- Painful cramps (dysmenorrhea) during menstruation.
- Heavy bleeding (menorrhagia) includes prolonged menstrual periods or excessive bleeding.
- Absence of menstruation (amenorrhea).
- Infrequent menstruation (oligomenorrhea) refers to menstrual periods that occur more than 35 days apart.
- Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin, generic) and naproxen (Aleve, generic) can help provide pain relief for cramps, and lessen menses.
- Oral contraceptives (birth control pills) can help regulate menstrual periods and reduce heavy bleeding. Mirena a progestin intrauterine device (IUD) can also lessen menstrual bleeding and cramping.
- Dilation and curettage may help restore your normal cycles.
- Endometrial ablation is a surgical option. This should only be considered when you are done childbearing, and you should use a highly effective form of birth control.
- Hysterectomy may be the treatment of choice for some women.
Features of Menstruation
Onset of Menstruation (Menarche). The onset of menstruation, called the menarche, typically begins between the ages of 12 - 13 years. Menarche may occur earlier in women with a higher BMI (body mass index) and women of certain races.
Length of Monthly Cycle. The average menstrual cycle is about 28 days but anywhere from 21 days to 35 days is considered normal.
Duration of Periods. Most women bleed for around 3 - 5 days but a normal period can last anywhere from 2 - 7 days.
Normal Absence of Menstruation. Normal absence of periods can occur in any woman under the following circumstances:
- Menstruation stops during pregnancy.
- When women breast-feed they are unlikely to ovulate.
- Perimenopause starts when the intervals between periods begin to lengthen, and it ends with menopause itself (the complete cessation of menstruation). Menopause usually occurs at about age 51.
Dysmenorrhea (Painful Cramps)
Dysmenorrhea is severe, frequent cramping during menstruation. Pain occurs in the lower abdomen but can spread to the lower back and thighs.
Menorrhagia (Heavy Bleeding) Menorrhagia is the medical term for significantly heavier periods. A rough gauge is changing your pad more than 3-6 times per day. Women should consult their doctor if any of the following occurs:
- Soaking through at least one pad or tampon every 1 - 2 hours for several hours
- Heavy periods that regularly last 7 or more days
- Bleeding between periods or during pregnancy. Spotting or light bleeding between periods is common in girls just starting menstruation and sometimes during ovulation in young adult women, but it is still a good idea to speak with a doctor. Women who experience any post-menopausal bleeding should definitely contact their doctors.
- Flow that is longer or heavier than your normal.
Metrorrhagia (Irregular bleeding) Metrorrhagia also called breakthrough bleeding. The bleeding occurs between periods or is unrelated to periods.
- Menometrorrhagia refers to heavy and prolonged bleeding that occurs at irregular intervals.
- Dysfunctional uterine bleeding (DUB) is a general term for abnormal uterine bleeding that usually refers to extra or excessive bleeding caused by hormonal problems, usually lack of ovulation (anovulation).
- Other types of abnormal uterine bleeding include bleeding after sex and bleeding after menopause (postmenopausal bleeding).
Amenorrhea (Absence of Menstruation)
- Primary amenorrhea occurs when a girl does not begin to menstruate by age 16. Girls who show no signs of sexual development (breast development and pubic hair) by age 13 should be evaluated by a doctor. Any girl who does not have her period by age 15 should be evaluated by her doctor.
- Secondary amenorrhea occurs when periods that were previously regular stop for at least 3 months.
Oligomenorrhea (Light or Infrequent Menstruation)
Oligomenorrhea is a condition in which menstrual cycles are infrequent, greater than 35 days apart.
Dysmenorrhea (Painful Periods)
Dysmenorrhea is caused by prostaglandins, hormone-like substances that are produced in the uterus and cause the uterine muscle to contract. Prostaglandins also play a role in the heavy bleeding that causes dysmenorrhea.
Dysmenorrhea can be caused by a number of medical conditions.
- Endometriosis is a chronic and often progressive disease that develops when the tissue that lines the uterus (endometrium) grows onto other areas, such as the ovaries, bowels, or bladder.
- Uterine Fibroids are benign growths that grow in the muscular wall of the uterus. They can cause heavy bleeding during menstruation and cramping pain.
- Other Causes. Pelvic inflammatory disease, ovarian cysts, ectopic pregnancy, and the intrauterine device (IUD) contraceptive can also cause dysmenorrhea.
Causes of Bleeding Problems
There are many possible causes for heavy bleeding:
- Hormonal Imbalances. Imbalances in estrogen and progesterone levels can cause heavy bleeding.
- Ovulation Problems.
- Uterine Fibroids are a very common cause of heavy and prolonged bleeding.
- Uterine Polyps are small benign growths.
- Endometriosis and Adenomyosis. Endometriosis, a condition in which the cells that line the uterus grow outside of the uterus in other areas, such as the ovaries, can cause heavy bleeding. Adenomyosis, a related condition where endometrial tissue develops within the muscle layers of the uterus, can also cause heavy bleeding and menstrual pain.
- Medications and Contraceptives. Certain drugs, birth control pills and IUDs can cause bleeding problems.
- Bleeding Disorders.
- Pregnancy or Miscarriage.
- Other Medical Conditions. Systemic lupus erythematosus, diabetes, pelvic inflammatory disorder, cirrhosis, and thyroid disorders can cause heavy bleeding.
- Weight. Being either excessively overweight or underweight can increase the risk for dysmenorrhea and amenorrhea.
- Menstrual Cycles and Flow. Longer and heavier menstrual cycles are definitely associated with painful cramps.
- Pregnancy History. Women who have had a higher number of pregnancies are at increased risk for menorrhagia. Women who have never given birth have a higher risk of dysmenorrhea, while women who first gave birth at a young age are at lower risk.
- Smoking. Smoking can increase the risk for heavier periods.
- Stress. Physical and emotional stress may block the release of luteinizing hormone, causing temporary amenorrhea.
4. Decreased Quality of Life
Menstrual Diary. A menstrual diary is a helpful way to keep track of changes in menstrual cycles. You should record when your period starts, how long it lasts, and the amount of bleeding and pain that occurs during the course of menstruation.
Pelvic Examination is a standard part of abnormal bleeding, and pelvic pain diagnosis.
Blood and Hormonal Tests. We may test thyroid function to make sure that low thyroid (hypothyroidism) is not present. Blood tests can also check follicle-stimulating hormone, estrogen, and prolactin levels. Patients who have menorrhagia may get tests for bleeding disorders.
Ultrasound and Saline Infusion Sonography are often used to detect certain conditions that may be causing menstrual disorders. Imaging can help diagnose fibroids, ovarian cysts or structural abnormalities of the reproductive organs.
Hysteroscopy is a procedure that can detect the presence of fibroids, polyps, or other causes of bleeding. Endometrial Biopsy or Dilation and Curettage (D&C) may be added to obtain a tissue sample in order to evaluate for cancer, infection and cycle concerns.
Laparoscopy, an invasive surgical procedure may be used to evaluate and treat some conditions that cause abnormal bleeding or pain concerns. Laparoscopy is currently the only definitive method for diagnosing endometriosis, which is a common cause of dysmenorrhea
Preventing and Treating Anemia
Dietary Forms of Iron. Women who have heavy menstrual bleeding can sometimes become anemic. Eating iron-rich foods can help prevent anemia. Such foods include beef, pork, poultry, fish, clams, oysters, and organ meats.
Other iron containing foods include eggs, dairy products, and iron-containing vegetables, which include dried beans and peas, iron-fortified cereals, bread, and pasta products, dark green leafy vegetables (chard, spinach, mustard greens, kale), dried fruits, nuts, and seeds.
Iron Supplements. It may be necessary for you to take an iron supplement, depending on your anemia.
It is important to take vitamin C and/or vitamin C rich foods, such as citrus fruits, to increase the absorption of iron, and prevent constipation caused by iron.
Other Lifestyle Measures
Exercise may help reduce menstrual pain.
Applying Heat. Applying a heating pad to the abdominal area, or soaking in a hot bath, can help relieve the pain of menstrual cramps.
Menstrual Hygiene. Change tampons every 4 - 6 hours. Avoid scented pads and tampons; feminine deodorants can irritate the genital area. Douching is not recommended because it can destroy the natural bacteria normally present in the vagina. Bathing regularly is sufficient.
Sexual Activity. There have been reports that orgasm the week prior to menses reduces the severity of menstrual cramps.
Acupuncture and Acupressure. Some studies have reported relief from pelvic pain after acupuncture or acupressure.
Yoga and Meditative Techniques that promote relaxation may help relieve menstrual cramps.
- Ginger tea or capsules may help to relieve nausea and bloating.
- Magnesium supplements may be helpful for relieving dysmenorrhea. Some women also report benefit with vitamin B1 (thiamine) supplements.
- Aromatherapy with topically-applied lavender, sage, and rose oils may help ease menstrual cramps, according to some small studies.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs). Nonsteroidal anti-inflammatory drugs (NSAIDs) block prostaglandins, the substances that increase uterine contractions. They are effective painkillers that also help control the inflammatory factors that may be responsible for heavy menstrual bleeding. These include Aspirin, Ibuprofen and Naprosyn.
Oral contraceptives (OCs), commonly called birth control pills contain combinations of an estrogen and a progestin.
OCs are often used to regulate periods in women with menstrual disorders, including menorrhagia (heavy bleeding), dysmenorrhea (severe pain), and amenorrhea (absence of periods). Oral contraceptives are as effective for treating pelvic pain from endometriosis. They also protect against ovarian and endometrial cancers.
Side effects. Common side effects of combination OCs include headache, nausea, bloating, breast tenderness, and bleeding between periods. The estrogen component in combination OCs is usually responsible for these side effects. In general, today’s OCs are much safer than OCs of the past because they contain much lower dosages of estrogen.
However, all OCs can increase the risk for migraine, stroke, heart attack, and blood clots. The risk is highest for women who smoke, who are over age 35, or who have a history of heart disease risk factors (such as high blood pressure or diabetes) or past cardiac events. Women who have certain metabolic disorders, such as polycystic ovary syndrome (PCOS), are also at higher risk for the heart-related complications associated with these pills.
Progestins (synthetic progesterone) are used by women with irregular or skipped periods to restore regular cycles. They also reduce heavy bleeding and menstrual pain, and may protect against uterine and ovarian cancers. Progestin-only contraceptives may be a good option for women who are not candidates for estrogen-containing OCs, such as smokers over the age of 35.
Oral. Short-term treatment of anovulatory bleeding (bleeding caused by lack of ovulation) may involve a 21-day course of an oral progestin on days 5 - 26. Medroxyprogesterone (Provera, generic) is commonly used.
Intrauterine Device (Mirena). An intrauterine device (IUD) that releases progestin can be very beneficial for menstrual disorders, regardless of its contraceptive effects. Mirena has been proven to reduce heavy bleeding and pain in many women who suffer from menorrhagia and dysmenorrhea.
Natural Progesterone is supplied by oral, vaginal or transdermal route and has fewer side effects than synthetic progestins.
Gonadotropin releasing hormone (GnRH) agonists are sometimes used to treat severe menorrhagia. GnRH agonists block the release of the reproductive hormones LH (luteinizing hormone) and FSH (follicular-stimulating hormone). As a result, the ovaries stop ovulating and no longer produce estrogen.
Commonly reported side effects, which can be severe in some women, include menopausal-like symptoms. These symptoms include hot flashes, night sweats, changes in the vagina, weight change, and depression. It is important to take a prescribed medication (Aygestin) along with the GnRH agonist to decrease your side effects.
GnRH treatments used alone do not prevent pregnancy. Furthermore, if a woman becomes pregnant during their use, there is some risk for birth defects. Women who are taking GnRH agonists should use non-hormonal birth control methods, such as the diaphragm, cervical cap, or condoms while on the treatments.
Danazol is a synthetic substance that resembles a male hormone. It suppresses estrogen, and therefore menstruation, and is occasionally used to help prevent heavy bleeding. It is not suitable for long-term use, and due to its masculinizing side effects it is only used in rare cases.
Adverse side effects include facial hair, deepening of the voice, weight gain, acne, and reduced breast size.
Tranexamic acid (Lysteda) is a recently approved medication for treating heavy menstrual bleeding. Lysteda is the first non-hormonal drug for menorrhagia treatment. Tranexamic acid is given as a pill. The FDA warns that use of this medication by women who take hormonal contraceptives may increase the risk of blood clots, stroke, or heart attacks.
Women with heavy menstrual bleeding, painful cramps, or both have surgical options available to them. Most procedures eliminate or significantly affect the possibility for childbearing, however.
Endometrial Ablation destroys the entire lining of the uterus (the endometrium). For most women, this procedure stops the monthly menstrual flow. In some women, menstrual flow is not stopped but is significantly reduced.
Endometrial ablation is not appropriate for women who:
- Have recently been pregnant
- Would like to have children in the future
- Have certain gynecologic conditions such as cancer of the uterus, endometrial hyperplasia, uterine infection, or an endometrium that is too thin
Hysterectomy is the surgical removal of the uterus. However, with newer medical and surgical treatments available, hysterectomies are performed less often than in the past. Hysterectomy, unlike drug treatments and less invasive procedures, cures menorrhagia completely, and most women are satisfied with the procedure. Hysterectomy may or may not be done with or without removal of your ovaries.