Problem Periods

Problem Periods

The menstrual cycle is an exquisitely elaborate biological system for human reproduction. Like all biological systems there can be problems with feedback mechanisms which throw it out of kilter. In the menstrual cycle, there is a complex communication between the ovaries which produce the hormones estrogen and progesterone, and the hypothalamus and its pituitary gland of the brain which produce the hormones FSH and LH. In most cases abnormal bleeding results from these communicative and biologically active hormones not being produced or not functioning in a normal way. There are cases of other abnormalities such as problems with clotting (for instance, if a patient on the blood thinner, Coumadin), cancer or infection of the lining of the uterus, threatened or completed miscarriage, or polyps inside the uterus which can cause abnormal bleeding, but these are relatively infrequent compared to the hormonal problems which otherwise cause irregular or heavy bleeding.

It would be appropriate to review the series of events which occur in the normal menstrual cycle. The hormones FSH and LH cause the ovary to begin to develop an egg for ovulation. This egg is surrounded by special cells which produce estrogen and progesterone. The estrogen causes the lining of the uterus to grow and thicken in preparation for receiving a fertilized egg. When the egg is released from the ovary (ovulation), the ovary produces increased amounts of progesterone to mature the uterine lining into the so-called secretory state. If the fertilized egg is not implanted, progesterone causes the lining to degenerate. Whatever of the blood and tissue is not reabsorbed by the uterus is released in the menstrual period. The length of the period varies from three to seven days, the average being five days. The average amount of blood loss is between thirty to eighty cc’s. If the period is longer or heavier than this, it is considered to be variably abnormal.

So what are some of the things that can go wrong? First of all, there is not an egg released. This happens from time to time in all females. It is called an anovulatory cycle. Adequate amounts of progesterone are therefore not released, and the lining of the uterus sheds little or not at all. A physician would order a pregnancy test to be sure this was the reason for the missed period. The next period may be heavier or lighter. The reason it could be heavier is that other areas and organs of the body can produce estrogen which causes the lining to grow and thicken. Estrogen can be produced by the adrenal glands, the liver, the breasts, and by fat tissue in active but smaller quantities than the ovary. A girl just starting her periods may have anovulatory cycles. A woman nearing menopause has more and more anovulatory cycles, until she ceases to have periods at all. This is the definition of menopause, that is, if she has no period in over a year, the month of the first missed period is the date of onset of her menopause. If sometime after that year she has bleeding, then she needs to be evaluated for some other cause of bleeding It is not clear exactly what the cues are for menopause to begin. It is known that for some reason a woman’s ovaries stop responding to the signals of FSH and LH to ovulate. For this reason the pituitary gland produces more FSH and LH in order to get a response, and these elevations of FSH and LH can be measured in the laboratory as evidence of menopause or other ovarian failure.

There are medical examinations and tests which need to be done if there is abnormal bleeding in a menopausal-aged woman. First of all she needs her regular Pap smear. A cancer of the cervix can bleed in an irregular way. She needs an internal exam to look for abnormal growths, for instance of the ovaries and uterus which might suggest cancer in either one. The internal exam would indicate whether the uterus is abnormally large, perhaps from uterine fibroids. Sometimes a small amount of tissue is scraped from the lining of the uterus for microscopic evaluation.

Treatment for the abnormal bleeding may range all the way from watch and wait to hysterectomy, the total cure for abnormal bleeding. The physician may recommend a long-lasting injection of progesterone to keep the lining thin. There is a device called the IntraUterine system which can be inserted to release small amounts of progesterone and keep the lining thin. If the bleeding is heavy, the patient may be given a medicine called transexamic acid to reduce flow by up to fifty per cent. Sometimes a patient may have a limited operation just to remove a uterine fibroid which is causing the heavy bleeding. There is a specialized heating device which can ablate the uterine lining. It is interesting that the United Kingdom has reduced the rate of hysterectomy by fifty per cent by using these other techniques to treat abnormal uterine lining associated with menopause.

So, take heart. You’ll probably sail through menopause without a hitch, but if you do have abnormal bleeding, there are many excellent treatments which can address any problems which arise.

John Drew Laurusonis M.D.
Doctors Medical Center