ABC Health & Wellbeing

Fact File

Period problems

by Sarah Urquhart

Rags, the curse, that-time-of-the-month ... for most women, periods are nothing more than a routine inconvenience, but for some, they are the bane of existence.

Published 11/10/2006

[Image source: iStockphoto]

• The menstrual cycle
• Painful periods
• Irregular periods
• Lack of periods
• Heavy periods
• Diagnosis
• Treatment
• Pre-menstrual syndrome
• More info

Menstruation is the periodic vaginal bleeding that gets the uterus ready for pregnancy by shedding the endometrium, or lining of the womb, and allowing a fresh one to grow in its place.

For most women, menstruation is nothing more than a minor discomfort, but it can cause serious and sometimes debilitating problems for others.

These problems are becoming more common in Western industrialised countries where women are putting off childbearing and having smaller families.

Menstruation stops during pregnancy and breastfeeding, so fewer pregnancies means more periods. If you're having more periods, there's more scope for associated problems to become a major issue.

Period-related woes are a common reason for visits to the GP and a significant cause of lost productivity. Most women will live with menstruation for around 40 years of reproductive life. Menopause, the time when periods stop, occurs around the age of 50 but can occur anywhere between 45 and 55.

Top

The menstrual cycle

Most girls get their first period, or menarche, around the age of 12 years, although anything between eight and 16 years is normal. The age of menarche is affected by genetic and environmental factors, and research around the world has shown that girls in Western countries are getting their periods earlier than their grandmothers did because of improved nutrition and health.

The menstrual cycle is usually described as a monthly event but this is only the case for about 12 per cent of women, or one in nine. Most women's cycles last somewhere between 21 and 35 days, with day one being the day that bleeding begins.

Four key hormones control menstruation. They are oestrogen and progesterone, produced by the ovaries, and follicle stimulating hormone (FSH) and luteinising hormone (LH), released by the pituitary gland in the brain.

This is how the cycle works:

• Halfway through a woman's cycle FSH levels rise, triggering egg-containing follicles in the ovaries to grow and produce oestrogen
• The oestrogen causes the lining of the uterus to thicken and develop a rich supply of blood in readiness for a fertilised egg
• The oestrogen also causes the vagina to secrete sugars, which local bacteria convert into lactic acid, helping reduce the risk of infection
• Mucus from the cervix becomes thinner to allow sperm easy passage
• As oestrogen levels peak, the pituitary releases a surge of FSH and LH, triggering ovulation, or the release of an egg from one of the follicles in the ovary
• The ovary now starts producing progesterone, which helps prepare the endometrium to nourish a growing embryo
• If an embryo implants and begins to grow, the placenta takes over production of oestrogen and progesterone from the ovary, keeping the endometrium in good condition until the baby is born.
• If there's no embryo, the ovary stops producing oestrogen and progesterone. This causes the endometrium to break down, triggering a period and resetting the cycle

We think of menstrual fluid as blood but it's actually a mixture of tissues and secretions from inside the uterus. It includes water, mucus, blood and glandular tissue.

Most women menstruate for two days to a week and lose between 20 and 80 millilitres of blood.

The wall of the uterus is also a source of stem cells. This allows the endometrium to replenish itself, but researchers in Japan recently announced they'd harvested stem cells from menstrual blood and say they're hopeful these can be coaxed to turn into heart cells to treat failing or damaged hearts.

Top

Painful periods

Most women experience period pains (dysmenorrhoea) at some time. This can range from mild discomfort to excruciating pain with nausea and vomiting. Dysmenorrhea falls into two categories: primary and secondary.

Most of what we think of as period pain is primary dysmenorrhoea. This occurs when there is an increased sensitivity to the prostaglandins, hormone-like fatty acids that are produced around the period that cause contractions of the uterine muscles or myometrium.

The contractions are similar to the ones that push a baby out during labour, but in the case of menstruation they help cut off blood supply to the endometrium, reduce blood loss and push the menstrual fluid out of the vagina.

Over-the-counter painkillers can ease symptoms and exercise can be helpful because it releases the body's natural painkillers, endorphins.

Primary dysmenorrhea also seems to lessen with age and after having children. It's not entirely clear why this occurs but it may be related to the dilation of the reproductive organs or changes in the way the uterus responds to the body's biochemistry.

Preliminary results of a University of Western Sydney trial into the use of traditional Chinese medicine to treat primary dysmenorrhoea also indicate that a Chinese herbal remedy can relieve period pain.

Secondary dysmenorrhoea occurs when there is a pathological cause for the pain, such as endometriosis. This needs further investigation by a doctor and treatment of the underlying problem.

Top

Irregular periods

Irregular periods (oligomennorhoea) are common in the first two or three years after periods start, after childbirth, miscarriage or termination and in the lead-up to menopause.

Some women never establish a regular cycle, although the reasons for this are unclear. This can make planning holidays and other activities difficult, but it can also make it harder to fall pregnant because it makes ovulation tricky to predict.

Irregular periods can be caused by:

• Stress
• Starting or changing contraception
• Pregnancy, miscarriage or an ectopic pregnancy, where the baby grows in the fallopian tube or somewhere else outside the uterus
• Polycystic Ovarian Syndrome (a hormonal disorder that causes small cysts to grow on the ovaries)
• Change in diet or sudden weight loss or gain
• Hormonal imbalance

Top

Lack of periods

Lack of periods (amenorrhoea) falls into two categories. Primary amenorrhoea occurs when periods don't start at all. Secondary amenorrhoea, which is more common, happens when periods begin but then suddenly stop for more than six months.

Amenorrhoea can usually be treated once a cause is identified.

Various factors can cause amenorrhoea. They include:

• Pregnancy
• Delayed puberty
• An intact hymen (the membrane at the entrance of the vagina). This can be fixed by having gynaecologist make a small hole in the membrane.
• Being underweight. Fat must make up 15 per cent of a woman's body in order for her to menstruate. Excessive exercise and eating disorders can also cause periods to stop.
• Hormonal problems caused by stress, excess weight, or abnormal signaling between the hypothalamus and pituitary gland in the brain and the ovaries.
• Travelling can stop a period although it's unclear why. It may be because travelling is a form of stress that can have an impact on chemistry in the brain related to menstruation.
• Polycystic ovarian syndrome
• Ovarian or pituitary tumours
• Premature menopause

Top

Heavy periods

Heavy periods (menorrhagia) is the most common reason for a woman to be referred to a gynaecologist. Losing more than 80 millilitres of blood during a period is considered excessive.

You can gauge the heaviness of your periods by counting the number of tampons or pads you use a day. Using more than 10 tampons or pads a day usually indicates a heavy period.

Excessive bleeding can lead to iron deficiency anaemia, with symptoms of fatigue, paleness, lack of energy and shortness of breath. The following factors can cause heavy periods:

• Dysfunctional uterine bleeding. This describes heavy bleeding that occurs shortly after periods start or close to menopause. It usually occurs during a cycle when you don't ovulate
• Miscarriage or ectopic pregnancy
• Hypothyroidism, or an underactive thyroid gland
• Use of non-hormone releasing IUDs, such as a Copper Coil
• Fibroids. These are non-cancerous tumours on the muscle wall of the uterus
• Endometriosis. This occurs when pieces of the womb lining grow where they shouldn't be, such as on the ovary, fallopian tube, outside the bowel or inside the wall of the pelvis. For more information read our endometriosis fact file.
• Pelvic infections such as gonorrhoea, trichomonas vaginalis, bacterial vaginosis (BV), thrush and chlamydia.
• Polyps, small mushroom-shaped growths from the lining of the uterus
• Blood disorders, such as difficulties clotting

Top

Diagnosis

You should see your doctor if your periods have been irregular, more heavy than usual or more painful than usual for more than four to six months.

You should also get checked up if you've noticed spotting between periods, bleeding after sex or bleeding during pregnancy. It's sometimes helpful to keep a menstrual diary recording period dates, length and heaviness, as well as the times and dates of any spotting or bleeding. This will help your doctor decide on what sort of tests you need. They may include:

• Blood tests
• Pap smear test
• Swabs to detect infection
• Ultrasound scan
• Pipelle (a biopsy of the endometrium)
• Hysteroscopy (where a camera is passed into the womb through the vagina under local or general anaesthetic)
• Laparoscopy (keyhole surgery)
• Laparotomy (a bikini line operation)
• Colposcopy (direct visular examination of the cervix and vagina using a special lighted instrument called a colposcope)

Top

Treatment

Your GP should be able to recommend the most appropriate course of treatment. Options include:

• Painkillers including non-steriodal anti-inflammatories (NSAID) such as paracetamol, ibuprofen, aspirin, naproxen sodium (Naprogesic) and mefenamic acid (eg. Ponstan). They're effective for period pain because as well being analgesics they act as anti-prostaglandins, which means they suppress the muscular contractions that cause cramping
• Drugs like tranexamic acid, mefenamic acid and norethisterone can reduce bleeding
• The oral contraceptive pill can regulate your cycle, reduce pain, and make bleeding lighter
• Antibiotics to treat sexually transmitted infections
• Removal of an inter-uterine device (IUD)
• The Mirena coil. This is an IUD that contains progesterone-like hormone that thins the lining of the womb and makes periods lighter.
• Dilation and curettage (D&C) or polypectomy. This is a surgical procedure where the cervix is dilated and the uterus lining scraped with a curette to remove polyps or small fibroids.
• Myomectomy. An abdominal operation to remove fibroids done under general anaesthetic via the bikini line.
• Hysterectomy, or removal of the uterus via the vagina abdominally. This is only an option if you're not planning any more children.

Top

Pre-menstrual syndrome

Also known as PMT (pre-menstrual tension). Most women notice some symptoms of PMS around the time of their period.

Common complaints include breast tenderness, headache, backache, abdominal bloating or food cravings (often carbohydrates or chocolate). Other PMS symptoms include acne, anxiety, fatigue, insomnia, fainting, altered sex drive, swelling of fingers or feet and ankles, depression and mood swings.

In extreme cases PMS can lead to aggressive behaviour or suicidal thoughts. Symptoms can vary from month to month and underlying depression and stress can make symptoms worse.

Some research even suggests that having a male partner can make your PMS worse. For more information read our feature: Do men cause PMS?

Self-help measures to reduce PMS include:

• A good diet
• Drinking plenty of water
• Reducing smoking and alcohol intake
• Exercise
• Relaxation techniques
• Self-help groups
• Soaking in a hot bath

Periods can be a drag but they don't have to make your life a misery.

Ask your GP for a referral to a gynaecologist if self-help measures aren't giving you any relief from period problems, and see your doctor if you have any post-menopausal bleeding, as this isn't normal and needs further investigation.

The good news is that your periods won't be with you all your life. The bad news is that even when you think you're kissing your old friends goodbye forever they often leave a parting gift. Around 20 per cent of women seek medical treatment for symptoms of menopause including hot flushes, palpitations, vaginal dryness, irritability, depression, memory difficulties and the bone thinning disease osteoporosis.