Menstruation and Menstrual Problems

Too Scanty and Spaced-out (oligomenorrhea)

An overactive thyroid function (hyperthyroidism) or certain kidney diseases can both cause hypomenorrhea. Oral contraceptive pills can also cause hypomenorrhea. It is important for women to know that lighter, shorter, or even absent menstrual periods as a result of taking oral contraceptive pills does not indicate that the contraceptive effect of the oral contraceptive pills is inadequate. In fact, many women appreciate this “side effect” of oral contraceptives.

Absent or Missed Periods (amenorrhea)

Amenorrhea is the name given to the condition that involves women experiencing no periods. It can occur in women of all ages but is most commonly found in those who are close to menopause. There are a number of conditions that can cause amenorrhea, and it is important that women experiencing it take action to sort it out before it develop into a more serious problem. Amenorrhea is often a sign of an underlying problem; therefore it is a good indicator that something is wrong with the body

Premenstrual Syndrome

Pre-Menstrual syndrome (PMS), also called Premenstrual Tension is a combination of monthly symptoms which occur in some women before their menstrual bleeding, which are often severe enough to badly affect quality of life before periods. These may include one or more of the following psychological and physical symptoms:

Psychological: feeling of tension, irritability, tiredness, aggression or anger, low mood, anxiety, loss of confidence, weepy. There may be changes in sleep pattern, sexual desire and appetite. Relationship with others, especially with immediate family members may become strained because of these symptoms.
Physical symptoms include: breast swelling, breast pain and tenderness, abdominal bloating, swelling of the feet or hands, weight gain, an increase in headaches. In some cases in sufferers, epilepsy, asthma, migraine or cold sores, may worsen before a period.

Profile of Women with PMS

PMS most commonly affects women between 30-40 years, but it is also possible in younger or older women. Most women can tell that a period is due by the way they feel both physically and mentally. For most, the symptoms are mild and do not cause much concern. However, these symptoms are severe in about 5% of women, affecting their day to day life, including work performance, ability to focus and concentrate on task, and also relationships, especially with friends and family.

Diagnosis

The diagnosis of PMS is based only on your symptoms, althoguh it is essential to have physical examination to exclude any incidental or associated findings. It can often be difficult to accept that the psychological or menatal spytoms are related to prenstrual symptoms, as most womne do not keep a record of such symptoms, until asked to do so, for example by their doctor or gynaecologist. Typically, symptoms start sometimes after ovulation, which occurs about two weeks before the start of a period, are worse during the seven days before a period and disappear within three to four days after your period starts.

Cause of premenstrual syndrome?

The cause of PMS is not known. However, PMS seems to occur mainly in menstrual cycles, during which ovulation – release of egg from an ovary – has occured. It is thought that women with PMS may be more ‘sensitive’ to the normal level of progesterone, which is produced into the bloodstream by the ovaries after ovulation. One effect of over-sensitivity to progesterone seems to reduce the level of a brain chemical (neurotransmitter) called serotonin. This may lead to symptoms, and may explain why medicines that increase the serotonin level work in PMS.

Treatment Options

Self-Help strategies are crucial in the treatment of PMS: Awareness helps to reduce anxiety about the symptoms. Keeping a diary helps to predict when symptoms are likely to occur, so that any alteration in lifestyle and schedule to cope with the symptoms can be made. For example, it may be possible to avoid an important business meeting or family event on the days when symptoms are likely to be severe. Discuss with those close to you, to help understanding and adjustment, Exercise regularly and frequently every week, Avoid some foods and drinks high in carbohydrates and caffeine. Avoid alcohol. There are some foods that are high in serotonin.

Understanding the problem, anticipating symptoms and planning a coping strategy are all that is required for many women. Some women find the self-help measures discussed above and such things as avoiding stress or doing relaxation exercises prior to a period can be enough. Various products are sold for the treatment of PMS, although there is a little evidence to support their use:

Magnesium. Taking magnesium (200-400 mg a day) during the two weeks before a period may improve symptoms.
Agnus castus (Chasteberry). This may provide some benefit in some women. It is claimed to work by restoring hormonal balance, by increasing the ratio of progesterone to oestrogen, by balancing excess oestrogen. Read more: http /en.wikipedia.org/wiki/Vitex_agnus-castus
Calcium. Some studies have shown that taking calcium (1000-1200 mg a day) may improve premenstrual symptoms

Medical Treatments

These treatments have been shown in studies to be the most effective for women with PMS. Your doctor may recommend at least one of these treatments for you.

Selective Serotonin Re-uptake Inhibitors (SSRIs)

SSRI medications, for example fluoxetine, proxetine are commonly prescribed to treat more severe PMS. Although these medicines were first developed to treat depression, they have also been found to ease the symptoms of PMS. They work by increasing the level of serotonin in the brain (see above under “Causes”). Research suggests that taking an SSRI for just half of the cycle (the second half of the monthly cycle) is just as effective as taking an SSRI all of the time.

The combined oral contraceptive pill (COCP)

In theory, any medication, such as the pill which prevents ovulation should help PMS. This is because the release of progesterone into the bloodstream after ovulation seems to trigger symptoms of PMS. However, most pills do not help with PMS as they contain progestogen hormones (with a similar action to progesterone). A newer type of pill called Yasmin® contains a progestogen called drospirenone which does not seem to have the downside of other progestogens. If you have PMS and require contraception, then this pill may be a possible option to use for both effects.

Oestrogen

Oestrogen given via a patch or gel has been shown to improve symptoms. Oestrogen tablets are not effective though. However, you will also need to take progestogens if you have not had a hysterectomy. These can be taken as tablets or by having the intrauterine system (Mirena®) inserted. The doses of oestrogen in a patch are much lower than in the COCP, so a patch does not work as a method of contraception.

Other treatments

These treatments may be used sometimes in the treatment of PMS, although there is little evidence from research trials that they are effective:

Gonadotrophin-releasing hormone analogues are drugs that can prevent ovulation. Although these often work well, side-effects commonly occur which limit their usefulness for PMS.
Vitamin B6 (pyridoxine). This vitamin is part of a normal diet, but extra amounts (not more than 10mg per day) are thought to help with PMS. However, the evidence to support this is still conflicting. Vitamin B6 can be taken in the two weeks before periods, or every day.
St John’s wort & Evening Primose Oil: are herbal remedies which can be bought from pharmacies. However, there is only very limited evidence that they are effective. Evening primrose oil may ease breast discomfort.
Bright light. One study showed improvement in symptoms in some women with severe PMS who looked at bright light from a face mask for a time each day. This is a similar treatment to that used for a condition called ‘seasonal affective disorder’. The reason why bright light may help in PMS is not known. More research is needed to clarify if this is a useful treatment.
Surgery to remove both ovaries prevents ovulation and is likely to cure PMS. However, it is a very drastic treatment and is therefore not done except in the most severe cases where nothing else has helped.
Diuretics (‘water tablets’) – (spironolactone) may sometimes help reduce fluid retention and bloating.
Non-steroidal anti-inflammatory painkillers (e.g. ibuprofen) may reduce painful symptoms.

Too Scanty and Spaced -out (Oligomenorrhea)

An overactive thyroid function (hyperthyroidism) or certain kidney diseases can both cause hypomenorrhea. Oral contraceptive pills can also cause hypomenorrhea. It is important for women to know that lighter, shorter, or even absent menstrual periods as a result of taking oral contraceptive pills does not indicate that the contraceptive effect of the oral contraceptive pills is inadequate. In fact, many women appreciate this “side effect” of oral contraceptives.

Absent or Missed Periods (Amenorrhea)

Amenorrhea is the name given to the condition that involves women experiencing no periods. It can occur in women of all ages but is most commonly found in those who are close to menopause. There are a number of conditions that can cause amenorrhea, and it is important that women experiencing it take action to sort it out before it develop into a more serious problem. Amenorrhea is often a sign of an underlying problem; therefore it is a good indicator that something is wrong with the body

Inter-menstrual, Irregular Bleeding (metrorrhagia), Post-Coital Bleeding

Postcoital bleeding is non-menstrual bleeding that occurs immediately after sexual intercourse. Intermenstrual bleeding refers to vaginal bleeding (other than postcoital) occurring at any time during the menstrual cycle other than during normal menstruation. It can sometimes be difficult to differentiate true intermenstrual bleeding from metrorrhagia, which is vaginal bleeding at irregular intervals, particularly between the expected menstrual periods. Polymenorrhea (too frequent periods): is the term used to describe a condition when women have periods at much shorter intervals, usually less than 21 days apart, and periods may not be regular or predictable either. Polymenorrhea is different from metrorrhagia. It is an actual menstrual period that occurs shortly after the last one.

Causes:

Women who are ovulating normally can experience light bleeding (sometimes referred to as mid – cycle or ovulation “spotting”) between menstrual periods. Oral contraceptive pills, minipills or patches, as well as some intra-uterine contraceptive devices (coils) may sometimes lead to light bleeding between periods. Psychological stress, certain medications such as anticoagulant drugs, and fluctuations in hormone levels may all be causes of light bleeding between periods. Also irregular menstrual cycles, may occur first, before the onset of true menopause. It is important to understand that these are not diagnoses, but symptoms, which need further investigation or assessment. For example, conditions of the cervix, such as cervical ectopy (commonly called cervical erosion), benign growths in the cervix, such as cervical polyps, infections of the uterus (endometritis) and or cervix (cervicitis), may also be associated with intermenstraul and or post-coital bleeding. Genital tract malignancies (cancer of the cervix, womb or vagina) are uncommon causes of post-coital and/or intermenstrual bleeding are rare causes in young women. (see below).

Other causes include those pregnancy-related ones, such as ectopic pregnancy, undiagnosed threatened miscarriage and molar pregnancy, progesterone-only pills, Emergency contraception, Tamoxifen, Following smear or treatment to the cervix, Drugs altering clotting parameters, e.g. anticoagulants, SSRIs, corticosteroids, Alternative remedies, e.g. ginseng, ginkgo, soy supplements, and St John’s wort, Vaginitis, Infection – chlamydia, gonorrhoea, cervical warts, Endometrial polyps, and oestrogen-secreting ovarian cancers.

Diagnosis: It is helpful if you have detailed information of your menstrual bleeding. Be prepared for questions, such as when was your last menstrual period and was the last period ‘normal’. Do you suffer from heavy periods? Are your periods regular and what is the length of your cycle? When is the timing of bleeding in the menstrual cycle? Are there associated symptoms, e.g. abdominal pain, fever, vaginal discharge or painful sex? Your doctor may also ask you about your previous pregnancies and deliveries, the type of contraceptive method you use, and your last cervical smear test information. Do not feel offended, if information is requested on your sexual activities, and your partners’ or if you have had sexually transmitted infection in the past. Information about other conditions for which you may or may not be taking medications, could also be relevant, such as; bleeding disorders.

Your doctor will perform general examination and that of the abdomen and vagina, a swab may be taken. It will be quite obvious if you have swelling in the abdomen, womb, and pelvis; or if you have any ulcers, erosion, polyps, discharge, cervical ectropion, cervicitis, and any special areas that are tender will be noted. Tests such as pregnancy test, vaginal swabs, blood count, thyroid function tests, and if necessary, hormonal profile, ultrasound scan of the pelvis and thickness of the linning of the womb, may be requested. Depending on whether you see a gynaecologist or your doctor, a biopsy of the lining of the womb, may also be done, so also is a hysteroscopy (telescope inspection of the inside of the womb.)

Treatment Options for Intermenstrual Bleeding

The most important step is to treat the underlying cause of the bleeding. It is helpful if you keep a menstrual chart, to monitor the improvement from cycle to cycle.

Infection: Your doctor or gynaecologist will prescribe antibiotics that are most suitable initially, while waiting for the results of the vaginal swab test. If there is likelihood of sexually transmitted infection, it may be neceesary to also treat your partner, to avoid re-
Bleeding from Hormonal Contraception: It is quite common to bleed at the begining of use of oral contraceptives, and Mirena intra-uterine system. If the bleeding persists for longer than three or six months depending of the hormonal contraception in use, or if the woman is older than 45 yrears, or is not up to date with her cervcial screening, appropriate steps will need to be taken. For contraceptive pills user, the options is to continure use for a slightly longer time, or to change the pill, or adjust the relative amount of the pill being taken. For progestogen – only implants, depots and IUS users, adding an oral combined oral contraceptive pill may help.
Cervical ectropions / Cervicitis: The options for intermentriual bleeding caused by cervical ectopy is to withdraw the use of the combined pill or to treat it by freezing or cauterising the area involved with electro-cautery and diathermy, cryosurgery or laser. Electrocautery of secondarily infected Nabothian follicles is sometimes performed for chronic cervicitis.
Cervical polyps: Polyps should be avulsed and sent for histology. It may still be necessary to perform an ultrasound, and possibly a hysteroscopy, to rule out the presence of associated endometrial polyp.

Painful Periods (Dysmenorrhea)

Most women have some pelvic pain during their menstrual periods. It is usually mild requiring no treatment or just mild pain-killers. In about 1:10 women, the painful periods (dysmenorrhea) can be severe enough to affect day to day activities. It is common in teenagers and young adults, but become less of a concern, after childbirth and as they get older. There are two types of painful periods – primary dysmenorrhea where there is no underlying problem of the uterus (womb), tubes or pelvis and secondary dysmenorrhea caused by a problem of the uterus, tubes or pelvis.

Primary dysmenorrhea

In this type of painful periods, there is build up of normal body chemicals called prostaglandins within the lining of the uterus. These prostaglandins normally help the uterus to contract and shed the lining of the uterus during a period. In women with bad period pains there seems to be a build-up of too much prostaglandins, or the uterus may be too sensitive to the prostaglandins. This causes the uterus to contract too hard, which reduces the blood supply to the uterus, leading to pain, – similar to the pain of angina. The main symptom is crampy pain in the lower abdomen, which often spreads to the lower back, and upper thigh and usually starts just before or as the bleeding starts, lasting between 12-72 hours. The pain may also be associated with headaches, tiredness, faintness, breast tenderness, feeling sick, bloating, feeling down or diarrhoea. There is usually nothing abnormal found during examination and doing further tests, such as pelvic ultrasound. The information you give to your doctor, is often sufficient to allow treatment to start, immediately.

Treatment options for primary dysmenorrhea

There are a number of treatments that may help if you have primary dysmenorrhoea.

Heat Therapy (Warmth): Use of hot water bottle, safely, or having a warm bath can help.
Simple analgesics such as non-steroidal anti-inflammatory painkillers or paracetamol, with or wiothout codeine, are usually sufficient for majority of women. These are usually quite effective in about 80% of cases. They work by blocking the effect of the prostaglandin chemicals that are thought to cause the pain. It is useful to use the painkillers regularly three to four times per day, for about 2-3 days.
Hormonal Contraceptives: this is a suitable option where contraception is required. The pill causes the lining of the uterus to become thin, and the amount of prostaglandin is much reduced, leading to less bleeding. Progestogen contraceptives : such as Cerazette® contraceptive pill or Depo-Provera – an injectable progestogen contraceptive is also useful.
The intra-uterine system (IUS): Mirena coil is a special intra-uterine contraceptive device which slowly releases a progestogen hormone called levonorgestrel. This ‘thins’ the lining of the uterus and reduces the amount of pain and bleeding during periods
Transcutaneous electrical nerve stimulation (TENS) machine: work by interfering with pain signals which are sent to the brain from the nerves, by giving out small electrical currents. This could be useful in women who prefer not to use any medication.
Alternative medicine treatments : there is not enough evidence so far to support the use of other treatments for painful periods. For example, herbal and dietary supplements, acupuncture, exercise and spinal manipulation.

Secondary dysmenorrhea

Causes: Secondary dysmenorrhea occurs because there is an underlying problem affecting the pelvic organs. Such problems include, endometriosis, large uterine polyps, fibroids, or infection of the uterus and Fallopian tubes (pelvic inflammatory disease). In some women, the use of certain type of intrauterine contraceptive device may also cause painful periods.

Symptoms: The most important factor in this type of painful period is that the period has been generally normal, with minimal pain previously. There is recent onset of unusually painful – moderate to severe – crampy lower abdominal pain, often begining a few days before the period starts, and continuing through it, sometimes getting worse, as the menstrual bleeding reaches its maximum flow. There are usually other symptoms that may be associated, such as; irregular periods, bleeding in between periods, pains between periods or during sex.

Diagnosis: Once you‘ve related your symptoms to your doctor, you will be examined in your tummy and internally – vaginal examination – this may include taking some swabs, to test for the presence of infection. Your doctor will want to feel for possible abnormality, such as an enlarged womb, and see if there is any area that is particularly tender or swollen in your pelvis. It may be necessary to arrange other tests, such as an ultrasound of the pelvis. Your gynaecologist may need to be involved, to carry out further investigations, such as a telescope examination of the linning of the womb (see hysteroscopy) or of the internal organs of the pelvis ( see laparoscopy). The laparoscopy may be reveal that treatment should be done at the same time, such as breaking down scar tissues (adhesiolysis), involving the pelvic organs.

Treatment options for secondary dysmenorrhoea?

Certainly the treatment options include controlling the pain in general, as in primary dysmenorrhea, and it can aslo be helpful to control the hormone effects, to keep the organs in a state where they can cause less pain. Options are:

Heat Therapy (Warmth): Use of hot water bottle, safely, or having a warm bath can help, so also is the use of TENS machine (see primary dysmenorrhea).
Simple analgesics such as non-steroidal anti-inflammatory painkillers or paracetamol, often with codeine, are usually helpful for many women. It is useful to use the painkillers regularly three to four times per day, for the duration of the pain.
Hormonal Control: using injections such as Depo-Provera, or implants, scuh as Implanon or other preparations such as Gonadotrophin Releasing Hormonal analogue – can help in the treatment of seocndary dystmenorrhea due to endometriosis.
The intra-uterine system (IUS): Mirena coil is a special intra-uterine contraceptive device which slowly releases a progestogen hormone called levonorgestrel. This can also be useful in some cases of endometriosis.

The most effective treatment of secondary dysmenorrhoea depends on the underlying cause. See information under ‘Endometriosis‘ ‘Uterine Fibroids’ and ‘Pelvic Inflammatory Disease’, which

describe the treatments available for these conditions. If the presence of an IUCD is identified to be the cause, this will need to be removed, and alternative contraceptive method arranged.

Heavy Periods (Menorrhagia)

Heavy periods, also called menorrhagia, are when a woman loses an excessive amount of blood from her womb, through her vagina, during several consecutive menstrual cycles. (see menstruation). This may happens approximately every 24-35 days, depending on the length of the cycle. Menorrhagia can occur by itself or in combination with other symptoms, such as menstrual pain (dysmenorrhoea). Heavy bleeding, affecting 1 in 10 women does not necessarily mean there is anything seriously wrong, but it can affect a woman physically, emotionally and socially, and can cause disruption to everyday life.

How do I know my bleed ing is heavy or excessive”?

It is difficult to define exactly what a heavy period is because the amount of blood that is lost during a period can vary considerably between women. It is usually considered normal for a woman to lose about 30-40ml during a period. As about 90% of women will lose less than 80ml, over a maximum of about seven days, an amount more 80ml (millilitres) or lasting longer than seven days, will be regarded as heavy. It is quite difficult to know how much 30ml or 80ml is, when sanitary towels or tampons are used over three to seven days of bleeding. Therefore, other ways of assessing the amount of loss, is common. It does not have to be precise and accurate. Most women have a good idea about how much bleeding is normal for them during their period and can tell when this amount increases or decreases. In general, any amount of bleeding that disrupts everyday life, causes flooding (quickly soaking through clothing or bedding), or passage of large congealed blood (clots) or need to have “double protection” of tamons and towels togther, will be regarded as heavy.

Do visit your doctor or specialist if your periods are heavier than usual, or if they are disrupting everyday life

What Is My Doctor Thinking?

Your doctor will want to ensure that you have not lost too much blood to the extent of your blood iron level (heamoglobin) dropping – anaemia, so a blood test may be required. Your doctor also may be thinking of likely reason(s) for you heavy periods. In most of cases, this is a temporary concern, due to temporary hormonal imbalance, but there could also be conditions, such as

Uterine fibroids,
Endometriosis or Adenomyosis
Low thyroid homrone (hypothyroidism)
Hormonal imbalance – dysfunctional uterine bleeding, associated with polycystic ovaries, or around the time of puberty or menopause – in many cases, no underlying reason is found.
If you are over 45yrs, your doctor will also want to exclude any sinister cause, endometrial hyperplasia, or polyp or cancer.

Your doctor or specialist will examine you and may arrange further tests, either immediately or quite often after starting some treatments, for a couple of months. The test may include full blood count, ultrasound of your pelvis, thyroid hormone levels. Depending on your particular circumstances, you may need to be referred to a gynaecologist who will in addition arrange to arrange a biopsy of the lining of the womb, with the transvaginal scan, and camera look inside your womb (see hysteroscopy).

What treatments are available?

As the amount of blood that is lost during a woman’s period varies considerably from one person to another, it is common for many women to suffer for a long time, wothout realising the need to go for help, therefore menorrhagia (heavy periods) is not always diagnosed. If menorrhagia is diagnosed, your GP will discuss all the possible treatment options with you. Your GP will discuss how effective the treatment options are, considering the down-sides and the need for contraception or to preserve fertility. The aims of treatment are: a) to correct iron-deficiency anaemia caused by heavy menstrual bleeding and b) to reduce or stop excessive menstrual bleeding, in order to to improve the quality of life of women with heavy menstrual bleeding , assessing the need for surgical treatments, if conservative or medical tretment fails or not feasible.

Medications for Heavy Periods

Medical treatment is often started while waiting for results of further tests, if in the first instance; there are no symptoms or signs that suggest a serious underlying cause. Trying this for a couple of months should help determine, if it is likely to be effective, at least in the short term. If a particular medication is unsuitable, or ineffective, another one may be recommended. The different types of medication that are used to treat menorrhagia are:

Levonorgestrel-releasing intrauterine system (LNG-IUS) – The levonorgestrel-releasing intrauterine system (LNG-IUS) is a small plastic device that is placed inside the womb and slowly releases a hormone called progestogen. It prevents the lining of your womb from growing quickly and it is also a form of contraceptive. LNG-IUS reduces blood loss by 70-95% and is the preferred first choice treatment for women with menorrhagia, unless its use is contra-indicated. Possible side effects of using LNG-IUS include: irregular bleeding, breast tenderness, acne, headaches and amenorrhoea.
Tranexamic acid: Tranexamic acid tablets work by helping the blood in the womb to clot, reducing blood loss by 20-60%. Tranexamic acid tablets are taken after heavy bleeding has started. They are not contraceptive and they can be combined with a non-steroidal anti-inflammatory drug (NSAID). Side effects include: indigestion, diarrhoea and headaches
Non-steroidal anti-inflammatory drugs (NSAIDs), such as Ibuprofen, Mefenamic acid or Naproxen: have been shown to reduce blood loss by 20-50%. They are taken only during heavy periods.NSAIDs work by reducing the body’s production of a hormone-like substance called prostaglandin, which is linked to heavy periods. NSAIDs are also painkillers. They are not a form of contraceptive, but they can be used with the combined oral contraceptive pills. Possible side effects of NSAIDs include indigestion and diarrhoea.
Combined oral contraceptive pills contain the hormones oestrogen and progestogen, with the benefit of regulating menstrual cycle and reducing menstrual pain (dysmenorrhoea). They combined oral contraceptive is a contraceptive that works by preventing your ovaries from releasing an egg each month. Common side effects of the combined oral contraceptive pill include: mood changes, headaches, nausea, fluid retention and tender breast.
Gonadotrphin Releasing Hormone Analogues (GnRH-a) – GnRH-a group of medication are not first line in the management of heavy periods. Their use is limited to temporary cessation of periods, while a more permanent (usually surgical) is being considered, because other medictions have failed or are unsuitable. They work by stopping the ovaries from producing the sex hormones (causing medical menopause). This way, there is no stimulation or build up of the linning on the womb, so there is very little or nothing to shed from the linning of the womb (endometrial thining). They are often used, while the patient is awaiting surgical treatment, such as endometrial ablation, hysterectomy, or myomectomy – uterine fibroid removal, and in cases, where the heavy period, is as a result of adenomyosis or endometriosis. They cause bone-thinning and therefore cannot be used, for more than six months, without hormone replacement therapy. In addition, they cause hot-flushes, night sweats, dry skin, and other masculine side-effects. Examples are goserelin, buserelin, etc.
Oral norethisterone; Oral norethisterone works by preventing the lining of the womb (endometium) from growing quickly. It has to be taken for 2 -3 out of four weeks, each cycle – It is not an effective form of contraception and can have unpleasant side effects, including: weight gain, bloating , breast tenderness, headaches and acne. A high dose of oral norethisterone can stop bleeding in 24 to 48 hours, if period is unusually prolonged.
Injected progestogen: This works like any other progestogen, causing endometrial thining. An example is medroxyprogesterone acetate, which is also a potent form of contraception. It may cause a delay in return of fertility for up to 18 months. The side effects of injected progestogen are similar to that of oral progestogen. The injection is given once every twelve weeks, for as long as treatment is necessary.

Medical treatment of any underlying cause – for example, Thyroxine for hypothyroidism

Surgery

Your gynaecologist may suggest surgery if medical treatments are not effective in controllong the heavy periods. There are several types of operation that can be used to treat menorrhagia. IF the underlying reason for the heavy periods is that which demand surgery, then the surgery is as it is for that condition, for example, as in menorrhagia caused by uterine fibroids. These are:

Hysteroscopy , Dilatation and Currettage / Removal of Polyp – a camera is inserted through the cervix, into the uterine cavity, and a scrapping of the cavity occurs, mainly for testing the specimen obtained. This may improve the heavy period, but thi sis not usually sustained; therefore it is strictly not a treatment options. In some women however, following this procedure, especially, if they had excessive growth of the linning of the womb (endometrial hyperplasia), that is not associated, with cancer or precanceruous condition (atypia), there may be a lasting improvement in symptoms, such that medical treatment become a suitable effective option. Some polyps (small growth inside the womb – endometrial polyp) can cause heavy periods, if they occurs in crops; and it may be possible to remove these during the hysteroscopy.
Endometrial Ablation – : where the womb lining is destroyed, using various techniques and devices. In microwave endometrial ablation, the probe that uses microwave energy (a type of radiation) is inserted into the womb to heat up and destroy the womb lining. In thermal balloon ablation: the balloon is inserted into the womb and is inflated and heated to destroy the womb lining. This proceure will cure or improve heavy periods, in about 60 -70% of cases.
These procedures can be carried out under local anaesthetic (painkilling medication) or general anaesthetic (where you are unconscious). They are fairly quick to perform, taking around 20 minutes, and you can often go home the same day. Read more ..
Hysterectomy – surgical removal of the womb, which may sometimes also involve the removal of the cervix (neck of the womb), fallopian tubes and ovaries (oophorectomy). Hysterectomy is fast becomeing the last resort, as a treatment option for heavy periods. This is because there are often other less invasive and effective treatment. Aside the complications and the longer recovery of hysterectomy, the satisfaction rate of this surgery to treat heavy periods, reamins high. Read more on hysterectomy.
Uterine artery embolisation : This minimally invasive procedure is done by inserting a small tube through the groin blood vessel and then following this to the blood vessel (artery) that feeds the fibroid and uterus. Once this has been achieved, small plastic beads are injected into the arteries supplying blood to the fibroid. This blocks the arteries and causes the fibroid to shrink over the subsequent six months. This treatment is ony useful if the fibroids are the main reason for the heavy periods, avoiding the need for a hysterectomy or myomectomy.
Myomectomy is the operation for the removal of fibroids in the uterus. Less and less of this surgery is being done for small fibroids. Very large fibroid can be treated through this operation, especially, if the woman still wants children, and is not suitable for a uterine artery embolisation.

Menstruation And Menstrual Problems

Menstruation

From puberty to the menopause, the ovaries produce a mature egg (ovum) approximately every 28 days. If the egg becomes fertilized, the ovaries also produce hormones – oestrogen and progesterone (sex hormones) – to prepare the lining of the womb to receive the fertilised egg(s) which grow(s) into a baby. This process is also under the control and signals of special horones and chemical produce from the parts of the brain called the pituitary and hypothalamus. This coordination of the activities of the hypothalamus, pituitary, ovaries and the lining of the womb, is what is responsible for the regular monthly changes that women have which results in the menstrual bleeding, if the egg produced is not fertilised. The whole series of activiutes and effects, occurring in the same way every monthly is called menstrual cycle. The menstrual cycle is the time from the first day of a woman’s period to the day before her next period. This process is very complex and whatever affects any part of the process can result in problems with the menstrual cycle and menstrual bleeding or periods, as it is usually called. The ability of a woman to get pregnant – female fertility -depends on the cycle occurring normally. For the purpose of timing, the first day of the menstrual cycle (Day 1) is the first day of menstrual blood loss. This is when the uterus begins to shed its lining and bleeding occurs. The last day (Day 21 – 35), is the last day of the cycle, the day before the bleeging starts again.

Ovulation

The most important of the special hormones controlling the menstrual cycle and therefore fertility are oestrogen, progesterone (from the ovaries), luteinizing hormone (LH) and follicle stimulating hormone (FSH) – from the pituitary gland. The FSH encourages few follicles (egg-containing ‘sacs’) in each ovary to grow each month, till one of them, the dominant ovum, becomes mature enough to be released, ready for fertlisation. When the egg is released, this is called ovulation, and it occurs, usually about 14 days before the next cycle begins – this usually corresponds to the mid-cycle. This first half of the ovarian cycle is known as the follicular phase and the second half is called the proliferative phase. Usually one egg is released each cycle, but occasional release of two or more eggs, is possible, in some individual, either because of hereditary or due to fertility treatment with medications. Common test for ovulation, rely on testing for high level of the luteinizing hormone (LH) excreted in the urine during ovulation. It is the sharp increase in the level of LH in the blood is necessary for ovulation, and it is passed in the urine. Any problem with the production of the LH may affect ability to ovulated, and therefore conception. At the time of ovulation there is a small rise in body temperature. This small rise can be used to indicate when ovulation occurs. Some women feel mild pain in the abdomen around the time of ovulation, lasting from a few minutes to a couple of hours. This is often called mid-cycle or ovulation pain (Mittelschmerz). The hormonal changes occurring during ovulation also causes the cervical glands to produce, very thin, see-through vaginal secretion or normal vaginal discharge. This can also be used to indicate ovulation, which some women use as part of their “safe period” method of contraceptive.

After ovulation, in the second half of the menstrual cycle, the hormones produced by the ovaries,

especially progesterone, together with oestrogen, help to prepare the lining of the womb to receive the fertilised egg, if there is conception. If ovulation did not occur in a particular cycle, the production of the progesterone is affected – this is the basis for testing the progesterone level in infertility work-up. This is because, after ovulation, it is the cells remaining in the ruptured follicle that multiply rapidly to form the corpus luteum, which produces higher amounts of progesterone and some oestrogen. These hormones act on the lining of the womb — it becomes thick and spongy and its glands secrete nutrients that can be used by the embryo if fertilization has occurred . If fertilization does not occur, towards the end of the cycle the process regresses and build-up of the lining of the womb stops, and the remaining glands and thickened lining containing blood vessels, are shed away, as menstrual loss. The process then repeats itself in the next menstrual cycle.