Understanding the Menstrual Cycle
A woman’s menstrual cycle is an interplay and balance of the hormones estrogen and progesterone released from the ovaries, which are respectively dominant before and after ovulation (egg release). These ovarian hormones are further regulated by hormones called gonadotropins (follicle stimulating hormone-FSH and luteinizing hormones-LH) released from the pituitary gland at the base of the brain. The gonadotropin hormones are in turn regulated by gonadotropin releasing hormone (GnRH) from the hypothalamus in the brain.
Estrogen helps in the development of the egg and the ‘ripening’ of the follicle containing it. Estrogen level thereafter drop to cause the egg to be released (ovulation). Thereafter progesterone levels rise to prepare the lining of the uterus (endometrium) by increasing thickening and blood supply. If fertilization/conception does not occur, progesterone levels fall, and menses (bleeding) starts to shed the thickened lining and blood. As progesterone supports the lining of the uterus, its relative deficiency can cause earlier, heavy and prolonged periods.
A normal menstrual cycle has a usual frequency of about 25-35 days, and lasts around 5-7 days. Abnormal uterine bleeding (AUB) implies abnormal menses in terms of frequency, regularity, duration or amount of bleeding.
INCREASED MENSTRUAL BLEEDING
This refers to menses which are heavier, longer than usual, or that occur at a frequent or irregular time. This is sometimes also referred by terms like menorrhagia or hypermenorrhea (heavy or prolonged periods). Heavy periods imply the need to change the tampon/pad in less than 1-2 hours, requirement for double padding or changing pads in the night, or associated with the passage of large clots of more than one quarter pad size. Prolonged period refers to the bleeding lasting more than a week. Polymenorrhea is a term used to describe a menstrual cycle that is shorter than 21 days, and if present with menorrhagia is called polymenorrhagia. Metrorrhagia is abnormal bleeding that occurs between periods or bleeding not associated with menstruation.
Around 5-10% women suffer from increased bleeding and heavy periods, which can have a significant impact on their quality of life, activities and productivity during the period, and cause fatigue and weakness, and anemia.
Usually, increased menstrual bleeding happening once in a while and mainly on the first 2-3 days of the period can be managed with rest, reassurance, stress management and analgesics if there is associated menstrual cramps. However, if this occurs as a regular feature, it is advisable to get a few tests done. These tests include a gynecological physical examination, blood tests (complete blood counts, blood sugar, and thyroid, kidney, liver function), a Pap test and an ultrasound. Further tests maybe advised if needed (like hysteroscopy/hysterography and endometrial biopsy).
Healthy diet, regular physical exercise and stress management go a long way in managing menorrhagia.
Medicines are prescribed to:
Dysmenorrhea is the term given for period pain (also called menstrual cramps). It is an extremely common condition, and many women suffer from it in varying degrees. Pain in the lower back and lower abdomen which may also spread to the legs. The pain may come and go or be present as a dull constant ache.
Types of Dysmenorrhea
Painful periods can be distressful for women impacting them not only physically but emotionally and occupationally. Tackling it involves solutions combining lifestyle modification and appropriate medicines.
In severe cases, not responsive to treatment, a gynecologist should be consulted who will perform a detailed pelvic exam, and order an ultrasound to rule out or pick up any underlying conditions. In some cases, a laparoscopy may be necessary for the diagnosis (by an instrument called a laparoscope inserted through a key hole incision to look at the abdominal organs).
Premenstrual Syndrome (PMS) is a group of symptoms which effects many women a few days before the start of their menses, and typically settles down once the period starts. The cause is related mainly to change in hormonal levels. The type and severity of symptoms, can vary in different women and can include both physical and emotional symptoms.
The physical symptoms include bloating, weakness, fatigue, joint/muscle pains, low back pain, indigestion, changes in bowel habits (diarrhea or constipation), flaring up of acne, tender feeling in breasts, difficulty in sleeping and headaches. The emotional symptoms include mood swings, anxiety or depression, irritability, crying spells, increased sensitivity and disinterest in sexual activities.
PMS can sometimes cause significant disturbance in the personal and professional life of women, and the symptoms are frequently mis-labelled as maladjusted personality traits or behavioral issues. PMS can be managed by medical evaluation, lifestyle modifications and most importantly care, understanding and support from loved ones and colleagues.
Here are 5 important measures which can help:
It is important to rule out other medical conditions which can present similar to PMS or exaggerate the symptoms of PMS. PMS symptoms typically increases by around 30% in the 6 days before menstruation, ease out with the start of the period and are not present in the initial 2 weeks of the cycle (this pattern being definite in at least two consecutive cycles).
A general history and medical examination and ruling out presence of any other medical conditions like migraine, irritable bowel syndrome (IBS), allergies or metabolic disorders is essential. BP check and baseline blood tests like CBC (to rule out anemia), blood sugar, thyroid function, vitamin D and B12 levels should be done. A personal and family history of mood disorders, anxiety-depression or substance abuse should be enquired about. PMS should be differentiated from dysmenorrhea (pain/cramps after start of period), and an appropriate consult to rule out presence of gynecological conditions like endometriosis, fibroids, polycystic ovarian syndrome (PCOS), contraceptive use, possible start of menopause, or other menstrual irregularities, is also recommended.
MAINTAINING A SYMPTOM DIARY
Maintaining a record of on which day of the period the symptoms started, what were all the symptoms, and a note of the diet, lifestyle, physical activity and other events during that period can be one of the most useful things to do. This not only helps to diagnose PMS, raise possibility of any other medical condition and evaluate the severity, but also understand triggers and aggravating factors.
Some such readymade record keeping formats are available, however it is best that each woman maintains the record in the way most convenient and comfortable for her. Record keeping often reduced the stress and anxiety which comes with and aggravates the symptoms and helps organize lifestyle better on those days.
Incorporate a healthy and nutritious diet. Reduce intake of salt, as that helps to decrease bloating, breast tenderness and water retention. Also cut down on sugar, processed foods and fats on these days. Eat a diet rich in vegetables (especially green leafy vegetables), fruits, whole grains, unsalted nuts (like almonds and walnuts), soy, fish, eggs, olive oil and low-fat dairy items. This helps to increase intake of B group vitamins, vitamin D, vitamin E, omega 3, calcium and Iron (can also be taken as nutritional supplements). Restrict alcohol and caffeine during this period and instead increase water intake, which helps to smoothen digestive complaints and mood swings.
LIFESTYLE AND EXERCISE
At least 30-45 minutes of physical exercise should be included daily throughout the cycle. Aerobic activities like jogging, brisk walking, swimming or cycling are appropriate. Yoga, and breathing exercises help reduce anxiety, and stress. Getting 8 hours of good quality sleep every night is very important. Cutting down smoking on these days can also have a favorable impact.
In patients, who have significant water retention or bloating, diuretic medicines are sometimes prescribed. Oral contraceptives or hormonal therapy may be used in certain women with severe symptoms under the guidance of a gynecologist. In cases where mood swings or emotional symptoms are prominent or severe, antianxiety/antidepressant medications may be prescribed. If body pain, muscle pains or joint pains are the major symptoms, drugs of class NSAID (non-steroidal anti-inflammatory drugs) are advised. Evening primrose oil may be of some benefit in reducing associated breast tenderness.
PCOS and endometriosis are two different conditions causing period (menstrual) problems in women, and sometimes ‘cysts’ (fluid-filled sacs in the ovary). Both can occur together also.Polycystic Ovary Syndrome (PCOS) is a condition that affects the normal functioning of the ovaries, and ovulation. PCOS occurs possibly due to an increase in the level of androgens (male hormones) over and above the small amount that all women naturally have.
Endometriosis is a condition where the lining tissue of the uterus (endometrium) grows outside of it in other organs like the ovary, fallopian tube, associated spaces or support ligaments and rarely the intestines, rectum, diaphragm, etc. The cause of this is linked to excess estrogen (female hormone).
SIMILARITIES between PCOS and endometriosis in their presentation are as follows:
Menstrual Problems in the form of irregular cycles, heavy bleeding and painful periods are present in both conditions. Age groups affected can include teens to mid-40s, and in both conditions, the irregular cycles and impact on the functioning of the ovary can create some challenges in getting pregnant. Both conditions can have an adverse psychological impact, affect daily routine and activities, as well as reduce the quality of life.
DIFFERENCES in the manifestation of PCOS and endometriosis, can give diagnostic clues:
PCOS: Pain (dysmenorrhea) and heavy bleeding may be present during periods.
Endometriosis: Pain is the hallmark symptom which is usually sudden, shooting or cramp like that comes anytime not essentially related to period but can worsen around that time. Pain can also be present during sexual intercourse, urination and bowel movement.
PCOS: Delayed periods, prolonged absence, or missed periods and/or unpredictable irregular periods are hallmark symptoms.
Endometriosis: Periods maybe heavy and painful, and there may also be bleeding in between periods.
PCOS: Increase in body hair (coarse hair on the face, chest, abdomen, or upper thigh referred to as hirsutism), hair fall sometimes leading to male pattern baldness and oily skin, or severe acne not responding to usual treatments maybe seen, often along with weight gain.
Endometriosis: Bloating and indigestion may be seen.
PCOS- family history, rapid weight gain or being overweight or obese, and presence of diabetes or insulin resistance (body is unable to effectively use insulin).
Endometriosis: early onset of menstruation (<11 years of age), periods which are frequent (<27 days) and/or heavy/prolonged (>7 days) and presence of infertility or never giving birth.
There may be a slightly increased risk of cancer (ovarian/uterine) with both these conditions.
Cysts in the ovary may be present part of the normal course of the menstrual cycle (functional cysts) and may not cause symptoms or require any intervention. These can also occur normally during pregnancy. Many of these cysts disappear spontaneously.
In spite of the name, many women with PCOS may not have ovarian cysts. In those that do, the cysts themselves usually do not cause symptoms or problems. These cysts are actually follicles (contain the developing egg).
Endometriotic ovarian cysts are also called chocolate cysts due to the presence of old blood in them, and these cysts cause symptoms especially when large.
Apart from PCOS and Endometriosis, other causes of ovarian cysts include ovarian/pelvic infections, trauma, some fertility drugs and certain tumors of the ovary.
Diagnosis is usually made by ultrasonography. Other tests include a clinical pelvic examination, BP check and blood tests (complete blood counts, sugar, and lipids, along with hormone levels, inflammatory markers like CRP and tumor markers like CA-125).
A balanced nutritious diet and regular exercise is recommended, with use of medicines for pain (over the counter analgesics) when needed. Oral contraceptives (estrogen-progesterone combination) are commonly prescribed in both conditions to regularize hormone levels. Other hormonal treatments may also be used. Fertility medicines/treatment is given to those desiring pregnancy.
The ovarian cysts in PCOS itself usually require no intervention. Surgery, to remove the endometrial growth, or symptomatic large endometriotic cysts (sometimes the affected ovary itself) may be performed. In case of high risk or suspected cancer, removal of the ovaries with or without the uterus is also considered, especially when nearing menopause.
Complications of ovarian cysts
Complications of ovarian cyst may be seen when the cysts are large, also causing enlargement of the ovary, which is seen mostly with endometriotic cysts. These include:
Rupture can happen due to rigorous physical activity or intercourse, leading to severe pain and sometimes internal bleeding (hemorrhage).
Torsion is due to an extra-mobile large ovary twisting itself, leading to abrupt and severe pain, sometimes along with nausea and vomiting. Torsion can lead to loss of blood flow to the ovary. Such complications should be treated immediately as an emergency.
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