to look for other signs of menstrual disorders.

Depending on your clinical history and physical examination, your doctor may request some other tests to confirm the underlying causes of the problem. These tests may include the following depending on the specific case:

• Blood tests to check for the level of hormones such as follicle stimulating hormone, luteinizing hormone, estradiol, thyroid stimulating hormone and prolactin.
• Pregnancy test
• Complete blood count
• Thyroid function test
• Tests to look for the presence of sexually transmitted diseases
• Ultrasound

How are menstrual disorders managed?

The choice of treatment depends on the underlying cause. Once the workup has been done and diagnosis confirmed, your doctor will choose the treatment option that is most appropriate according to your particular conditions. In general, treatment options include the following:

• Hormonal therapies
• Gaining weight and reducing exercise levels in the case of eating disorders
• Clomiphene citrate in the case of Polycystic ovarian syndrome
• Combined oral contraceptive pills for those who are not attempting to conceive
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Intrauterine devices that release progestin can decrease menstrual bleeding
• Anti-fibrinolytic medications for those with bleeding disorders
• Antibiotics if infection is present

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