Problems with your Periods

Edited excerpts from our book
A Gynecologist's Second Opinion

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PROBLEMS WITH YOUR PERIODS
Throughout history, menstruation has been associated with myth and superstition. Menstrual blood was felt to cure leprosy, warts, birthmarks, gout, worms and epilepsy. It has been used to ward off demons and evil spirits. Menstruating women have been separated from their tribes in order to prevent a bad influence on the crops or the hunt. As recently as 1930, the cause of abnormal menstrual bleeding was felt to be an undue exposure to cold or wet just prior to the beginning of the period. 

In modern times we have learned that menstruation is the end of the monthly cycle a woman's body goes through if conception has not occurred, allowing the uterine lining to start over again for the next cycle. We have made quantum leaps towards understanding the role menstruation plays in preparing a woman's body for reproduction. And we have learned a great deal about the treatment of many of the problems of abnormal periods. Science has thankfully dispelled the myths and superstitions that surrounded menstruation and sexuality, but the mystery and wonder of these processes stays with us still. 

Since the days that I studied the female hormone system in medical school, new research has revealed an astonishingly complex system of hormones and nerve transmitter proteins that interplay to regulate the monthly menstrual cycle. The system is balanced, but in certain situations - such as times of stress, when body weight changes, when taking medications - it is easily upset. Once the balance is upset, bleeding can occur that is outside of the normal pattern. Also, cells that form abnormal growths within the uterine lining - polyps, hyperplasia, cancer- can cause bleeding as they develop. In the first part of this chapter, we will deal with the circumstances and solutions for problems with your periods. The second part of the chapter will deal with painful periods and the new ideas and treatments for this common, bothersome and, sometimes, incapacitating problem. 

WHAT KIND OF PERIOD IS NORMAL?
The onset of menstrual periods occurs between the ages of 9-17 with the average age being 13. Adolescents tend to have periods that are far apart and then establish more regularity over the subsequent few years. Most adult women will have a menstrual cycle, measured from the first day of any bleeding to the next episode of bleeding, about every 21-35 days. Although women expect to bleed every 28 days, only 15% of women actually have cycles that length. Bleeding usually lasts 4-6 days with some women bleeding a few days longer or shorter. Most women lose about 6 teaspoons of blood each month. Interestingly, the number of days between periods changes over time, with periods becoming further apart as women reach their forties. 

WHEN IS BLEEDING ABNORMAL?
Abnormal bleeding is said to occur if you have a period more often than every 21 days, less often than every 35 days, or if you have bleeding or spotting in between periods. Very heavy bleeding, saturating a pad or tampon every hour or two for more than a few hours, is also abnormal. There are a number of causes of abnormal bleeding, and the good news is that almost all of them are benign and easily treatable. The most common causes are hormonal changes, ovarian cysts, uterine or cervical polyps, overgrowth of the uterine lining cells (hyperplasia), fibroids, and, rarely, precancer or cancer of the uterus. The following sections will explain each of these problems in detail. 

WHAT SHOULD BE DONE IF YOU HAVE ABNORMAL BLEEDING DURING PERIMENOPAUSE OR AFTER MENOPAUSE?
As menopause approaches, most women will experience lighter and less frequent periods. However, the likelihood of bleeding from other causes such as hyperplasia (lining overgrowth), polyps, or precancer or cancer of the uterus increases at this time of your life. Bleeding that is irregular, very heavy (need to change a pad every hour or two) or prolonged (more than seven days) is abnormal and it is important to establish the cause. The best way to accomplish this is with a sampling of the cells from the uterine lining. The diagnostic methods available include hysteroscopy, endometrial biopsy, and D&C. These methods are fully described in this chapter.

WHAT IS HYSTEROSCOPY?
This test allows the doctor to look inside the uterus by placing the hysteroscope, a small telescope, through the vagina and into the opening in the cervix. Once inside the uterus, the lining cells can be inspected. Polyps, fibroids, hyperplasia and cancer can all be seen with the hysteroscope. The procedure, called hysteroscopy, can be done in the office in about 5 minutes and usually does not require any anesthesia. The information the doctor can get from this procedure is invaluable. Because many problems can be clearly seen, the diagnosis is often certain. A number of studies have shown that the diagnosis made by hysteroscopy followed by scraping the visualized abnormal area of lining cells is more accurate than when a D&C is performed blindly without the hysteroscope. 

WHAT IS AN ENDOMETRIAL ABLATION?
Endometrial ablation is an outpatient surgical procedure used to stop or decrease bleeding from the uterus. Using electrical energy passed into the uterus at the end of a telescope, the lining of the uterus is burned and destroyed. The ovaries continue to make normal amounts of hormone, but without lining cells, bleeding can not occur. 

In 50% percent of patients, all the lining cells have been destroyed, and these women never have another menstrual period again. In an additional 40% percent of women, a few lining cells have been left behind, and these women will experience a light flow for a few days each month. For 10% of women, no improvement is noted. Still, 90% of the women who have this procedure are extremely happy not to have to tolerate the severe and debilitating monthly bleeding they had previously had. Women who have had an endometrial ablation are often the most satisfied patients I take care of. After surgery, they are able to return to normal activity and life unencumbered by the fatigue and inconvenience associated with heavy bleeding.

Endometrial ablation may only be performed on women who do not wish to have any, or any more, children. Once the lining cells of the uterus are destroyed by the procedure, there is no place for a developing fetus to attach within the uterus. Despite this, it is best to use some form of contraception after the procedure. If some cells remain following endometrial ablation, there exists the rare possibility of pregnancy. In the few cases where pregnancy has occurred, termination of the pregnancy has been recommended. Doctors have been concerned that without adequate cells lining the inside of the uterus, the placenta would grow abnormally, directly into the muscle wall of the uterus and take hold like the roots of a tree. As a result, the placenta would not be able to separate at the time of delivery, and hemorrhage could occur. 

WHAT ARE THE CAUSES OF PAINFUL PERIODS (DYSMENORRHEA)?
Dysmenorrhea refers to the pain accompanying a period. Most menstruating women have uterine contractions of moderate strength that each last for less than thirty seconds and occur about every 3 to 5 minutes. However, women who experience severe dysmenorrhea have cramps that last up to 90 seconds with only a few seconds of rest in between. And, the strength of the contraction may be up to 5 times greater than normal. 

We now know that dysmenorrhea results from the release of a chemical substance, called prostaglandin, from the lining cells of the uterus at the time of the menstrual period. The prostaglandin causes contractions of the muscle wall of the uterus, "menstrual cramps". In fact, if you give prostaglandin to a woman by injection, severe menstrual cramps result. Along the same lines, prostaglandin is now used to help start the contractions of labor in women who, for medical reasons, need to deliver their babies promptly. 

Women who have dysmenorrhea have been found to produce more prostaglandin in the lining cells of the uterus than woman who do not have cramps. And, when the increased amount of prostaglandin is released at the time of the period, stronger uterine contractions are the result. As we will discuss, new medications are now available that prevent the formation of prostaglandins in the uterus and thus can prevent or decrease menstrual cramps. 

The following questions and answers can be found in our book

ABOUT YOUR PERIODS

• WHAT KIND OF PERIOD IS NORMAL? 
• WHAT MAKES YOUR CYCLE REGULAR? 
• WHEN IS BLEEDING ABNORMAL? 

HORMONAL PROBLEMS

• ARE ADOLESCENTS PRONE TO ABNORMAL BLEEDING? 
• CAN STRESS INTERFERE WITH YOUR PERIODS? 
• CAN YOUR WEIGHT AFFECT YOUR PERIODS? 
• CAN CHANGES IN THE AMOUNT OF EXERCISE YOU DO CAUSE ABNORMAL BLEEDING? 
• CAN ANOREXIA NERVOSA INTERFERE WITH YOUR PERIODS? 
• CAN ANY MEDICATIONS INTERFERE WITH THE MENSTRUAL CYCLE? 
• CAN DRUG OR NARCOTIC USE CAUSE ABNORMAL PERIODS? 
• CAN PROBLEMS WITH YOUR THYROID GLAND INTERFERE WITH YOUR PERIODS? 
• CAN OTHER HORMONAL PROBLEMS INTERFERE WITH YOUR PERIODS? 
• CAN OVARIAN CYSTS CAUSE IRREGULAR PERIODS? 
• CAN MISSING PERIODS LEAD TO ANY OTHER PROBLEMS?

TREATMENT FOR ABNORMAL PERIODS

• WHAT IS THE TREATMENT FOR ABNORMAL PERIODS?
• WHAT IS THE TREATMENT IF IRREGULAR BLEEDING IS DUE TO MISSED OVULATION?
• WHEN IS A D&C NECESSARY FOR ABNORMAL HORMONAL BLEEDING?
• ARE THERE HOMEOPATHIC REMEDIES FOR ABNORMAL BLEEDING DUE TO HORMONAL CAUSES?
• WHAT IS POLYCYSTIC OVARIAN DISEASE (PCO)?
• WHAT IS PREMATURE MENOPAUSE?

MENOPAUSAL BLEEDING

• WHAT KIND OF BLEEDING PROBLEMS MAY DEVELOP IN MENOPAUSE?
• WHAT SHOULD BE DONE IF YOU HAVE ABNORMAL BLEEDING DURING PERIMENOPAUSE OR AFTER MENOPAUSE?
• WHAT IF YOU ARE BLEEDING WHILE YOU ARE ON HORMONE REPLACEMENT THERAPY FOR MENOPAUSE?

POLYPS, FIBROIDS, HYPERPLASIA AND CANCER

• WHAT ARE UTERINE POLYPS?
• CAN POLYPS BE CURED?
• WHAT KIND OF BLEEDING PROBLEMS CAN FIBROIDS CAUSE? 
• WHAT IS THE BEST TREATMENT IF THE CAUSE OF BLEEDING IS FIBROIDS?
• WHAT IS HYPERPLASIA (OVERGROWTH ) OF THE UTERINE LINING?
• CAN ABNORMAL BLEEDING BE A SIGN OF CANCER?

TESTS FOR ABNORMAL BLEEDING

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• HOW DO WE FIND OUT WHAT IS CAUSING YOUR ABNORMAL BLEEDING?
• WHEN ARE FURTHER TESTS NEEDED?
• WHAT IS HYSTEROSCOPY?
• WHAT HAPPENS DURING AN OFFICE D&C?
• WHAT IS AN ENDOMETRIAL BIOPSY?
• CAN A SONOGRAM BE USED TO DIAGNOSE THE CAUSE OF ABNORMAL BLEEDING?

TREATMENT FOR ABNORMAL BLEEDING

• WHAT IS THE BEST TREATMENT IF THE BLEEDING DOES NOT GO AWAY?
• WHAT IS AN ENDOMETRIAL ABLATION?
• WHEN IS A HYSTERECTOMY NECESSARY FOR ABNORMAL BLEEDING?
• WHAT CAN BE DONE IF YOU HAVE UTERINE PRECANCER OR CANCER?

BLEEDING PROBLEMS AND PREGNANCY

• WHAT IF YOU ARE PREGNANT AND HAVE BLEEDING?
• WHAT SHOULD BE DONE IF YOU ARE MISCARRYING?
• CAN BLEEDING MEAN YOU HAVE AN ECTOPIC PREGNANCY?
• WHAT CAUSES AN ECTOPIC PREGNANCY?
• HOW CAN THE DOCTOR TELL IF YOU HAVE AN ECTOPIC PREGNANCY?
• WHAT ARE THE POSSIBLE TREATMENTS FOR AN ECTOPIC PREGNANCY?
• WHAT IS THE CURRENT RESEARCH REGARDING TREATMENT OF ECTOPIC PREGNANCY?

PAINFUL PERIODS

• HOW COMMON ARE PAINFUL PERIODS (DYSMENORRHEA)?
• WHAT SYMPTOMS CAN OCCUR WITH PAINFUL PERIODS?
• WHAT ARE THE CAUSES OF PAINFUL PERIODS (DYSMENORRHEA)?
• HOW IS THE DIAGNOSIS OF DYSMENORRHEA MADE?

TREATMENT FOR PAINFUL PERIODS

• WHAT IS THE BEST TREATMENT FOR PAINFUL PERIODS?
• CAN HOMEOPATHICS AND HERBAL THERAPIES BE USED FOR PERIOD PAIN?
• CAN ACUPUNCTURE BE USED TO TREAT PAINFUL PERIODS?
• CAN SURGERY HELP PERIOD PAIN?
• WHAT IF YOUR PAIN OCCURS IN THE MIDDLE OF THE CYCLE?