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Abnormal menstrual bleeding is common in women from the menarche (=first menstrual bleeding) until the early menopause (=last menstrual bleeding). As this spans a time frame of 30 to 35 years for most women, irregularities affect potentially roughly 1/3 of all women at one point or another. The table above lists some common menstrual irregularities (Ref.1). In the following I will briefly comment on each of these important menstrual abnormalities. Dysfunctional Uterine Bleeding This is the most common abnormality of a woman's menstrual cycle. Ordinarily the first day of the period would be 28 days (26 to 30 range) apart. In more than 70% of cases there has not been an ovulation in the ovary (no egg release) in that cycle that causes a dysfunctional bleeding. More than 50 % happen in women that are older than 45 years, 20% in adolescents. As there is a persistent ovarian follicle where estrogen is produced when ovulation does not occur, the lining of the uterus grows more than usual. This leads to a heavy menstrual period that might be late or irregular (on and off). Women with such conditions as polycystic ovary disease (PCOD) or endometriosis often have dysfunctional uterine bleeding. Treatment: Treatment might be quite different depending on the age of the woman, the underlying disease process and the severity of bleeding. If the bleeding is mild to moderate the physician might decide to use the birth control pill for the bleeding. The effect often sets in within 12 to 24 hours. This will also regulate the periods. Should this fail to stop the bleeding, a D&C (dilatation of the cervical canal and curretage of the uterus) is usually done. This method has the advantage that it stops the bleeding reliably and it provides the physician with lining material from the uterine cavity, which can be sent to the pathologist for analysis. The downside is the risks of the anesthetic, of uterine perforation and uterine infection as there is an internal wound in the uterus for a few days. If there is an anovulatory period (meaning no egg was released) and the woman would like to get pregnant, then clomiphene citrate (brand name: Clomid) can be given or else human chorionic gonadotropin. Usually these specialized treatments are given and supervised by a gynecologist/obstetrician. If obesity is present a dietary plan to reduce sugar and starch consumption will help to shed some weight and will normalize blood insulin levels. In cases of polycystic ovaries, where often there is also syndrome of insulin resistance present at the same time, treatment of insulin resistance will help balance the female hormones and thyroid dysfunction. Every case needs to be investigated by the specialist on its own merit. Amenorrhea There is a division between primary amenorrhea and secondary amenorrhea. When a woman did not get a period by age 16, then physicians call this primary amenorrhea. In secondary amenorrhea a woman who has had previous menstrual periods fails to have periods for more than 3 months.
One of the common causes of amenorrhea is anovulation. In this condition there are functional ovarian follicles, but due to a hormonal dysbalance at the hypothalamic, pituitary level or due to another hormonal dysbalance such as thyroid hormone disorder, polycystic ovary syndrome or obesity (hyperinsulinism) the final stimulus to induce ovulation is missing. Some of these women need a work-up by an endocrinologist. A good start is to see a gynecologist who may want to do certain tests first and perhaps refer to further specialists, if necessary, later. Treatment is specifically directed at the cause of each case, which will differ according to the underlying condition. Postmenopausal Bleeding Here the gynecologist must make every effort to rule out a hidden cancer. Usually a diagnostic D&C is done and possibly an MRI scan. The specialist may also decide to do a diagnostic laparoscopy, if ovarian pathology or endometriosis is suspected. Bleeding During Early Pregnancy Bleeding in early pregnancy is always a potentially dangerous condition. As the uterus is enlarged from the hormone changes of pregnancy, the blood vessels are engorged and bleeding after miscarriage (medically known as "spontanous abortion") can be profuse, causing severe anemia. This can be life threatening and needs immediate intervention with a D&C (dilatation of the cervix and curretage of the uterus) by a specialist. For every life birth there is a miscarriage, in other words half of all pregnancies never make it to completion. It is important to ensure that all of the fetal tissue and retained placental tissue is removed in these situations, otherwise there is the risk of developing a choriocarcinoma or a hydatiforme mole. Use this link to learn more about this preventable cancer. Even though early pregnancy associated bleeding is often devastating to a couple, as dreams of family are preliminarily shattered, it is not all bad news. We could perhaps rethink our perception about nature and realize that in some instances nature wants to mature the uterus more, so with the next attempt it is ready to carry through with a successful pregnancy. In other cases there may be lethal mutations or genetic malformations that are incompatible with life and nature decided to spontaneously abort this pregnancy. We need to overcome the human tendency to lay blame onto the husband's sperm or the mother's egg. The truth is that very often the cause cannot be determined, so we are better off to simply accept what cannot be changed and when we are emotionally ready to simply try again. One thing seems to be for certain that every new pregnancy gives the uterus a boost and makes the woman more fertile for about one to two years.
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