Normally, the menstrual cycle has a duration of 23–35 days, on average 28 days. The number of bleeding days is normally 2–7 and the blood volume lost is, on average, 25–40 ml. Normally, the maximum volume of blood loss during a menstrual cycle is 80 ml. Manifestations of menstrual disturbances are abnormal duration of the menstrual cycle, number of bleeding days or bleeding volume. Breakthrough bleedings not related to the normal menstrual cycle are also considered a menstrual disturbance. Bleedings after menopause (the time when the last menstruation occurred) is always abnormal and must be evaluated by a physician.
Booking a visit to a physician is always a good idea, if menstrual disturbances affect your normal life in some way.
Oligomenorrhea is when your periods occur at longer intervals than 5 weeks and polymenorrhagia is when they occur repeatedly at intervals shorter than 23 days. Variations in the length of the menstrual cycle are common for teenagers and women above 40–45 years of age. If the cycle varies only slightly and if the periods are not excessive, this is not a medical condition.
If periods that have been regular stop, the usual cause is pregnancy. Other reasons for changes in the menstrual cycle are stress, rapid weight loss, eating disturbances, overweight, discontinuation of contraceptive pills, disturbed thyroid function and excessive secretion of prolactin. A fairly common cause for irregular periods is the polycystic ovary syndrome (PCOS). Increased hair growth and overweight are signs of PCOS.
If there are no periods for 3 months, a physician should be consulted. Of course, a pregnancy test is indicated sooner, if periods stop and there has been sexual intercourse. If irregular periods disturb normal life or if they are associated with general symptoms like fatigue, it’s worthwhile consulting a physician. The same holds true if the periods increase in number or duration or if there are breakthrough bleedings.
When menstrual disturbances are treated, normalizing nutrition and weight, if abnormal, is in order. If the reason for the menstrual disturbance is assumed to be mental stress, it is best to wait until the situation clears. Irregular periods do not necessarily require treatment, provided that the interval between periods is shorter than three months. If periods are treated to normalize the time interval between menstruations, a monthly 10–12-day course of a progestin (progesterone-like hormone) may be appropriate. If the woman also needs contraception, the combination pill is a suitable alternative, if there are no contraindications (see Contraception).
Heavy menstruation or menorrhagia is when the duration of the periods is normal, but the volume of menstrual blood exceeds repeatedly 80 ml. It is not possible to measure the volume exactly and estimating the volume of blood relies on what the woman experiences in terms of blood volume and discomfort. To facilitate the evaluation a specially designed form is filled with information about test results and treatment effects. It is important to measure the blood hemoglobin after periods.
The most common reasons for menorrhagia related to the uterus are fibroids and polyps, both benign conditions, which, nevertheless, may increase menstrual blood loss. A rare cause of heavy menstruation is endometrial cancer, which accounts for 0.08% of instances of menorrhagia. Despite its rarity, cancer must be kept in kind, especially for women approaching menopause. General diseases, like thyroid conditions and diabetes, may also increase menstrual blood loss. The copper-IUD and medication that reduces blood coagulation are well-known and rather common causes of menorrhagia. Still, about for about 50% of women with menorrhagia, no specific cause is found despite examinations.
A physician must be consulted if the periods suddenly become more profuse and, especially, if there are breakthrough bleedings and/or pain. Booking a visit to a physician is always a good idea if menstrual disturbances affect your normal life in some way.
Treatment depends on the cause. If the cause is a non-gynecological, general disease, it is important to have it treated. If, for example, the cause is a polyp in the uterus, the polyp should be removed. If fibroids are the cause for heavy periods, they can be treated with medicines or surgery. Excessive bleeding may be controlled with medication, some of which is quite innocuous (tranexamic acid, NSAIDs). Of the hormonal treatments available, the hormone-IUD is the most effective one. Combined contraceptive pills reduce also menstrual blood loss.
Breakthrough bleeding occurs when there is vaginal bleeding at unexpected times, i.e., between periods. The duration of the bleeding and the volume of blood lost vary. Breakthrough bleedings may occur regardless of regular or irregular periods.
In essence, all gynecological hormonal drugs (contraceptives, hormonal replacement drugs), may cause breakthrough bleeding. Gynecological infections and inflammations, cell pathology of the uterine cervix or a benign tumor of the uterus, like a polyp or fibroid, may cause breakthrough bleedings. Various menstrual disturbances, including breakthrough bleedings, occur often among women with disturbed ovulation or disturbed maturation of ova. Bleedings associated with ovulation are benign. General illnesses and some medicines may also cause breakthrough bleedings.
If a woman experiences a breakthrough bleeding for the first time or if breakthrough bleedings recur often, an examination by a physician is needed. It’s very valuable for assessing the situation, and helps the physician, if the patient records the history of her periods over several months. Often, a pap smear and a test for Chlamydia are in indicated. Taking a sample of the endometrium (inside lining of the uterus) may be considered and will provide valuable information, especially if the patient is above age 40 years.
The treatment depends on the cause.
Vaginal bleeding after menopause (postmenopausal bleeding) must always be examined and assessed by a physician; often at least an endometrial sample is needed.