The average menstrual cycle is 21 – 30 days. What is normal for one may be abnormal for another. When women are asked about the quantity of blood they lose each month, here’s where women differ on what they perceive as normal and regular. Experience teaches as beauty is in the eyes of the beholder, so is what constitutes normal and heavy bleeding.
Questions about the normalcy, frequency, duration and quantity of bleeding during the menstrual cycle is crucial information when identifying and determining the cause of menstrual irregularities.
Longer, shorter, heavy or scant cycles are considered menstrual irregularities. Most menstrual irregularities do not pose a problem to a woman’s overall health. However, prolonged irregularities may present health problems and need to be identified and corrected as soon as possible. Some solutions require no intervention while others require either a conservative or surgical approach.
The average amount of blood loss per cycle is 80cc. Many women experience much more blood loss than this each month on a regular basis. Although this amount of blood may be predictable and occurring with regular frequency, it is abnormal and may pose a serious health problem.
Identifying the cause of menstrual irregularities requires a good history, examination, blood work, pelvic sonogram and in some cases an endometrial biopsy or D&C (dlation and currettage). More common causes of menstrual irregularities are hormone imbalance, presence of endocervical/uterine polyps, fibroids, ovarian cysts, endometrial thickening, endometrial thinning or cancer.
It is not uncommon for women with more fuller figures to experience menstrual irregularities because of the presence of excess estrogen. Excess estrogen is found in adipose tissue as well from taking of exogenous estrogen from over the counter products. Women with too little or estrogen deficiencies may experience scant or no bleeding at all.
Progesterone helps regulate the effects of estrogen. Excess progesterone does not affect the cycle and causes breast tenderness, anxiety, depression, bloating and decreased libido. Not enough progesterone is more common and can cause problems with ovulation and therefore fertility. Too little progesterone will cause estrogen to be the more dominant hormone. This dominance of estrogen leads to excessive growing of the lining or endometrium and therefore more tissue to release during the menstrual cycle. This excessive tissue is seen as heavier bleeding, more blood clots and more blood loss.
Too much testosterone is associated with polycystic ovarian syndrome. The hallmark of this disorder is very irregular cycles, weight gain and excessive body hair.
Prolactin is the hormone responsible for milk production and lactation. Too little can lead to breastfeeding problems. Too much prolactin increases milk production but also shuts down the menstrual cycle. Excessive prolactin may also be due to pituitary tumors which are usually benign.
Women with both underactive (hypothyroidism) and overactive (hyperthyroidism) may experience menstrual irregularities. Therefore maintaining thyroid hormones in balance will help with regulation of the menstrual cycle.
Women with diabetes may also experience menstrual irregularities. Women may have irregular cycles, heavier periods, delayed onset and early menopause.
POLYPS, FIBROIDS, CYSTS
99% of the time, polyps in the cervix or uterus are benign in nature. Their significance is not the same as polyps in the colon. Excessive or overgrowth of the endometrium may result in the creation of a polyp and bleeding abnormalities.
The presence of ovarian cysts may lead to menstrual irregularities. Intact ovarian cysts may cause a variety of symptoms to include no symptoms, pain, or no cycles. If the cyst ruptures the amount of bleeding can be scant or excessive. Cysts may require observation only with no treatment, hormonal suppression with birth control pills, or surgical intervention with aspiration or if very large actual removal of the ovary.
More common causes of excessive bleeding is the presence of solid masses in the uterus referred to as fibroids. Fibroids are smooth muscle tissue that vary in size from mere millimeters to large oversized masses. The location of the fibroids is the main factor that impacts the amount of bleeding. The size of the fibroids impacts the amount of bloating, pain or discomfort a woman may experience.
Intramural fibroids are located in the muscle portion of the uterus and have very little effect on the amount of bleeding. Subserosal fibroids are located just beneath the surface of the uterus and also have very little impact on bleeding experienced. Submucosal and intracavitary fibroids are located within or protrude into the endometrial cavity and have a significant impact on bleeding. Pedunculated fibroids hang off the uterus and don’t affect bleeding.
Fibroids may be managed conservatively or surgically. Conservative management includes observation, application of cold or heat, or diminishing blood supply to the uterus (uterine artery embolization). Cold or hot probes can be inserted directly into the fibroid to shrink the fibroid.
Surgical removal of fibroids requires a myomectomy. Smaller submucosal fibroids can be destroyed with a hysteroscopic myomectomy or endometrial ablation. Larger fibroids are best removed with either an open or laparoscopic myomectomy.
Thickening of the endometrium over time can cause very heavy bleeding where a woman is needing to change her pad or tampon every hour. This amount of excessive bleeding lasting longer than a few hours to days can prove to be a health problem. Rapid loss of a large amount of bleeding over a short period of time or even loss of moderate amounts over a longer period of time may lead to anemia.
Anemia from acute or chronic blood loss may lead to fatigue, dizziness, headache, poor blood blow and ultimately excess stress on the heart. Treatment of minor anemia may require iron supplements whereas anemia which is symptomatic may require blood transfusions.
Thinning of the endometrium due to less estrogen causes the lining to be fragile and undergo some breakage which may cause irregular bleeding. This less estrogen may be physiologic and due to perimenopause where the amount of hormone produced by the ovaries is diminished or in menopause the production has ceased.
Cervical cancer may present with abnormal bleeding. More commonly heavy bleeding or any abnormal bleeding that occurs after menopause may indicate endometrial cancer. All abnormal bleeding should be investigated with a possible endometrial biopsy.
The menstrual cycle and medical history are important components of a woman’s history and may prove to be the important link to solving your medical dilemma. Be sure to alert your healthcare provider to menstrual irregularities; especially any that lead to heavy and prolonged bleeding.