The Abnormal Menstrual Cycle

Margaret Rees, Sally Louise Hope, Veronica A. Ravnikar, Margaret Rees, Sally Louise Hope, Veronica A. Ravnikar

• Publisher: CRC Press
• Year: 2005
• eBook ISBN: 9781135402020
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

Disorders of menstruation are among the most common problems encountered in womens' health and include early, delayed and irregular menstrual cycles, painful menses and excessive menstrual bleeding, and early menopause. Their treatment presents a variety of complex challenges, especially since some of the treatments used can themselves result in fu

1: Consultation for an abnormal menstrual cycle

S.Hope

IS IT NORMAL TO HAVE PERIODS?

Modern woman is a victim of her own success. One of her priorities was to have safe, effective contraception. A natural consequence of this is that we now have regular menstrual periods or withdrawal bleeds. If you summate the number of days a 21st century woman bleeds for throughout her lifetime it is between 4 and 6 years. Effective contraception had a major impact on the 20th century and within three generations of women there has been a complete role reversal. Our great grandmothers got married and had up to 17 children and spent most of their adult life pregnant and breast feeding. Most late 20th and 21st century women want one or two children and therefore the vast majority of their adult life is dominated by cyclical menstruation. Women now perceive periods as being ‘natural’ whereas one could argue they are highly unnatural. Women often ask for advice but do not necessarily want treatment, as they feel inducing amenorrhea by various methods would be ‘interfering with nature’. However, one could argue that amenorrhea is the ‘natural’ state of an adult primate.

THE SIZE OF THE PROBLEM

Women are brought up to believe that they have a menstrual cycle that lasts 28 days and that they bleed for between 4 and 7 days. Women do come and seek advice if they are outside these strict parameters. Often young girls who have just started the menarche are very worried by highly irregular cycles and also women in their mid- to late forties are again worried by irregularity of cycles. It is obvious living in a community with other women one’s own age, either at school or work, that different women experience different amounts of pain and disability from their menstrual cycle. This is another reason why women seek advice from their family doctor or primary-care nurse, often with opportunism when they are having a cervical smear.

In many cases, the most challenging part of the consultation for a general practitioner is to obtain an accurate history. Discussions about periods are common; for example, 5% of women between the ages of 30 and 49 consult their general practitioner in the UK for excessive menstrual blood loss in one year¹.

Menorrhagia has the gynecological definition of heavy cyclical menstrual bleeding occurring over several consecutive cycles (blood loss > 80 ml per menstruation)² . However, blood loss is not routinely measured either in general practice or in gynecological out-patient clinics. It is therefore impossible for a general practitioner to apply objective evidence-based medicine in this field as a primary diagnosis cannot be made with certainty in most cases. One population study accurately measuring women’s menstrual loss showed that 30% of women think they have menorrhagia, compared with 10% who actually do³ . The number of pads or tampons used does not correlate with blood loss, and the validity of a menstrual blood loss pictorial chart is debated. Measurement of menstrual blood lost using the alkaline hematin method with collected sanitary pads is accurate, but is only used in the research setting. To help in the primary-care setting a pictorial blood loss assessment chart (PBAC) was developed. However, the results of studies correlating PBAC scores and menstrual blood loss are conflicting, and it has not been widely adopted⁴ . The definition of menorrhagia is utterly useless in clinical practice until someone comes up with a simple, cheap acceptable way of measuring menstrual blood loss accurately.

There is no actual difference in blood loss between patients who have periods of different length because the vast majority of blood loss happens in the first 3 days of a period. Accepting the complaint a woman gives of ‘heavy periods’ may commit that woman to very expensive drug treatments for a number of years or even major surgery; a sobering thought when 40–60% of women may not have menorrhagia at all but only perceived menorrhagia⁵ ,⁶ . This may reach the extreme of actually removing the uterus simply because the woman finds periods unacceptable. In the UK one in five women under the age of 60 has had a hysterectomy, at least 50% of which are found to be normal at histological examination⁷ . A woman with menorrhagia may not be anemic, although menorrhagia is the commonest cause of anemia in menstruating women²,⁸ .

SECRET AGENDAS

Physicians need to be aware of possible secret agendas that cause a woman to discuss abnormalities of her periods. Such agendas can take various forms. Consider the teenager who is really hoping that her general practitioner will offer an oral contraceptive as a means of ‘normalizing’ her periods because she is too shy or frightened to ask for contraception but needs it desperately. Or, the teenager who discusses her abnormal menstrual cycle in the hope of being examined because she is actually concealing a 6month pregnancy, and who is too terrified to admit it to herself or to anyone else. Similarly, some cases of sexual abuse may be too difficult to raise openly but women come in complaining bitterly of gynecological problems in the hope that the doctor will either raise this issue, or notice something at examination, and thus enable these women to discuss the issues that are destroying their lives.

Other women may actually be worried that they have some real or imagined venereal disease and wish for a gynecological examination to reassure them in the misplaced belief that a doctor will detect any sexually transmitted disease by a simple examination. Older women in their mid- to late forties may be worried about issues surrounding the menopause, and loss of fertility and femininity, and may be grieving if infertility has occurred. Some women desire a hysterectomy as an ultimate means of contraception when they have failed to persuade their partner to volunteer for sterilization and who simply cannot contemplate another pregnancy. Others, who are prevented by their religious beliefs from using any contraception, may consciously or subconsciously wish for a hysterectomy, as will women with lesbian orientation whose monthly menstruation is a constant reminder of their femininity.

ABNORMAL PAIN

Some women have a change in the pain of their periods, which brings them to the doctors surgery. This implies a disease process is going on. Specific chapters in this book are devoted to dysmenorrhea and endometriosis. Secondary dysmenorrhea is associated with pelvic pathology such as endometriosis, adenomyosis, pelvic inflammatory disease, submucous leiomyomas and endometrial polyps⁹ . Others have always had painful periods, but for some reason, just reach the end of their tether and want relief.

Abnormal pain can be associated with menstruation but other pelvic and musculoskeletal causes must be excluded. Again, the woman might have a secret agenda that she is unable to explain. For example, a regretted termination 8 years ago may be weighing on her mind every time she has a period and she may attribute the extra pain perceived to that termination and have issues regarding future fertility. Similar problems occur with people who have been treated for sexually transmitted diseases in the past or abnormal smears with colposcopy. The complex interaction between irritable bowel syndrome and pain perceived as gynecological pain is discussed at length in a special chapter of this book.

It is always worth remembering that rare things can occur and women can have more than one complaint at one time. For example, to my shame, I treated a lady for 10 years for irondeficient anemia as did the gynecologist for menorrhagia. It was only after the menopause when she still had iron-deficient anemia that I investigated her further and found that she had celiac disease.

WHAT IS ABNORMAL?

Delayed menarche: primary amenorrhea

The menarche occurs between the ages of 10 and 16 in most girls in developed countries¹⁰. Some children in the UK are now getting their periods at 8 years of age. ‘Early’ menarchy is a more common reason for consultation than delayed menarche, as mothers can remember getting their periods at the age of 12, and are shocked when their daughters start menstruating when still at primary school. Because the first cycles tend to be without ovulation there is a wide variation of cycle length and menstrual pain and loss. Intense exercise from ballet dancers, marathon runners and gymnasts is associated with a delayed menarche and indeed women who take up such exercises can become amenorrheic. Any girl who has not had her first period by the age of 16 should be investigated (full history, family history, examination for secondary sexual characteristics, follicle stimulating hormone (FSH), luteinizing hormone (LH), estrogen, testosterone, prolactin, thyroid function test (TFT), ?chromosomes).

Secondary amenorrhea or oligomenorrhea

Women who have had periods which then become very infrequent or nonexistent should be investigated. The patient might have polycystic ovary syndrome¹¹ ,¹² (see Chapter 7).

Irregular periods

As already mentioned periods become irregular with both the long and short cycles at either end of reproductive life, around the time of the menarche or in the perimenopause. These cycles are usually anovulatory. Usually a young girl with irregular periods just needs a discussion of what can be expected for the future, although it may be that she is actually requesting contraception. For a woman in the perimenopause irregularity of periods is extremely common and indeed she may be wishing for a discussion about contraception or abortion too. If periods become heavy and irregular or there is intermittent or postcoital bleeding, further investigation is advised.

Prolonged menstruation

Women on average menstruate 6 days per cycle. For the management of menorrhagia, medical and surgical see Chapters 5 and 10¹³ ,¹⁴ . Most blood loss occurs during the first 3 days of menstruation. Periods may be prolonged by using the progesterone-only pill or depot injection or by using a copper intrauterine device (IUCD). Women may experience continual slight spotting after insertion of a levonorgestrel intrauterine contraceptive system (LNG-IUS, Mirena®), but the levonorgestrel IUS can be a very helpful solution¹⁵ ,¹⁶ .

There have been published guidelines for menorrhagia in primary and secondary care by the Royal College of Obstetricians and Gynecologists (RCOG)¹⁷ ,¹⁸ , but uptake of the recommendations in primary care has not been uniform throughout the UK and substantial differences in management still exist between practices when investigating and prescribing for menorrhagia¹⁹ ,²⁰ .

Days of spotting before a period can be a sign of an endometrial or cervical polyp or a sexually transmitted disease (STD), or even a malignancy and examination should therefore be performed.

Variations in smell of vaginal dis...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• LIST OF CONTRIBUTORS
• PREFACE
• 1: CONSULTATION FOR AN ABNORMAL MENSTRUAL CYCLE
• 2: PAINFUL MENSTRUATION: ENDOMETRIOSIS
• 3: PAINFUL MENSTRUATION: PRIMARY DYSMENORRHEA
• 4: CHRONIC PELVIC PAIN WITHOUT ENDOMETRIOSIS
• 5: EXCESSIVE MENSTRUAL BLEEDING
• 6: UTERINE FIBROIDS
• 7: THE IRREGULAR CYCLE: POLYCYSTIC OVARY SYNDROME
• 8: PREMATURE OVARIAN FAILURE
• 9: MOOD AND THE MENSTRUAL CYCLE
• 10: SURGICAL INTERVENTIONS: HYSTERECTOMY/ENDOMETRIAL DESTRUCTION FOR EXCESSIVE MENSTRUAL BLEEDING
• 11: LAPAROSCOPIC SURGERY
• 12: ALTERNATIVE MEDICINES
• 13: CONTRACEPTIVE PREPARATIONS AND THE ABNORMAL MENSTRUAL CYCLE
• 14: MENSTRUAL MIGRAINE
• 15: THE PERIMENOPAUSE