The Basics of Menstrual Disorders

Some women sail through their monthly periods with little or no concern. With few symptoms to worry about, other than the menstrual flow itself, their periods are like clockwork, starting and stopping at nearly the same time every month. For other women, however, the menstrual cycle introduces a host of physical and emotional symptoms that cause discomfort or worry. Menstrual cycle disorders include abnormal uterine bleeding, fibroids, premenstrual syndrome and premenstrual dysphoric disorder, among conditions.

Most menstrual cycle disorders are benign, but that doesn't mean that they aren't overwhelming or shouldn't be evaluated. There are many treatment options to correct menstrual cycle disorders. The first and most important step is to discuss your symptoms with your health care professional so he or she can accurately diagnose your condition and help you choose the best way to make your menstrual cycle tolerable.

Abnormal Uterine Bleeding

Heavy menstrual bleeding is a common problem for many women. One in five women bleed so heavily that they sometimes have to put their normal lives on hold just to deal with the heavy blood flow. The general term for this condition is called "abnormal uterine bleeding" (AUB). It is used to describe menstrual periods that are too heavy (menorrhagia), too long (hypermenorrhea) and bleeding that occurs between periods (metrorrhagia). AUB may also be used to describe missed periods (amenorrhea).

How heavy is heavy? In general, AUB describes menstrual bleeding heavy enough to interfere with normal activities. Blood loss during a normal menstrual period is about 2.5 ounces, but if you have AUB, you may bleed as much as 10 to 25 times that amount each month. It's a distressing and, sometimes, painful problem.

The Basics of Menstrual Disorders <i>(cont'd)</i>

Irregular periods can be common at various stages of your life — during your teen years when you first begin to menstruate, and as you near menopause, around the age of 50, for example. In the three to five years just prior to menopause, your periods may suddenly become lighter or heavier because you are ovulating less often. If you are past menopause and you aren't taking any hormones, any uterine bleeding you experience is considered abnormal and should be evaluated immediately by a health care professional.

The best way to determine if your periods are normal is to determine how predictable the time between your periods is. A woman having periods every 21 to 35 days lasting three to four days does not have AUB. A woman having periods every 21 to 35 days lasting three days some months and 10 days other months is likely not to be ovulating regularly and may have AUB.

Types of AUB

There are three types of abnormal uterine bleeding: dysfunctional, structural and bleeding secondary to underlying disorders, such as von Willebrand's disease and hemophilia, for example.

Dysfunctional uterine bleeding can be caused by hormonal imbalances. As many as 75 percent of women with excessive menstrual bleeding have a hormone-related disorder that is responsible for their AUB condition. Hormonal imbalances occur when your body produces too much or not enough of certain hormones. These imbalances also be associated with:

  • weight loss or gain
  • a heavy exercise regimen
  • stress
  • illness
  • use of some medications

The Basics of Menstrual Disorders <i>(cont'd)</i>

Nearly one-half of women with AUB and almost all of women with dysfunctional uterine bleeding are not ovulating regularly. Ovulation, which is the release of the egg from the ovary, is accompanied by production of progesterone, the hormone that is most important in keeping periods regular.

Women who fail to ovulate for many months or years can end up with endometrial hyperplasia - a condition where the lining of your uterus grows excessively. It happens because the delicate balance between the hormones of progesterone and estrogen in your body is disrupted. If left untreated for a long time, the condition can become cancerous.

Chronic failure to ovulate may cause the ovaries to produce excessive levels of androgens (a reproductive hormone found in small amounts in women and in greater amounts in men). This condition may cause cysts to develop on your ovaries and is known as polycystic ovarian disease. The symptoms of polycystic ovarian disease include:

  • irregular uterine bleeding
  • irregular periods from an early age
  • infertility
  • acne
  • excessive facial hair or hair on your abdomen or chest
  • obesity

The Basics of Menstrual Disorders <i>(cont'd)</i>

Other hormonal causes of dysfunctional uterine bleeding include thyroid or adrenal gland imbalance. Heavy bleeding may be caused by medical conditions, such as:

  • blood clotting disorders such as Von Willebrand's disease, ITP or hemophilia
  • liver or kidney disease
  • leukemia
  • medications, such as anticoagulant drugs and some synthetic hormones
  • the Copper-T IUD, which may also cause heavy periods
  • normal pregnancy
  • miscarriage
  • ectopic pregnancy, which occurs when a fertilized egg begins to grow outside your uterus, typically in your fallopian tubes
  • chronic medical problems, such as diabetes, lupus or sarcoidosis

Structural causes of excessive bleeding include:

  • polyps
  • scar tissue
  • infection
  • pre-cancerous conditions
  • uterine fibroids

Fibroids don't always cause excessive bleeding. In fact, about half of all women who have fibroids don't have any symptoms at all.

The Basics of Menstrual Disorders <i>(cont'd)</i>

Amenorrhea — No Bleeding

Some women don't have heavy menstrual bleeding — they have the opposite problem: no menstrual periods at all. This condition, called amenorreha, or the absence of menstruation, is normal before puberty, after menopause and during pregnancy. If you don't have a monthly period and don't fit into one of these categories, then you need to discuss your condition with your health care professional.

  • Primary amenorrhea: is diagnosed if you reach the age of 18 and haven't yet begun to menstruate. It's usually caused by some problem in your endocrine system, which regulates your hormones. This medical condition can be caused by a number of things, such as a problem with your ovaries, your nervous system, your adrenal glands or an abnormally functioning pituitary gland that affects how you mature at puberty. Birth defects that prevent some of your reproductive anatomy from developing normally (Turner's syndrome, for example) are other causes of primary amenorrhea.
  • Secondary amenorrhea: is diagnosed if you've had regular periods, but then they suddenly stop for at least three months or longer. This condition can be precipitated by other problems that affect estrogen levels, including stress, weight loss, exercise or illness; or problems affecting the pituitary (elevated levels of the hormone prolactin), thyroid (hyperthyroidism or hypothyroidism) or adrenal glands (Cushing's disease, for example). Secondary amenorrhea can also occur if you've had an ovarian tumor or have had your ovaries surgically removed. Celiac disease, which causes abnormalities in the digestive tract, is also associated with late puberty, early menopause and amenorrhea.

The Basics of Menstrual Disorders <i>(cont'd)</i>

Menstrual Cramps, PMS and PMDD

Most women have experienced menstrual cramps before or during their period at some point in their lives. For some, it's part of the regular monthly routine. But if your cramps are especially painful and persistent, you should consult your health care professional.

Pain from menstrual cramps is a result of contractions of your uterus, which are caused by prostaglandins. Prostaglandins circulate in your bloodstream and they can cause diarrhea because they also speed up contractions in your intestines. They can also lower your blood pressure by relaxing blood vessels. If you're having severe menstrual pain, you might also find you have some diarrhea or an occasional feeling of faintness where you suddenly become pale and sweaty.

Premenstrual syndrome, or PMS, is a term commonly used to describe a wide variety of severe physical and psychological symptoms associated with the menstrual cycle. Approximately 30 to 40 percent of all women experience symptoms severe enough to disrupt their lifestyles. PMS symptoms are more severe and disruptive than the premenstrual symptoms that as many as 75 percent of all women experience.

There are more than 150 documented symptoms of PMS; the most common is depression. Symptoms develop about seven to 10 days before each period, and disappear once your period begins or soon after.

Some of the physical symptoms associated with PMS are:

  • bloating
  • swollen, painful breasts
  • fatigue
  • constipation
  • headaches
  • clumsiness

The Basics of Menstrual Disorders <i>(cont'd)</i>

Some of the emotional symptoms associated with PMS are:

  • anger
  • anxiety or confusion
  • mood swings and tension
  • crying and depression
  • an inability to concentrate

No one knows what causes PMS. However, researchers now know that PMS is not a simple result of an imbalance of estrogen and progesterone — commonly referred to as "female hormones," or any other single hormonal factor.

A complex interaction of neurotransmitters (such as dopamine, norepinephrine and serotonin) as well as other brain chemicals are now suspected of having a more direct relationship in triggering PMS. But, exactly how these brain chemicals change with or affect the menstrual cycle remains unclear. Estrogen excesses, progesterone deficiencies, vitamin B6 deficiencies, low levels of serotonin (a brain chemical that affects mood), an excess of prolactin (a protein hormone that induces lactation) and altered glucose metabolism are among the many different theories that attempt to explain PMS, but none has been proven.

Features of PMS that distinguish it from other menstrual cycle symptoms are:

  • symptoms tend to increase in severity as the cycle progresses
  • symptoms are relieved when menstrual flow begins or shortly after
  • symptoms are present for at least three consecutive menstrual cycles

The Basics of Menstrual Disorders <i>(cont'd)</i>

Symptoms of PMS may worsen with age and increase in severity following each pregnancy. Women who experience PMS may have an increased sensitivity to alcohol at specific times during their cycle. They often have a sister or mother who also suffers from PMS, suggesting a genetic component exists for the disorder.

Premenstrual dysphoric disorder (PMDD) is different from the more common PMS - it's far more severe. Women who experience PMDD (about five to seven percent of all women) say that it significantly interferes with lives. Experts equate the difference between PMS and PMDD to the difference between a mild tension headache and a migraine.

The most common symptoms of PMDD are heightened irritability, anxiety and mood swings. Women who have a history of major depression, postpartum depression or mood disorders are at higher risk for PMDD than other women. Although some symptoms of PMDD and major depression overlap, they are different:

  • PMDD-related symptoms (both emotional and physical) are cyclical. When a woman starts her period, the symptoms subside within a few days.
  • Depression-related symptoms, however, are not associated with the menstrual cycle. Without treatment, depressive mood disorders can persist for weeks, months or years.