Menstrual problems are the most common gynaecologic complaint.
For some they can be troublesome but for others menstrual problems can be debilitating. There are many causes and effective treatments.
No women should have to endure the problem of abnormal uterine bleeding.
Classification of Abnormal Uterine Bleeding (AUB)
- Regular Heavy bleeding.
- Irregular periods.
- Absent periods.
There are two causes for menstrual problems (AUB):
- Hormone Imbalance (80%).
- Some Physical Abnormality with the uterus, Ovaries, or pelvis (20%).
Understanding menstrual problems
The hormonal regulatory system of the body that controls normal periods is the Ovarian – Pituitary axis. Factors such as stress, large weight loss or weight gain and various medications used to treat stress can all affect this system.
Most menstrual problems have a hormonal cause. Women with such problems need to be investigated systematically by measuring the relevant hormone levels.
Surgical causes for abnormal uterine bleeding need operative treatments.
Hormone imbalance is the commonest cause for menstrual problems.
They can be caused from problems such as:
- Functional Ovarian cysts.
- Polycystic Ovarian Syndrome.
- Dysfunctional Uterine Bleeding.
- Stress affects most people.
- Financial pressures.
- Marital relationship disharmony.
- Work problems.
- Pressure from student examinations etc.
Functional Ovarian cysts
- Ovarian cysts are common.
- They may be either physiological or pathological cysts.
- Functional cysts can produce abnormal patterns of hormone.
- Such cysts can have a direct role in causing abnormal uterine bleeding. Functional cysts are benign and usually resolve by themselves without the need for any treatment. Occasionally some ovarian cysts may be pathological and may require surgical treatment.
Polycystic Ovarian Syndrome (PCOS)
PCOS is common and it can cause a variety of problems including:
- Period problems.
- Fertility problems.
- Testosterone problems such as excessive body hair and acne.
- Weight problems.
Periods may be absent (amenorrhea), infrequent or light (oligomenorrhea).
The diagnosis is made principally on blood tests and also on the ultrasound scan appearance of the ovaries.
Treatment of period problems may involve:
- Weight loss programs.
- Hormonal treatment.
- Occasionally surgical treatment such as “Golf Balling” of ovaries.
Young women should preferentially not have surgical treatment as this may have an effect on scarring and in turn cause fertility problems.
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional bleeding results from hormone imbalance and is often seen in older women.
The climacteric is that 10-year period between the ages of 40-50 preceding the onset of the menopause. At this time ovulation is not regular, progesterone hormone is not released and hormonal dysfunction occurs.
The hormonal mechanics are complex but the essence to understanding DUB is to recognize that progesterone provides endometrial protection. A deficiency of progesterone will lead to an overstimulation of the lining of the uterine cavity (endometrium) and this will cause heavy and prolonged periods.
Heavy periods are a big problem. They are upsetting and inconvenient. They may cause iron deficiency, anaemia and tiredness. More importantly some women will develop endometrial hyperplasia. Endometrial hyperplasia can proceed from simple, to complex, atypical and ultimately to endometrial malignancy.
It is important that women who have heavy periods should have a uterine curettage to biopsy the endometrium and thereby exclude pathological changes.
For women with DUB one option for treatment might include the use of a medicated IUCD (Mirena). This medicated IUCD slowly releases progesterone directly in to the uterine cavity over a 5 year period. This method takes away the worry of having to remember taking pills.
The Mirena I.U.C.D. also protects the patient by not exposing the liver to higher doses of progesterone that would be absorbed when progesterone is taken orally.
Mirena I.U.C.D. thereby reduces the risks of hormone side effects. Mirena is a great way of treating dysfunctional uterine bleeding. It is simple, safe and effective.
Progesterone can still be taken orally, as can other alternative oral treatments such as Cyclokapron (prevention of clot breakdown). These alternative treatments are in my opinion less effective.
Non-hormonal reasons for abnormal uterine bleeding
Statistically a physical abnormality will be found in 20% of cases of AUB
The reasons include:
- Fibroid Uterus.
- Pelvic inflammatory disease.
- Endometrial polyps.
A fibroid uterus and a uterus with adenomyosis usually cause regular and heavy menstrual bleeding.
Endometriosis and pelvic inflammatory disease usually cause painful and irregular menstrual bleeding.
Endometrial polyps usually cause irregular and light bleeding.
Non-hormonal reasons for abnormal uterine bleeding will require some surgical intervention such as Hysteroscopy, Laparoscopy or Hysterectomy for diagnosis and cure.
Comprehensive history and examination help identify the most likely cause of abnormal uterine bleeding.
The history will determine the details of the bleeding.
The gynaecologic examination will determine if the uterus is abnormal (enlarged irregular or “fixed” in the pelvis).
Detailed ultrasound examinations are usually required to confirm the findings.
Treatment will be determined by:
- Investigation findings (ultrasound, blood tests, pap smear).
- The age of the patient (preservation of fertility, Proximity of menopause).
- The severity of symptoms (anaemia, severe pains etc.).
- Previous treatment failures (operative treatment if previous conservative treatments have failed).
The benefits and risks of any treatment option would always be discussed fully.
Treatments can include:
- Conservative treatments, which can sometimes be completely satisfactory.
- A laparoscopy may be needed to divide adhesions and excise endometriosis.
- Endometrial ablation (burning the endometrium) may be required.
- Ultimately some women may require definitive treatment with a hysterectomy.
It is wise not to treat patients on the assumption that they have a particular problem. It is always better to investigate first and then treat as required.