Menstrual (MEN-stroo-al) disorders result in abnormal menstrual periods. Usually, these disorders occur when the hormones * that control menstruation (men-stroo-AY-shun) are out of balance, but in some cases another medical problem is the cause. Menstrual disorders include pain during periods, changes in the length of the menstrual cycle, and heavy, prolonged, or too frequent periods.
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Abnormal uterine bleeding
Kim plays soccer in the fall, plays basketball in the winter, and does gymnastics in the spring and summer. Her friends call her the "lean, mean, fighting machine," because she is almost all muscle and no fat. Kim is proud of her athletic ability, but she wishes her body had a few more curves. She feels self-conscious because she just turned 16 and still has not gotten her period, whereas all of her friends got their first period years ago. Kim is embarrassed and a little bit scared, because her mother made Kim an appointment with a gynecologist * to find out why Kim has not had her period.
* hormones are chemicals that are produced by different glands in the body. Hormones are like the body's ambassadors: they are created in one place but are sent through the body to have specific regulatory effects in different places.
* gynecologist (gy-ne-KOL-o-jist) is a doctor who specializes in the reproductive system of women.
The doctor examined Kim and asked her a number of family history and health questions, including questions about sports and how long she has been playing. She told Kim that there was probably nothing wrong with her; some girls just get their period later than others. To be sure, the doctor ordered some blood tests that would show if Kim had a medical condition affecting her menstrual cycle. The tests showed that there was nothing wrong, and three months later Kim got her first period.
What Is Menstruation?
Menstruation, also called menses (MEN-seez), is a normal part of being a healthy female of reproductive age. During menstruation, the lining of a woman's uterus (YOO-ter-us) is shed, resulting in blood and tissue being expelled from the body.
Menstruation is just one part of a cycle that the female reproductive system undergoes each month when a woman is not pregnant. The female reproductive system, located in the abdomen * , consists of two ovaries (O-va-reez), two fallopian (fa-LO-pe-an) tubes, and the uterus, cervix (SER-viks), and vagina (va-JY-na). The almond-sized ovaries contain the female reproductive cells, or eggs. The ovaries also make chemicals called hormones that act as messengers throughout the body. Eggs are carried through the fallopian tubes to the uterus, which is a pear-shaped, muscular organ in which a fertilized egg can grow and develop into a baby. If the egg is not fertilized, the lining of the uterus, which had thickened in preparation for pregnancy, is shed. The blood and tissue fragments exit the uterus through its opening, the cervix, and travel through the vagina to the outside of the body.
The menstrual cycle is controlled by hormones that are in a delicate balance. The hormones interact with each other and with the reproductive organs to either take care of a fertilized egg that will become a baby or cause menstruation to occur.
* abdomen (AB-do-men), commonly called the belly, is the portion of the body between the chest and the pelvis.
The hormonal balancing act: a typical menstrual cycle
The following are the major events in a typical menstrual cycle.
- Day 0 to 5: At the very beginning of the cycle, the levels of the hormones estrogen (ES-tro-jen) and progesterone (pro-JES-te-rone) in the body are low. Menstruation begins, and blood and tissue are expelled from the uterus. The ovaries begin making more estrogen, and the lining of uterus, called the endometrium (en-do-ME-tree-um), begins to thicken. Meanwhile, an egg in one of the ovaries begins to mature in a small sac of tissue.
- Day 14: The egg leaves the ovary (which is called ovulation [ov-yoo-LAY-shun]) and travels through the fallopian tube to the uterus. Ovulation is controlled by gonadotropin (gon-a-do-TRO-pin)-releasing hormone (GnRH), follicle (FOL-i-kul)-stimulating hormone (FSH), and luteinizing (LOO-tee-in-eye-zing) hormone (LH). The empty sac in the ovary that once held the egg is now called the corpus luteum (KOR-pus LOO-te-um), and it makes the hormone progesterone. The combination of estrogen and progesterone cause the endometrium to keep growing thicker. A woman can get pregnant just before, during, or right after ovulation. If the egg is fertilized, the thickened endometrium is ready to nourish the developing embryo * .
- Day 17 to 27: If the egg is not fertilized, hormone levels decrease.
- Day 28: The endometrium begins to break down, and menstruation begins. The hormone prostaglandin (pros-ta-GLAN-din) is produced by cells in the uterine lining. Prostaglandin causes blood vessels to narrow, which slows the supply of oxygen to the uterus and causes the muscles of the uterus to contract. This process helps to expel the blood and tissue of the uterine lining.
* embryo (EM-bree-o) in humans, an embryo is the developing organism from the end of the second week after fertilization to the end of the eighth week.
What Is Normal?
In a woman who is not pregnant, the menstrual cycle occurs approximately every 28 days. However, the length of the cycle can vary from 21 to 35 days in normal healthy girls and women. Cycle length is calculated from the first day of one period to the first day of the next. Usually, bleeding lasts for a period of several days, hence the term menstrual "period." A woman wears a pad in her panties or a tampon inserted into the vagina to absorb the blood.
The first time a young girl gets her period is called menarche (MEN-ar-kee) and can be a scary thing or a much anticipated event, depending on the girl. In the United States, the average age when menarche occurs is 12, but some girls start menstruating at 10, others at 16. After menar-che, a woman usually will get her period for 30 to 40 more years, until she goes through menopause * .
There is huge variation among women in the length and duration of their menstrual cycle and whether they bleed a lot or a little. Some women have a period every 23 days, others every 35. Some periods last 3 days, whereas others last 7. And some women use 3 tampons or pads a day, whereas others need 10. Because of this wide range of "normal," determining if a woman has a menstrual disorder can be difficult. It requires that a woman knows her own body and what is normal for her.
What Are Menstrual Disorders?
Menstrual disorders occur when something goes wrong with the normal monthly menstrual cycle. There are many different types of disorders. Usually, they occur when the hormones controlling menstruation are out of balance for some reason. However, menstrual disorders can be caused by underlying medical conditions. A woman who experiences changes in her menstrual cycle, especially if these changes include heavy bleeding or cause problems with daily living, should see her doctor right away.
Disorders in menstrual cycle length
Amenorrhea (a-men-o-REE-a) means "no menstrual periods." Primary amenorrhea means not ever having a first period. Secondary amenorrhea is when a women or girl stops getting her monthly period.
A related problem is oligomenorrhea (OL-i-go-men-o-REE-a), which means having menstrual periods that are more than 35 days apart. Once doctors diagnose problems with menstrual cycle length, they then try to find out what is causing it. .,
Shelly, a 25-year-old woman who usually gets her periods like clock-work, stopped having her period for 3 months. The first thing her doctor ordered was a pregnancy test; it was a surprise to Shelly and her husband, but she was pregnant. Pregnancy is the most common cause of amenorrhea in women in their reproductive years.
When Anne turned 48, the amount of time between her periods started getting longer and longer. When she did not get her period for 4 months, she went to see her doctor. The doctor examined Anne and did some tests; Anne's amenorrhea was caused by approaching menopause. Menopause is another perfectly natural cause of amenorrhea.
* menopause (MEN-o-pawz) is the time in a woman's life when she stops having periods and can no longer become pregnant.
Kim provides a good example of primary amenorrhea, which refers to a girl not getting her first period by the time she is 16. This condition may be caused by a hormonal imbalance or a developmental problem. Young female athletes often experience primary or secondary amenorrhea or both; strenuous exercise seems to lower estrogen levels, thus causing periods to stop. Altered hormone levels can cause anovulation (an-ov-yoo-LAY-shun), when ovulation does not occur, which in turn often causes amenorrhea. Hormones are affected when a woman exercises too much, loses or gains a lot of weight, is stressed, is breast-feeding a baby, or has an eating disorder; all these things can lead to amenorrhea.
Medical problems, such as cysts (fluid-filled sacs) in the ovaries, abnormal growths or tumors * in the reproductive organs, anorexia nervosa * , and diabetes * , can also cause amenorrhea or oligomenorrhea.
Sometimes women have menstrual disorders in which they bleed too much, too often, or for too long. For example, Sally has menorrhagia (men-o-RA-jah), which means very heavy periods, and the bleeding goes on for almost 12 days. Sally will not even go to work on the first day of her period; she goes through a tampon and a pad every hour for the first five hours, and every month she ends up with bloodstains on her pants. Barb, on the other hand, gets her period every 19 days, which is far too often for her liking; this condition is called polymenorrhea (pol-ee-men-o-REE-a). These conditions are classified as abnormal uterine bleeding, or AUB. AUB also includes bleeding, or spotting, between periods and bleeding after menopause.
Eighty percent of women with menorrhagia have it because of a hormone imbalance or because they have fibroids (FY-broidz), which are abnormal growths in the uterus. Women with endometrial (en-do-ME-tree-al) cancer, infections of the vagina or cervix, small growths on the cervix or uterine wall (polyps), thyroid * conditions, or diseases of the liver * , kidney * , or bloodstream often experience menorrhagia.
Menorraghia and other bleeding disorders that are caused by hormonal imbalances also are called dysfunctional uterine bleeding (DUB). Often, DUB occurs because of anovulation or when estrogen and progesterone are out of balance. Without proper hormonal cues, normal monthly shedding of the uterine lining does not occur, and the endo-metrium keeps building up. The abnormally thick endometrium eventually starts to break down and results in heavy and prolonged bleeding. DUB is common in teenagers, whose hormones have not yet been fine-tuned and who often do not ovulate regularly. Anovulation is also common in women about to go through menopause.
Linda's teacher was really beginning to get annoyed with her by midsemester. For four months in a row, Linda went home sick each time she started her period. Linda was not faking it; she went home to bed with a backache and severe cramps, only getting up when she thought she might have to throw up.
* tumors (TOO-morz) usually refer to abnormal growths of body tissue that have no known cause. Tumors may or may not be cancerous.
* anorexia nervosa (an-o-REK-se-a ner-VO-sa) is an emotional disorder characterized by dread of gaining weight, leading to self-starvation and dangerous loss of weight and malnutrition.
* diabetes (dy-a-BEE-teez) is an impaired ability to break down carbohydrates, proteins, and fats because the body does not produce enough insulin or cannot use the insulin it makes.
* thyroid (THY-roid) is a gland located in the lower part of the front of the neck. The thyroid produces hormones that regulate the body's metabolism (me-TAB-o-liz-um), the processes the body uses to convert food into energy.
* liver is a large organ located in the upper abdomen that has many functions, including storage and filtration of blood, secretion of bile, and participation in various metabolic (met-a-BOLL-ik) processes.
* kidney is one of the pair of organs that filter blood and get rid of waste products and excess water as urine.
Linda suffers from dysmenorrhea (dis-men-o-REE-a), or painful periods. Almost every woman has this condition at some time in her life. The symptoms of dysmenorrhea range from mild, uncomfortable cramps to abdominal pain, a sore back, nausea, and vomiting. Linda has primary dysmenorrhea, which means painful periods with no underlying medical disease. This type of dysmenorrhea is very common, especially among teenagers. The symptoms are caused by the hormone prostaglandin, which is released by the cells that are being shed from the uterus.
Secondary dysmenorrhea is caused by medical conditions such as polyps * , fibroids, and narrowing of the cervix. One common cause is endometriosis (en-do-me-tree-O-sis). Endometriosis is a condition in which uterine tissue grows outside the uterus, and it affects both young and older women. Even though fragments of endometrial tissue, also called implants, are not in the uterus, they still respond to hormones just as the normal endometrial tissue does. Therefore, in response to estrogen and progesterone, the implants grow, break down, and bleed. Because there is no opening through which the blood can leave the body, the blood irritates the body, which can be very painful. Sometimes, the implants keep growing and form scar tissue or they act as an adhesive and stick organs together. Endometriosis can make it impossible for a woman to get pregnant, because implants may block the fallopian tubes or prevent the eggs from leaving the ovary. Endometriosis is found in 10 to 15 percent of 25-to 33-year-old women who actively are menstruating.
Another type of pain that accompanies menstrual periods is caused by infections of the endometrium. This pain, seen in pelvic inflammatory disease (PID), needs rapid diagnosis and medical treatment.
Every month, Stacy can tell her period is a week away by a trio of signs: her skin breaks out, her lower back begins to ache, and her breasts feel sore. Her friend Sonya experiences a different set of symptoms: she feels bloated, is incredibly tired, has bad headaches, and is depressed and grumpy.
Stacy and Sonya have premenstrual syndrome, or PMS, which is a set of symptoms that includes both physical and emotional complaints. Most women with PMS have a set of symptoms that occur each month at the same time. Fortunately, the symptoms disappear when the period begins.
PMS is often referred to as a "phenomenon," which indicates that it is still a controversial topic. Part of the problem with PMS is that no one knows for sure what causes it, but most scientists agree that it is linked to hormones. PMS symptoms appear during the second half of the menstrual cycle, after ovulation has taken place, when progesterone levels are highest.
* polyps (POL-ips) are protruding growths from a mucous (MU-kus) membrane,
Is There Such a Thing as
Too Much Exercise?
How much estrogen a woman's body produces appears to be linked to her level of body fat. Young gymnasts, ballerinas, and other athletes who regularly take part in strenuous exercise typically do not have much body fat and do not make much estrogen. If their hormone production is low enough, they might not get their first period until they are 16 or 17. Other young athletes who have normal periods for a while may develop amenorrhea when they resume strenuous exercise.
Because bone mass is linked to the level of estrogen in the body, some scientists suggest that even a few years of amenorrhea, especially during a girl's teens, can have lasting effects on bone formation or contribute to excessive bone loss. Young athletes should see their doctor if they experience a menstrual disorder; diet and hormone therapy may fix the immediate problem and have a positive effect long into the future.
Treatment for Menstrual Disorders
To determine if a woman has a menstrual disorder, doctors will take a medical history and ask questions about her menstrual cycle. Doctors need to know what has changed from past normal periods. A pelvic exam may also be necessary; doctors will examine the reproductive organs by feeling and pushing on the uterus through the abdomen and by feeling the vagina, cervix, uterus, fallopian tubes, and ovaries through the vaginal opening. This procedure is slightly uncomfortable but not painful, and it takes only 5 to 10 minutes. Blood tests also may be used to measure the levels of hormones in the body. In rare cases, a doctor will use ultrasonography (ul-tra-so-NOG-ra-fee), where sound waves are used to produce images of organs inside the body, and hysteroscopy (his-ter-OS-ko-pee) or laparascopy (lap-a-ROS-ko-pee), where instruments are inserted into the body through a small incision to take a direct look at the internal organs, to find out what is happening in a woman's body.
For all menstrual disorders, treatment depends on the underlying cause. Therefore, it is important to see a doctor if anything seems to be wrong.
When a hormonal imbalance is the cause of a menstrual disorder, hormone therapy often helps menstrual cycles return to normal. Hormone therapy includes taking birth control pills, mixtures of estrogen and progesterone, or just progesterone.
Dysmenorrhea and PMS
Products such as ibuprofen (i-bu-PRO-fen) and naproxen (na-PROKS-en) suppress prostaglandin and are helpful in treating dysmenorrhea. Over-the-counter products to relieve menstrual cramps and bloating help some women with PMS. Birth control pills also reduce painful periods in some women, as does exercise.
Endometriosis and other conditions
For some women with endo-metriosis, the doctor can prescribe medicines to relieve symptoms. However, for women with severe endometriosis, surgery to remove implants may be necessary.
Severe menstrual disorders can be eliminated by destroying the endometrial tissue in the uterus or by hysterectomy (his-ter-EK-to-mee), which is the removal of uterus (and sometimes also the ovaries). This treatment is better for older women who are past childbearing years. This is not a treatment for younger women who want to have children.
For medical conditions, such as fibroids, polyps, or cancer, surgery and other treatments may be needed to correct the problem.
Literal Meanings of
Many words used to describe menstruation and menstrual disorders come from Latin ("mensis" means month) and Greek. For example:
- Menarche, a girl's first period, comes from "mensis" + "archaios" (from the beginning).
- Menopause, or the end of monthly periods, comes from "mensis" + "pausis" (to cease).
- Menorrhagia means heavy or prolonged bleeding and is derived from "mensis" + "rhegynein" (to burst forth).
- Menorrhea comes from "mensis" + "rhoia" (to flow) and means the normal flow of blood and tissue from the uterus during a menstrual period (also called menses and menstruation).
- The prefix "a" means not; amenorrhea is the cessation of menses. The prefix "dys" means bad or painful, and dysmenorrhea means painful periods. The prefix "oligo" means little or few; oligomenorrhea is having infrequent periods. "Poly" means many, and so polymenorrhea means periods that come too frequently.
Gillooly, Jessica B. Before She Gets Her Period: Talking with Your Daughter about Menstruation. Memphis, TN: Perspective Publishing, 1998.
Gravelle, Karen, Jennifer Gravelle, and Debbie Palen. The Period Book: Everything You Don't Want to Ask (but Need to Know). New York: Walker and Co., 1996.
American Society for Reproductive Medicine, 1209 Montgomery Highway,
Birmingham, AL 35216-2809.