Some Types of Menstrual Disorders

Overview

Some women get through their monthly periods easily with few or no concerns. Their periods come like clockwork, starting and stopping at nearly the same time every month, causing little more than a minor inconvenience.

However, other women experience a host of physical and/or emotional symptoms just before and during menstruation. From heavy bleeding and missed periods to unmanageable mood swings, these symptoms may disrupt a woman’s life in major ways.

Most menstrual cycle problems have straightforward explanations, and a range of treatment options exist to relieve your symptoms. If your periods feel overwhelming, discuss your symptoms with your health care professional. Once your symptoms are accurately diagnosed, he or she can help you choose the best treatment to make your menstrual cycle tolerable.

How the Menstrual Cycle Works
Your menstrual period is part of your menstrual cycle—a series of changes that occur to parts of your body (your ovaries, uterus, vagina and breasts) every 28 days, on average. Some normal menstrual cycles are a bit longer; some are shorter. The first day of your menstrual period is day one of your menstrual cycle. The average menstrual period lasts about five to seven days. A “normal” menstrual period for you may be different from what’s “normal” for someone else.

Types of Menstrual Disorders
If one or more of the symptoms you experience before or during your period causes a problem, you may have a menstrual cycle “disorder.” These include:

• abnormal uterine bleeding (AUB), which may include heavy menstrual bleeding, no menstrual bleeding (amenorrhea) or bleeding between periods (irregular menstrual bleeding)
• dysmenorrhea (painful menstrual periods)
• premenstrual syndrome (PMS)
• premenstrual dysphonic disorder (PMDD)

A brief discussion of menstrual disorders follows below.

Heavy menstrual bleeding
One in five women bleed so heavily during their periods that they have to put their normal lives on hold just to deal with the heavy blood flow.

Bleeding is considered heavy if it interferes with normal activities. Blood loss during a normal menstrual period is about 5 tablespoons, but if you have heavy menstrual bleeding, you may bleed as much as 10 to 25 times that amount each month. You may have to change a tampon or pad every hour, for example, instead of three or four times a day.

Heavy menstrual bleeding can be common at various stages of your life—during your teen years when you first begin to menstruate and in your late 40s or early 50s, as you get closer to menopause.

If you are past menopause and experience any vaginal bleeding, discuss your symptoms with your health care professional right away. Any vaginal bleeding after menopause isn’t normal and should be evaluated immediately by a health care professional.

Heavy menstrual bleeding can be caused by:

• hormonal imbalances
• structural abnormalities in the uterus, such as polyps or fibroids
• medical conditions

Many women with heavy menstrual bleeding can blame their condition on hormones. Your body may produce too much or not enough estrogen or progesterone—known as reproductive hormones—necessary to keep your menstrual cycle regular.

For example, many women with heavy menstrual bleeding don’t ovulate regularly.Ovulation, when one of the ovaries releases an egg, occurs around day 14 in a normal menstrual cycle. Changes in hormone levels help trigger ovulation.

Certain medical conditions can cause heavy menstrual bleeding. These include:

• thyroid problems
• blood clotting disorders such as Von Willebrand’s disease, a mild-to-moderate bleeding disorder
• idiopathic thrombocytopenic purpura (ITP), a bleeding disorder characterized by too few platelets in the blood
• liver or kidney disease
• leukemia
• medications, such as anticoagulant drugs such as Plavix (clopidogrel) or heparinand some synthetic hormones.

Other gynecologic conditions that may be responsible for heavy bleeding include:

• complications from an IUD
• fibroids
• miscarriage
• ectopic pregnancy, which occurs when a fertilized egg begins to grow outside your uterus, typically in your fallopian tubes

Other causes of excessive bleeding include:

• infections
• precancerous conditions of the uterine lining cells

Amenorrhea
You may also have experienced the opposite problem of heavy menstrual bleeding—no menstrual periods at all. This condition, called amenorrhea, 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.

There are two kinds of amenorrhea: primary and secondary.

• Primary amenorrhea is diagnosed if you turn 16 and haven’t menstruated. It’s usually caused by some problem in your endocrine system, which regulates your hormones. Sometimes this results from low body weight associated with eating disorders, excessive exercise or medications. This medical condition can be caused by a number of other things, such as a problem with your ovaries or an area of your brain called the hypothalamus or genetic abnormalities. Delayed maturing of your pituitary gland is the most common reason, but you should be checked for any other possible reasons.
• Secondary amenorrheais diagnosed if you had regular periods, but they suddenly stop for three months or longer. It can be caused by problems that affect estrogen levels, including stress, weight loss, exercise or illness.

Additionally, problems affecting the pituitary gland (such as elevated levels of the hormone prolactin) or thyroid (including hyperthyroidism or hypothyroidism) may cause secondary amenorrhea. This condition can also occur if you’ve had an ovariancyst or had your ovaries surgically removed.

Severe menstrual cramps (dysmenorrhea)
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, this is called dysmenorrhea, and you should consult your health care professional.

Pain from menstrual cramps is caused by uterine contractions, triggered by prostaglandins, hormone-like substances that are produced by the uterine lining cells and circulate in your bloodstream. If you have severe menstrual pain, you might also find you have some diarrhea or an occasional feeling of faintness where you suddenly become pale and sweaty. That’s because prostaglandins speed up contractions in your intestines, resulting in diarrhea, and lower your blood pressure by relaxing bloodvessels, leading to lightheadedness.

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

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

Physical symptoms associated with PMS include:

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

Emotional symptoms associated with PMS include:

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

PMS appears to be caused by rising and falling levels of the hormones estrogen and progesterone, which may influence brain chemicals, including serotonin, a substance that has a strong affect on mood. It’s not clear why some women develop PMS or PMDD and others do not, but researchers suspect that some women are more sensitive than others to changes in hormone levels.

PMS differs from other menstrual cycle symptoms because symptoms:

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

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

Premenstrual Dysphoric Disorder (PMDD)
Premenstrual dysphoric disorder is far more severe than the typical PMS. Women who experience PMDD (about 3 to 8 percent of all women) say it significantly interferes with their 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. If depression persists, you should consider seeking help from a trained therapist.

Diagnosis

To help diagnose menstrual disorders, you should schedule an appointment with your health care professional. To prepare, keep a record of the frequency and duration of your periods. Also jot down any additional symptoms, such as cramping, and be prepared to discuss health history. Here is how your health care professional will help you specifically diagnose abnormal uterine bleeding, dysmenorrhea, PMS and PMDD:

Heavy menstrual bleeding

To diagnose heavy menstrual bleeding—also called menorrhagia—your health care professional will conduct a full medical examination to see if your condition is related to an underlying medical problem. This could be structural, such as fibroids, or hormonal. The examination involves a series of tests. These may include:

• Ultrasound. High-frequency sound waves are reflected off pelvic structures to provide an image. Your uterus may be filled with a saline solution to perform this procedure, called a sonohysterography. No anesthesia is necessary.
• Endometrial biopsy. A scraping method is used to remove some tissue from the lining of your uterus. The tissue is analyzed under a microscope to identify any possible problem, including cancer.
• Hysteroscopy. In this diagnostic procedure, your health care professional looks into your uterine cavity through a miniature telescope-like instrument called a hysteroscope. Local, or sometimes general, anesthesia is used, and the procedure can be performed in the hospital or in a doctor’s office.
• Dilation and curettage (D&C). During a D&C, your cervix is dilated and instruments are used to scrape away your uterine lining. A D&C may also be used as a treatment for excessive bleeding and for bleeding that doesn’t respond to other treatments. It is performed on an outpatient basis under local anesthesia.

You can also expect blood tests to check your blood count for anemia and a urine test to see if you’re pregnant, as well as other laboratory tests.

The more information you can give your health care professional, the better. Take notes on the dates and length of your periods. You can do this by marking your calendar or appointment book. You might also be asked to keep a daily track record of your temperature to determine when you are ovulating. Ovulation kits, that use a morning urine sample, are available without a prescription and are easy to use.

During your initial evaluation with your health care professional, you should also discuss the following:

• current medications
• details about menstrual flow and cycle length
• any gynecologic surgery or gynecologic disorders
• sexual activity and history of sexually transmitted diseases
• contraceptive use and history
• family history of fibroids or other conditions associated with AUB
• history of a breast discharge
• blood clotting disorders—either your own or in family members.

PMS and PMDD

There are no specific diagnostic tests for PMS and PMDD. You’ll probably be asked to keep track of your symptoms and write them down. A premenstrual symptom checklist is one of the most common methods currently used to evaluate symptoms. With this tool, you can track the type and severity of symptoms to help identify a pattern.

Generally PMS and PMDD symptoms:

• tend to increase in severity as the menstrual cycle progresses.
• tend to be relieved when menstrual flow begins or soon afterward.
• are present for at least three consecutive menstrual cycles.

Treatment

Treatments for menstrual disorders range from over-the-counter medications to surgery, with a variety of options in between. Your treatment options will depend on your diagnosis, its severity, which treatment you prefer, your health history and your health care professional’s recommendation.

Abnormal uterine bleeding

Medication and surgery are used to treat AUB. Typically, less invasive therapies should be considered first. Treatment choices depend on your age, your desire to preserve fertility and the cause of the abnormal bleeding (dysfunctional or structural). Some treatments may reduce your menstrual bleeding to a light to normal flow.

Medication

Medication therapy is often successful and a good first option. The benefits last only as long as the medication is taken, so if you choose this route, you should know that medical treatment is a long-term commitment.

Low-dose birth control pills, progestins and nonsteroidal anti-inflammatory drugs (NSAIDs) may help control heavy or irregular bleeding caused by hormonal imbalances. If your periods have stopped, oral contraceptives and contraceptive patches are highly effective in restoring regular bleeding, although they will not correct the reason you stopped bleeding. Both can also help reduce menstrual flow, improve and control menstrual patterns and relieve pelvic pain during menstruation.

They are considered for PMS treatment if your symptoms are mostly physical, but may not be effective if your primary symptom is mood changes. However, a newer brand of oral contraceptive containing a form of progesterone called drospirenone and marketed under the names YAZ, Yasmin, Ocella, Gianvi and Zarah, may reduce some mood-related symptoms such as anxiety, irritability, tearfulness and tension. And Yaz is FDA-approved for the treatment of PMDD.

Natazia, which contains the synthetic estrogen estradiol valerate, is the first birth control pill FDA-approved for treatment of heavy menstrual bleeding that is not caused by a condition of the uterus. The combination estrogen-progesterone pill may help women who choose oral contraceptives for contraception and do not have risk factors that may make using hormonal birth control inadvisable.

Birth control pills may not be an appropriate treatment choice if you smoke, have a history of pulmonary embolism (blood clots in your lungs) or have bothersome side effects from this medication. The risk of these side effects is even higher if you use the birth control patch, because it contains higher levels of estrogen.

Progestins, either oral or injectable, are also used to manage heavy bleeding, particularly that resulting from a lack of ovulation. Although they don’t work as well as estrogen, they are effective for long-term management. Side effects include irregular menstrual bleeding, weight gain and, sometimes, mood changes.

The levonorgestrel intrauterine system (Mirena) is FDA-approved to treat heavy menstrual bleeding in women who use intrauterine contraception as their method of birth control prevention. The Mirena system may be kept in place for up to five years. Over this time, it slowly releases a low dose of the progestin hormone levonorgestrel into the uterus. Mirena is also referred to as an intrauterine device, or IUD.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are available over the counter and with a prescription and can help reduce menstrual bleeding and cramping. These medications include ibuprofen (Advil, Motrin) and naproxen (Aleve). Mefenamic acid (Ponstel) is a prescription-only NSAID. Common side effects include stomach upset, headaches, dizziness and drowsiness.

Tranexamic acid (Lysteda), although new to the United States, has been used successfully to decrease heavy menstrual bleeding in other countries for many years. These tablets are only taken on the days you expect to have heavy bleeding.

Surgery

Except for hysterectomy, surgical options for heavy bleeding preserve the uterus, destroying just the uterine lining. However, most of these procedures result in the loss of fertility, ending your ability to have children.

There are other important considerations for each of these treatment options. Risks common to all surgical options include infection, hemorrhage and other complications.

• Endometrial ablation. Endometrial ablation involves using heat, electricity, laser, freezing or other methods to destroy the lining of the uterus. These procedures are recommended only for women who have completed their families because they affect fertility. However, following treatment, you must use contraception. Although endometrial ablation destroys the uterine lining, there is a small chance that pregnancy could occur, which could be dangerous to both mother and fetus. Overall, endometrial ablation procedures have a good success rate at reducing heavy bleeding, and some women stop having menstrual periods altogether.
• Endometrial resection. During this surgical procedure, the surgeon uses an electrosurgical wire loop to remove the lining of the uterus.
• Dilation and curettage (D&C). During a D&C, your cervix is dilated and instruments are used to scrape away your uterine lining. A D&C may also be used to diagnose abnormal uterine bleeding. It is performed on an outpatient basis under local anesthesia. This treatment is often only a temporary solution to the heavy bleeding.
• Myomectomy. Fibroids are a common cause of heavy bleeding, and removal of fibroids with a procedure called myomectomy usually resolves the problem. Depending on the size, number and position of the fibroids, myomectomy may be performed with a hysteroscope, laparoscope or through a bikini abdominal incision.
• Hysterectomy. This is one of the most common surgical procedures performed to end heavy bleeding. It is the only treatment that completely guarantees bleeding will stop. But it is also a radical surgery that removes your uterus. Several factors make elective hysterectomy a serious consideration: It is major surgery and includes all the risks associated with any surgical procedure. A lengthy recovery period, often four to six weeks, may be necessary for some women. Fatigue associated with the procedure can last much longer.Several types of hysterectomy are available. More information is available atwww.HealthyWomen.org.

Menstrual cramps

If you are experiencing severe menstrual cramps (called dysmenorrhea) regularly, your health care professional might suggest you try over-the-counter and prescription medications and exercise, among other strategies.

Medications such as nonsteroidal anti-inflammatories (NSAIDs), like ibuprofen and naproxen, can be purchased without a prescription. Treatment works best if started hours before the onset of cramping. If you wait until you have pain, it doesn’t work as well. This will also help reduce heavy bleeding.

Oral contraceptive pills are also effective for menstrual cramps. If active pills are taken continuously for 90 to 120 days in a row, periods will only occur three to four times a year.

Other ways to relieve symptoms include putting heat on your abdominal area and mild exercise.

PMS and PMDD

To help manage PMS symptoms, try exercise and dietary changes suggested here and ask your health care professional for other options. If you suffer from PMDD, however, don’t try to treat on your own; make sure you talk to your health care professional.

Dietary options for PMS include:

• Cutting back on alcohol, caffeine, nicotine, salt and refined sugar, which can make PMS and PMDD symptoms worse.
• Increasing the calcium in your diet from sources such as low-fat dairy products, soy products, dark greens such as turnip greens and calcium-fortified orange juice. Increased calcium may help relieve some menstrual cycle symptoms.
• Increasing the amount of complex carbohydrates in your diet; these include fruits, vegetables, grains and beans.

Exercise is another good way to relieve menstrual cycle symptoms. You will get the greatest benefits from exercise if you do it for at least 30 minutes, five days a week. But even taking a 20- to 30-minute walk three times a week can:

• Increase brain chemicals that give you more energy and improve mood.
• Decrease stress and anxiety.
• Improve deep sleep at night.

Other medical therapies your health care professional might suggest include:

• Low doses of antidepressants such as paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa) and fluoxetine (Prozac). These are prescribed because they are effective in regulating the brain compound serotonin, which is related to PMS. Often these can be taken just during the times of expected symptoms.
• GnRH agonists (Lupron), sometimes in combination with estrogen or estrogen-progestin hormone therapy, for short-term treatment (less than six months). This treatment is used for very severe symptoms since it has numerous side effects, including hot flashes, headaches and vaginal dryness.
• Oral contraceptives that contain a progesterone called drospirenone may help reduce some mood-related PMS symptoms, such as irritability, anxiety, tearfulness and tension.
• Diuretic medications, such as spironolactone (Aldactone) to help with water weight gain and bloating.

There’s evidence that some nutritional supplements such as calcium, magnesium and vitamin B-6 may help ease symptoms of PMS. Discuss these and other strategies with your health care professional before taking any dietary supplement.

Prevention

1. Abnormal uterine bleeding (AUB) includes menorrhagia (heavy menstrual bleeding), metrorrhagia (bleeding in between menses) and hypermenorrhea (menses too long). Abnormal uterine bleeding also includes amenorrhea or absence of menstrual periods.
2. Abnormal uterine bleeding can occur at any age, but it is more likely to occur at certain times in a woman’s life. For instance, before menopause, your periods may suddenly become lighter or heavier because you are ovulating less often. If you have just begun to menstruate, you may also experience AUB.
3. Sometimes abnormal bleeding is caused by hormonal problems. A significant number of women with excessive menstrual bleeding fall into this category. Hormonal imbalances occur when your body produces too much or not enough of certain hormones.
4. Aside from hormonal problems, there are many other causes of abnormal uterine bleeding. They include:• certain birth control methods, such as the copper-T intrauterine device (IUD) and birth control pills
   • infection of the uterus or cervix
   • uterine fibroids
   • blood clotting problems
   • some types of cancer, including uterine, cervical and vaginal
   • chronic medical problems, such as hypo- and hyperthyroidism, liver disease, kidney disease and diabetes
5. Hysterectomy is the only treatment that completely guarantees heavy menstrual bleeding will end permanently. However, this is a radical surgery where your uterus is removed and you will no longer be able to have children.
6. Some premenopausal women don’t have periods at all. Called amenorrhea, or the absence of menstruation, this condition is normal before puberty, after menopause and during pregnancy. There are two kinds of amenorrhea: primary and secondary. Primary amenorrhea is diagnosed if you reach the age of 16 and haven’t yet begun to menstruate. Secondary amenorrhea is diagnosed if you’ve had regular periods, but they suddenly stop for more than three to six months.
7. Pain from menstrual cramps is caused by contractions of your uterus triggered by prostaglandins, hormone-like substances found in many types of tissue.
8. Both medication and surgery can be used to treat AUB. Typically, less invasive therapies should be considered first. Treatment depends on your age, desire to preserve fertility and the cause of the bleeding.
9. Premenstrual syndrome (PMS) is a term commonly used to describe a range of severe physical and psychological symptoms that some women experience about five to seven days prior to the start of their periods and end just after. To qualify as PMS symptoms, they must be associated with the menstrual cycle, become more severe as the menstrual cycle progresses and be present for at least three consecutive menstrual cycles.
10. Premenstrual dysphoric disorder (PMDD) is different from the more common PMS; it’s far more severe. Women who experience PMDD (about 3 to 8 percent of all women) say that it significantly interferes with their lives. 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.

Key Q&A

1. How is abnormal uterine bleeding (AUB) defined? Is my condition serious enough to be considered AUB?Abnormal uterine bleeding refers to menstrual periods that are abnormally heavy, prolonged or both. The term may also refer to bleeding between periods or absent periods.
2. I used to have regular periods, and they’ve suddenly disappeared over the past few months. Is this something to be concerned about?This condition, called secondary amenorrhea, can be caused by problems that affect estrogen levels, including stress, weight loss, exercise or illness. Also you may experience secondary amenorrhea because of problems affecting the pituitary, thyroid or adrenal gland. This condition can also occur if you’ve had ovarian cysts or have had your ovaries surgically removed. You should consult with a health care professional to determine what is causing you to skip periods.
3. Is there a certain age group of women who are more likely to have problems with AUB?Abnormal uterine bleeding can occur at any age, but it is more likely to occur at certain times in a woman’s life. For instance, for a few years before menopause, your periods may suddenly become lighter or heavier because you are ovulating less often. If you have just begun to menstruate, you may also experience AUB.
4. Can AUB be a problem for me if I’ve already gone through menopause?If you are post-menopausal, any uterine bleeding is considered abnormal and should be evaluated by a health care professional as soon as possible.
5. Aside from excessive or lengthy bleeding, what other problems can be described as AUB?Other types of AUB could include:
   • absence of periods (no bleeding)
   • bleeding between regular periods
   • spotting
6. What are my treatment options for AUB?Generally, both medications and surgery are options. Typically, less invasive therapies should be considered first. Treatment choices depend on your age, your desire to preserve fertility and the cause of the bleeding (dysfunctional or structural).
7. Is PMS (premenstrual syndrome) a problem I have to learn to live with every month or is there anything I can do to relieve my symptoms?PMS is not a disease but a collection of symptoms. Still, there are many things you can try to alleviate your pain, discomfort and emotional distress. They include dietary changes, exercise and medication options . Ask your health care professional for more information.