Menstrual problems

Types of menstrual problems

• Amenorrhoea. This is the complete absence of periods.
• Oligomenorrhoea. This is irregular or infrequent periods. Menstruation can occur anywhere between every six weeks and several months.
• Dysmenorrhoea. Period pains, or dysmenorrhoea, affect 40-70 per cent of women of reproductive age at some time.
• PMS or premenstrual syndrome. Many women experience physical and mood changes around the time of their period, but for some it can be a particularly difficult time.
• Menorrhagia This is recurrent heavy bleeding during menstruation. About a third of women describe their periods as heavy. The average blood loss during menstruation is typically about 40ml. With menorrhagia the loss is 80ml or more.

Causes of menstrual problems

Amenorrhoea. If an otherwise normal girl of 16 has never menstruated, this is called primary amenorrhoea. The same diagnosis is given to a girl of 14 who has never had a period if she also fails to show any signs of sexual development, such as breast growth or pubic hair growth.

Secondary amenorrhoea is when menstruation has stopped for over six consecutive months in a woman who has previously had regular periods. Excluding pregnancy as a cause, about 20 to 30 per cent of women experience amenorrhoea for a variable number of months at some time during their reproductive life.

Causes of amenorrhoea include problems with hormonal control from the hypothalamus or pituitary gland (such as under-activity of the gland or a tumour), anorexia and excessive weight loss, depression, excessive stress or exercise, or problems with the ovaries, including:

• High blood levels of male hormones.
• Polycystic ovary syndrome (PCOS).
• Premature ovarian failure.
• Genetic disorders such as Turner syndrome.

Oligomenorrhoea. This is irregular or infrequent periods. Menstruation can occur anywhere between every six weeks and six months. Many of the causes are the same as those for amenorrhoea.

A common cause is a condition called polycystic ovary syndrome (PCOS). This is a hormonal disorder that affects the ovaries of up to ten per cent of women (or as many as 20 per cent of overweight women). The ovaries have an abnormally large number of follicles - little swellings that develop each month to release an egg.

In PCOS the hormonal changes are complex, including high testosterone levels with associated insulin resistance and abnormal lipid levels. Generally the follicles remain immature meaning that eggs are often not released and the woman rarely ovulates and so is less fertile. In addition to irregular periods, women with PCOS may also have excess body hair and be overweight.

As with amenorrhoea, treatment of oligomenorrhoea depends on the underlying cause and what the woman wants. A woman with infrequent periods may still be fertile and should be advised of this.

Dysmenorrhoea. For about one in 10 women the discomfort and pain of periods is bad enough to interfere with their daily lives. A certain amount of discomfort around the time of ovulation and menstruation is normal, and it has been proposed that it’s related to the movements of the womb and the hormones and chemicals that circulate around the body at that time of the month.

The pain typically occurs in the lower abdomen and/or pelvis and can radiate to the back and along the thighs, lasting somewhere between eight and 72 hours. It may be a constant dull ache or occur as cramps before or during menstruation or both.

Headaches, diarrhoea, nausea and vomiting may accompany it. Sometimes dysmenorrhoea is a sign of an underlying disease.

If there is an underlying disease causing the dysmenorrhoea then this should be treated. Often there will be other symptoms too, such as heavy bleeding or pain or bleeding after intercourse.

The most common diseases associated with dysmenorrhoea are endometriosis and fibroids. Endometriosis is a condition where the cells that make up the lining of the womb are also found in places other than the womb. With each menstruation, this tissue outside responds to the same hormones that control periods and therefore builds up and breaks down and bleeds in the same way as the womb lining. This can lead to inflammation and pain. Fibroids are non-cancerous or benign growths in the uterus. A fifth of women develop them in their lifetime. They can be very small or as big as a melon.

Other less common causes of dysmenorrhoea are previous pelvic surgery and a pelvic infection which can, in some women, lead to significant pain and heavy periods.

PMS. There are more than 150 symptoms associated with premenstrual syndrome (PMS), but the common ones include:

• Low mood and irritability.
• Breast tenderness.
• Bloating.

Typically PMS symptoms appear in the days before a period and cease once menstruation begins. It’s not known what causes PMS but the normal hormonal changes that occur during the menstrual cycle are thought to be involved. PMS severity often increases around hormonal surges, such as puberty and pregnancy. Women aged 30-45 often experience the most severe PMS.

Menorrhagia. Women with menorrhagia may have to use double sanitary protection - towels and tampons - and the heavy bleeding may stop them from doing normal activities because of flooding through clothes, for example. They may also report passing large clots.

Treatment and prevention of menstrual problems

Amenorrhoea. The treatment depends on the underlying cause and what the woman wants. Some women may not view their condition as a problem unless they want to start a family, for example. Conversely, a woman with amenorrhoea may still be fertile and should be advised to use a contraceptive if she doesn’t want to become pregnant.

Oligomenorrhoea. As with amenorrhoea, treatment of oligomenorrhoea depends on the underlying cause and what the woman wants. Again, a woman with infrequent periods may still be fertile and should be advised of this.

Dysmenorrhoea. When there is no underlying cause, simple analgesia with a non-steroidal anti-inflammatory drug such as ibuprofen might be all that is needed. Some women find that going on the combined oral contraceptive pill lessens the discomfort. Others have reported being helped by acupuncture, TENS therapy (a painless way of stimulating the nerves using pulsed energy) or a hot water bottle applied locally to the area of discomfort.

Endometriosis can be treated with hormones or surgery to shrink or remove the problematic tissue, with variable success.

PMS. Lifestyle approaches ranging from diet and exercise to stress management may help. Drug treatments may also ease the symptoms. These include hormonal contraceptives and more potent hormonal drugs. Some may prefer to try non-hormonal alternatives such as vitamin B6 and evening primrose oil or diuretics.

Menorrhagia. In most cases no cause can be found. However, there may be an underlying cause such as endometriosis or fibroids. It’s important to investigate the bleeding and check that it’s not due to something more sinister like cancer of the uterus or cervix.

The treatment depends on the cause. The bleeding can often be reduced with non-hormonal tablets (for example tranexamic acid), oral contraceptives, or by fitting a progesterone-releasing contraceptive coil into the womb, if there is no underlying problem that needs treating. If these don't work, a woman might want to consider surgery to remove the uterus completely or have the womb lining stripped. She may also need to take iron or folic acid supplements if the blood loss has made her anaemic.