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The first type of problems comes from changes in the hormones which control menstruation. Their fine tuning is disrupted. This may be seen in the athlete whose periods slow or stop when she trains heavily. Another case may be the woman close to menopause who had irregular and heavy periods before they stop altogether.
Knowing how the normal menstrual cycle works helps one to understand how problems occur. The complete cycle is a series of timed events that prepare the uterus for pregnancy. There are three stages.
The first is the follicle stage. This lasts from the first day of menstrual flow until the egg is produced (ovulation) about two weeks later. During this time the levels of the female hormone estrogen rises and causes the uterine lining to thicken.
The second stage is ovulation, when the egg leaves the ovary to make its way toward the uterus. The few days close to ovulation are when a woman is most fertile, or most likely to become pregnant.
The third stage is the luteal stage, lasting from ovulation until the beginning of the next period. During this time, the female hormone progesterone is produced. It prepares the thickened lining of the uterus for a possible pregnancy. If one doesn’t occur, the progesterone level drops and the uterine lining is shed. One cycle ends and a new one begins.
Many women have some spotting around the middle of the cycle, during ovulation. This is normal and may be due to a fall in estrogen levels. Spotting just before or just after the menstrual period is also common and does not require treatment.
Some women with normal cycles bleed so heavily with their periods that their iron levels drops and they become anemic. The birth control pill or anti-inflammatory medication can help control this heavy bleeding.
Sometimes the ovary will not produce an egg during the menstrual cycle. This is a frequent cause of irregular periods. When an egg is not produced, the second and third stages of the menstrual cycle (ovulation and the luteal stage) do not occur. Instead, the first (follicular) stage when estrogen is produced lasts longer than the usual two weeks. This long exposure to estrogen causes the uterine lining to continue to thicken until it is so heavy that it sheds and menstrual flow results. This flow can be very heavy and last a long time. They may occur at random, not on a schedule as most normal cycles do. One can not predict when bleeding will begin when an egg has not been produced.
This type of bleeding is common in girls in the first few years of their periods when they do not yet ovulate on a regular basis. It is also common just before the menopause, as the ovaries stop egg production.
Treatment of irregular bleeding caused by lack of ovulation depends on the amount of bleeding. The birth control pill or other hormone pills may control heavy bleeding and cause a return of more normal patterns. Sometimes bleeding is so severe that a short stay in hospital is necessary.
A “D & C” (dilation and curettage, or scraping of the uterine lining) is often done in women with frequent heavy periods. In about half of women, this will stop the heavy bleeding while the woman waits for normal periods to resume.
The second group of problems causing abnormal periods are related to changes in the reproductive organs. In women aged 20 to 40 the other cause of irregular or very heavy periods is usually not related to the reproductive organs. The cause is usaly found elsewhere, for example an overactive or underactive thyroid gland.
Tumors: Growth in or around the uterus can cause irregular bleeding. Benign growths, such as fibroids or polyps, are common. They can grow into the wall of the uterus or into its cavity. When this happens, the periods may be quite a bit heavier than normal.
Cancer of the uterus or cervix can also cause unusual bleeding. Cancer of the cervix is more common in younger women. It can be detected with a pap smear. Regular pap smears can detect the problem at an early when it is more easily treated. Uterine cancer tends to occur in older women, usually after menopause. Unusual bleeding in women of this age should be reported to a doctor, as early detection of uterine cancer increases the chance of cure. A “D & C” may be done to take a sample of the uterine lining to examine under the microscope. A doctor may also thread a small tube into the uterus and collect a sample of the lining. This is called an endomentrial biopsy and it is usually done in the office.
Endometriosis: This is a disease in which bits of the lining of the uterus grow outside the uterus. These bits of tissue are still controlled by the hormones of the menstrual cycle. For reasons which we do not understand very well, endometriosis can cause abnormal menstrual flow.
Exercise and Nutrition: In women who exercise heavily, the periods may be interrupted. Exercise-related menstrual problems have become more common in the last 20 years. This is likely a result of increasing emphasis on fitness and athletic training.
Stopped menstruation is more common in women who do certain types of sports. Sports such as running, ballet and gymnastics cause the most problems, as they often require intense daily training and a thin body. Athletes in such sports may be more likely to limit the amount of food they eat to try to maintain a thin body.
This combination of heavy exercise and limited calories can cause periods to stop. It “turns off” the part of the brain that controls the menstrual cycle and the levels of female hormones, particularly estrogen, are reduced.
Women who are dieting, or those with eating disorders such as anorexia nervosa, may have no periods for similar reasons.
Estrogen has important effects on a woman’s long-term health. Among other things, it keeps the bones healthy and strong into old age. For this reason, women who stop menstruating because they are exercising too much or eating too little are encouraged to change their diet and exercise patterns so their cycle will return.
Problems related to pregnancy are the third cause of abnormal bleeding. Pregnancy, of course, is usually heralded by an absence of periods. However, pregnancy can sometimes be responsible for unusual bleeding. Miscarriage usually declares itself by cramping and bleeding. Tubal pregnancies can cause unusual bleeding and cramping as well. A doctor needs to determine whether or not a woman could have bleeding related to pregnancy before looking into other possible reasons for abnormal menstrual bleeding.
Infection in the body of the uterus can cause irregular bleeding. Infection in the cervix can make it fragile and can cause irregular bleeding.
Irregular or heavy periods can occur at any age. Treatment may not always be necessary. When it is, it is aimed at the particular problem causing the bleeding. Most of the time, pills such as the birth control pill or another medication such an anti-inflammatory will offer some benefit. Occasionally, as in the case of tubal pregnancy or some types of growths, surgery may be necessary to correct the problem.
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