NORMAL MENSTRUATION

Menstruation, or period, is normal vaginal bleeding that occurs as part of a woman's monthly
cycle. Every month, body prepares for pregnancy. If no pregnancy occurs, the uterus, or womb,
sheds its lining. The menstrual blood is partly blood and partly tissue from inside the uterus. It
passes out of the body through the vagina.

Periods usually start between age 11 and 14 and continue until menopause at about age 51. They
usually last from three to five days. Besides bleeding from the vagina, may have- Abdominal or
pelvic cramping pain, Lower back pain, Bloating and sore breasts, Food cravings, Mood swings
and irritability and Headache and fatigue.

MENSTRUAL IRREGULARITIES
A cycle is considered clinically irregular when the majority of cycles in the previous six months
are out of range. People with irregular cycles may notice that their periods happen infrequently,
frequently, or are very unpredictable.

For most women, a normal menstrual cycle ranges from 21 to 35 days. However, 14% to 25% of
women have irregular menstrual cycles, meaning the cycles are shorter or longer than normal;
are heavier or lighter than normal; or are experienced with other problems, like abdominal
cramps. Irregular cycles can be ovulatory, meaning that ovulation occurs, or anovulatory,
meaning ovulation does not occur.
The most common menstrual irregularities include:

 AMENORRHEA -or absent menstrual periods. Amenorrhea is characterized by absent

menstrual periods for more than three monthly menstrual cycles. When a woman does not
get her period by age 16, or when she stops getting her period for at least 3 months and is
not pregnant.

Types of Amenorrhea
 Primary amenorrhea: Menstruation does not begin at puberty.
 Secondary amenorrhea: Normal and regular menstrual periods that become
increasingly abnormal and irregular or absent. This may be due to a physical cause
typically of later onset.

 OLIGOMENORRHEA -or infrequent menstrual periods. Periods that occur more than
35 days apart.
 MENORRHAGIA - or heavy menstrual periods. Also called excessive bleeding.
Although anovulatory bleeding and menorrhagia are sometimes grouped together, they
do not have the same cause and require different diagnostic testing.
 PROLONGED MENSTRUAL BLEEDING: Bleeding that exceeds 8 days in duration
on a regular basis.
  DYSMENORRHEA- Painful periods that may include severe menstrual cramps.
Dysmenorrhea is characterized by severe and frequent menstrual cramps and pain
associated with menstruation.
1.PRIMARY DYSMENORRHEA- women experience abnormal uterine contractions
resulting from a chemical imbalance in the body.
2.SECONDARY DYSMENORRHEA- is caused by other medical conditions, most
often endometriosis.
 POLYMENORRHEA -Frequent menstrual periods occurring less than 21 days apart.
 Irregular menstrual periods with a cycle-to-cycle variation of more than 20 days.
 Shortened menstrual bleeding of less than 2 days in duration.
 INTERMENSTRUAL BLEEDING: Episodes of bleeding that occur between periods,
also known as spotting.
 PREMENSTRUAL SYNDROME (PMS)-PMS is any unpleasant or uncomfortable
symptom during cycle that may temporarily disturb normal functioning. Premenstrual
Dysphoric Disorder (PMDD) is a much more severe form of PMS which affects
approximately 3%-8% of women of reproductive age. The most common symptoms of
PMS can include any of the following:-Psychological symptoms (depression, anxiety,
irritability), Gastrointestinal symptoms (bloating), Fluid retention (swelling of fingers,
ankles and feet), Skin problems (acne), Headache, Vertigo, Fainting, Muscle spasms,
Heart palpitations, Infections, Decreased coordination, Diminished libido (sex drive),
Changes in appetite and Hot flashes

CAUSES MENSTRUAL CYCLE IRREGULARITIES

Menstrual cycle irregularities can have many different causes, including:

 PREGNANCY OR BREAST-FEEDING. A missed period can be an early sign of

pregnancy. Breast-feeding typically delays the return of menstruation after pregnancy.
 EATING DISORDERS, EXTREME WEIGHT LOSS OR EXCESSIVE
EXERCISING- Eating disorders — such as anorexia nervosa — extreme weight loss and
increased physical activity can disrupt menstruation.
 POLYCYSTIC OVARY SYNDROME (PCOS). Women with this common endocrine
system disorder may have irregular periods as well as enlarged ovaries that contain small
collections of fluid — called follicles — located in each ovary as seen during an ultrasound
exam.
 PREMATURE OVARIAN FAILURE. Premature ovarian failure refers to the loss of
normal ovarian function before age 40. Women who have premature ovarian failure — also
known as primary ovarian insufficiency — might have irregular or occasional periods for
years.
 PELVIC INFLAMMATORY DISEASE (PID). This infection of the reproductive organs
can cause irregular menstrual bleeding.
 UTERINE FIBROIDS. Uterine fibroids are noncancerous growths of the uterus. They can
cause heavy menstrual periods and prolonged menstrual periods.
SYMPTOMS OF HEAVY OR IRREGULAR PERIODS
The length of the menstrual cycle and amount of blood flow is unique to each woman. However,
most women have a cycle that ranges from 24 to 34 days. Blood flow averages about four or five
days, with a blood loss of about 40 cc (3 tablespoons). It’s important to remember that these are
just averages. “normal” may fall outside of these ranges. A blood loss of 80 cc (5 tablespoons)
or more is considered an abnormally heavy flow. Signs that your menstrual flow may be
abnormally heavy include:

 soaking through more than one tampon or sanitary pad in an hour for several hours at a
time.
 waking up during the night because you need to change protection
 passing large blood clots in your menstrual flow
 experiencing a menstrual flow that lasts more than a week

Also, an abnormally heavy flow can cause her to experience the following symptoms, which may
be an indication of anemia:-fatigue, pale skin, shortness of breath and dizziness.
While every woman’s cycle is different, irregularities such as bleeding mid-cycle or bleeding
after intercourse are abnormal symptoms.

DIAGNOSIS & TESTS

Diagnosis starts with a thorough medical history, including a detailed discussion of a girl’s
menstrual periods, what’s normal for her, and what irregularities are occurring. A physical exam
will also be conducted and when necessary, a pelvic exam.

In cases where a girl is sexually active, a pregnancy test and screening for infections may also
be performed. Depending on specific symptoms, diagnostic testing may include:

 PAP SMEAR-This test checks for various infections or cancerous cells in the cervix.
 BLOOD TESTS-Blood tests will be used to check for anemia, blood-clotting problems,
and thyroid function.
 PELVIC ULTRASOUND-A pelvic ultrasound will produce images of uterus, ovaries,
and pelvis.
 ENDOMETRIAL BIOPSY-If doctor wants to evaluate possible issues with uterus, they
may order an endometrial biopsy. During this procedure, a sample of uterine tissue is
taken so it can be analyzed. They may also use a diagnostic hysteroscopy to view the
inside of uterus. For a hysteroscopy, doctor will use a lighted tube to view the uterus and
remove the polyp.
 SONOHYSTEROGRAM-A sonohysterogram is an ultrasound that involves injecting
fluid into your uterus to help make an image of your uterine cavity. Your doctor will then
be able to look for polyps or fibroids.
TREATMENT & CARE
Treatment will depend on:-overall health, the reason for menstrual abnormalities and
reproductive history and future plans. Doctor will also need to address any underlying medical
conditions, such as thyroid dysfunction. Treatment depends on the individual, her symptoms,
and any underlying health issues causing the menstrual irregularity. Treatment strategies may
include:

 Pain medication
 Hormone therapy or birth control pills to help regulate the menstrual cycle
 Regular pelvic exams – to ensure underlying problems are treated as soon as possible
 Surgery, in rare cases
 LIFESTYLE CHANGES. Some women have changes in their period because
they exercise too much. Need to make workouts less intense, or exercise less often.
If stress is the problem, learning how to manage stress -- and possibly also talking with a
counselor -- may be helpful.

1. MEDICATION-Possible medication treatments doctor may suggest include:

 Nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen or naproxen, can
reduce mild blood loss.
 Iron supplements can treat anemia.
 Hormone replacement injections can treat hormonal imbalances.
 Oral contraceptives can regulate your cycle and shorten periods.

2. MEDICAL PROCEDURES

 D&C-Dilation and curettage, also known as D&C- is a procedure in which

doctor dilates cervix and scrapes tissue from the lining of uterus. This is a fairly
common procedure and generally cuts down on menstrual bleeding.

 SURGERY-Surgery is the most common treatment for cancerous tumors. It’s also
an option to treat fibroids, but it’s not always necessary. Removal of polyps can
be done using a hysteroscopy.

 ENDOMETRIAL ABLATION-Endometrial ablation is a procedure used in women

who haven’t had any success with medications being used to control heavy
bleeding and related symptoms. This procedure involves doctor destroying the
uterine lining, leaving little or no menstrual flow.
  ENDOMETRIAL RESECTION-Endometrial resection removes the uterine lining.
This procedure significantly decreases chances of a future pregnancy. If patient
planning to have children, she may want to discuss and consider other treatment
options.

 HYSTERECTOMY-A hysterectomy is the surgical removal of the uterus and

cervix. doctor may also remove ovaries, if necessary. This results in premature
menopause. This procedure may be the preferred treatment if patient has cancer
or fibroids. It can also treat endometriosis that hasn’t responded to other less
invasive treatment methods. Having a hysterectomy removes ability to bear
children.

HOME REMEDIES-Maintaining a healthful lifestyle can help reduce the risk of

some of the causes of irregular periods. This includes:
 exercising regularly to maintain a healthy weight and reduce stress
 following a healthful diet
Some herbal remedies, such as black cohosh, chasteberry, licorice root, and turmeric are all said
to help, but research has not confirmed their effectiveness, and they may have adverse effects. It
is better to speak to a doctor first.

COMPLICATIONS ASSOCIATED WITH HEAVY OR

IRREGULAR MENSTRUAL PERIODS
Heavy blood flow isn’t always a sign that something is wrong. However, excessive loss of blood
can deplete the body’s supply of iron and cause anemia. A mild case of anemia can cause fatigue
and weakness. A more severe case can result in the following symptoms:

 headaches
 dizziness
 shortness of breath
 rapid heart rate
A very heavy flow can also cause painful cramping, or dysmenorrhea, which sometimes requires
medication.
 REFERENCES

1. Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for
Contraceptive Use, 2016. MMWR Recomm Rep 2016;65(No. RR-4):1–66.
2. Hillard PJ. Menstruation in adolescents: what do we know? And what do we do with the
information?. J Pediatr Adolesc Gynecol. 2014 Dec;27(6):309-19.
3. Fraser IS, Critchley HO, Broder M, Munro MG. The FIGO recommendations on terminologies
and definitions for normal and abnormal uterine bleeding. Semin Reprod Med. 2011
Sep;29(5):383-90.
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