Hormonal Imbalance Series: Dysmenorrhoea

3.  Dysmenorrhoea  (Period pain)

Why dysmenorrhoea is a problem

Dysmenorrhoea is medical term for painful menstrual cramp of uterine origin just before the menstrual begin and usually subsided one or two days after.  Most of the time it is physiological but it is often associated with endometriosis and other uterine pathology.  Studies have shown the prevalence of dysmenorrhoea in female population vary from 45%-95%. It is indeed the most common gynaecological condition in women regardless of age and race and nationality.

Dysmenorrhoea affects productivity due to common absenteeism from work and school. Studies have shown almost 13% to 51% of women have been absent from work and school at least once and 5% to 14% are often absent owing to the severity of symptoms.  Yet despite this substantial effect on their quality of life and general wellbeing, few women with dysmenorrhoea seek treatment as many believe it would not help.

What types of dysmenorrhoea are there? 

There are two type of dysmenorrhoea based on what the underlying cause is.  Primary dysmenorrhoea is menstrual pain without a pelvic disease, and secondary dysmenorrhoea is menstrual pain due to identifiable disease. In primary dysmenorrhoea, menstrual cramp normally begins 6 to 12 months from the onset of the menarche (the first period) and occurs for 8 to 12 hours at the onset of menstrual flow. It is commonly accompanying by other symptoms like back and thigh pain, headache, diarrhoea, nausea, and vomiting. Primary dysmenorrhoea is common among the teenagers and young woman and one of the most common reasons for school absentism. Primary dysmenorrhoea often improves as a woman grow older and after childbirth.

Secondary dysmenorrhoea usually arises later when a woman is in her 30s or 40s, after the onset of an underlying pelvic disease. Other gynaecological symptoms, such as pain during intercourse, heavy menstruation, intermenstrual bleeding, and postcoital bleeding, may also be present depending on the underlying condition. Common causes of secondary dysmenorrhoea include endometriosis, fibroids (myomas), adenomyosis, endometrial polyps, pelvic inflammatory disease, and the use of an intrauterine contraceptive device. Secondary dysmenorrhoea often gets worse with time and the pain may become more severe in it intensity and duration and it may severely affect productivity and quality of life if not treated.

How would your gynae doctor  investigate dysmenorrhoea?

Firstly, your gynae doctor would get a detail history of your menstruation and performed a physical examination. Information about the onset, location, duration, and characteristics of pain, plus any aggravating or relieving factors, would be sought. The doctor would perform an Ultrasound of the pelvis to look for evidence of undelying disease  like endometriosis, uterine fibroid or polyp that may cause the menstrual pain.

Treatment and remedies for dysmenorrhoea

The aim of treatment of dysmenorrhoea is to releive pain and treating the underlying cause. The treatment modalities can be divided into two i.e non-hormonal drugs and hormonal drugs.

Simple analgesics (pain killer) - Simple analgesics like paracetamol and aspirin may be useful for mild to moderate menstrual pain

Non steroidal antiinflammtory drugs (NSAIDs) – is a good pain relief. Between 17% and 95%  of women achieve pain relief with an NSAID for moderate pain over three to five days. However gastrointestinal effects (nausea, vomiting, and/or diarrhoea) are of particular concern with NSAIDs.

Oral contraceptives (OC) – there are some evidences that showed oral contraceptives pills relief dysmenorrhoea significantly especially those with secondary dysmenorrhoea. OC also reported to reduce mentrual blood loss.  If a woman also wants to avoid pregnancy, then a combined oral contraceptive may well be a worthwhile treatment option. Adverse effects such as headache, nausea, abdominal pain, bloating, anxiety, loneliness, weight gain, and acne have all been reported in association with combined oral contraceptives.  

Levanogestrel Releasing  Intra-Uterine System (MIRENA) – MIRENA is an intrauterine device containing levonorgestrel hormone. It release the hormone into the uterine cavity for at least five years, thus preventing the thickening of the lining of the uterus. It has been shown to be effective in reducing dysmenorrhoea in women with endometriosis.

Alternative therapies

In all, 10-20% of women with primary dysmenorrhoea do not respond to treatment with NSAIDs or oral contraceptives. In addition, some women have contraindications to these treatments. Consequently, researchers have investigated many alternatives to drug treatments.

Herbal products or medicines, and dietary supplements - Herbal and dietary therapies are popular as they can be self administered and are available from health shops, chemists, and supermarkets. This availability, although helpful, can create problems with the control of dosage, quality, and drug interactions. Studies have shown that thiamine, pyridoxine, magnesium, and fish oil may be effective in relieving pain, although some of these may be associated with adverse effects. Vitamin E was also shown in some study to be effective in treating dysmenorrhoea, but it advises caution in use owing to potential adverse effects when used in high doses.

Exercise - Physical exercise may reduce dysmenorrhoea. It is postulated that exercise works by improving blood flow at the pelvic level as well as stimulating the release of β endorphins, which act as non-specific analgesics.

Summary points
Dysmenorrhoea is a common gynaecological condition that is underdiagnosed and undertreated
Simple analgesics and non-steroidal anti-inflammatories are effective in up to 70% of women
Oral contraceptives can be considered for women who wish to avoid pregnancy
For women seeking alternative therapies heat, thiamine, magnesium, and vitamin E may be effective

 

Hormonal Imbalance Series: Dysfunctional Uterine Bleeding

2. Dysfunctional Uterine Bleeding (DUB) 

What is Dysfunctional Uterine Bleeding (DUB)

Dysfunctional uterine bleeding (DUB) is abnormal bleeding from the uterus that is not due to pregnancy or other recognizable pathology in the women’s uterus, pelvic or systemic disease. It is a functional problem of the uterus largely due to hormonal imbalance and not related to structural or anatomical problem. It is commonly present as heavy menstrual bleeding (menorrhagia). However, the doctor can only derive to a diagnosis of DUB after all other causes for abnormal and heavy menstrual bleeding in a patient have been investigated and excluded. 

Who gets DUB and why is it important to know

Almost every woman is at risk of experience DUB in their lifetime. Dysfunctional uterine bleeding occurs most often in adolescent and in women after 40 and close to menopausal age. Studies showed that nearly 80% of heavy menstruation (i.e. menstrual blood loss >80 mls permonth) is caused by DUB. Heavy menstrual bleeding may affect a woman’s health both medically and socially causing problem such as iron deficiency anaemia and social phobia or discomfort respectively. Dysfunctional uterine bleeding is the commonest cause of iron deficiency anaemia in women in the developed world and of chronic illness in developing world.  It also affects productivity as almost 10 % of women absent from work due to heavy menstrual bleeding. For adolescent, heavy menstrual bleeding resulting in anaemia affects their school performance as they often feel lethargic and unable to participate in school activities too. 

What are other causes of abnormal menstrual bleeding?

Other than DUB, the functional problem that often responsible for heavy or abnormal menstruation, there are many structural and systemic cause that need to be investigated and excluded first before DUB can be diagnosed. Other causes of abnormal uterine bleeding include the following:

• Uterine Fibroid
• Uterine Polyp
• Uterine hyperplasia
• Uterine Cancer
• Adenomyosis
• Intrauterine Device (IUCD)
• Thyroid disease
• Blood disorders
• Kidney disease

Treatment of DUB: What to expect from your gynaecologist?

Although abnormal menstrual bleeding is often due to functional or hormonal imbalance but diagnosis of dysfunctional uterine bleeding cannot be made based on assumption without going through a full examination and investigation because it is not always the case. Your doctor will ask you about your personal and family health history and your menstrual cycle. It may be helpful to keep track on your menstrual cycle before your visit. Note the date, length, and type (light, medium, heavy, spotting) of your bleeding on a calendar. Based on your symptom your doctor might order some test which includes a pap test and ultrasound of the pelvis to rule out those structural causes of the abnormal bleeding. You also may have a test to see if you are pregnant. For women after 40, it is necessary to have a biopsy of the endometrium and a hysteroscopy to assess the endometrium and rule out serious pathology like endometrial hyperplasia or cancer.

The approach to the treatment of DUB is depending on the age and whether you want to have children. Most women with DUB can be treated medically and others may need surgery. The following are options of medical treatment that you may expect from your doctor.

• Tranexamic acid – to be taken for 5 days during heavy period; effective in reducing menstrual blood loss by 50%. For young woman and adolescent, it is recommended that tranexamic acid is the first line therapy for DUB.
• NSAID/Ponstan ─ to be taken for few days during heavy period; effective in reducing menstrual blood loss by 30-50% and relief period cramps.
• OCPill ─ to be taken everyday for months; effectively reduced menstrual blood loss by 30-50% and relief period cramps. It also offers protection against pregnancy.

• MIRENA IUS ─ a T shape intrauterine device containing progesterone hormones.  For older women, it is highly recommended that MIRENA IUS to be the first line therapy, i.e first treatment option to be offered to the patient as it is the most effective in reducing menstrual blood loss by almost 70-90%.
• Hysterectomy ─ removal of the uterus is reserved as the last option to be offered if everything else has failed.

Hormonal Imbalance series: Understanding Menstrual Cycle & Sex Hormones Function

1.      Understanding Menstrual Cycle and Sex Hormones Function

The Myths and The Facts About Menstruation

Menstruation is also known by the terms menses, menstrual period or period.  Menstruation is the monthly shedding of the lining of a women’s uterus (more commonly known as the womb). The menstrual blood—which is partly blood and partly tissue from the inside of the uterus—flows from the uterus through the cervix and out of the body through the vagina.

Some people refer menses as a women’s good friend as it is expected to revisit monthly without fail.  It is also regarded as a symbol of ‘womenness” and reproduction, without it women become less of a woman and incapable of childbearing which to some extent from a scientific point of view, it is a fact. Interestingly, many women regardless of their cultural and education background believe that menstrual period is a way that body eliminates dirty blood or bad element in their body monthly. Failing to have their monthly menstrual bleeding, it will make them unwell.  For Muslim women and the Jews , having menstrual period means a holiday from all religious rituals and sexual intercourse as women during this period are regarded as in the state of ‘spiritually unclean’.

Many women do not know when it is considered normal menstrual blood loss and when it is not. Some women believe that heavier menstrual blood loss and longer days is better than less as dirtier element or blood is flushed out from the body. There are a number of women who are concern about the color and thickness of the menstrual blood as they fear it may be associated with some disease.

Phases of a normal menstrual cycle and it significance

Girls starting menstruation simply mean they are entering into the reproductive phase of life where their reproductive system is now begin to function preparing their body for a possibility of pregnancy each month. Most girls start menstruating at the age of 12, however, girls can begin menstruating as early as 8 years of age or as late as 16 years of age. The menstrual cycle is controlled by the rise and fall of hormones, namely oestrogen, progesterone from the ovaries, and hormones from the hypothalamus and the pituitary in the brain.  A normal menstrual cycle has 4 phases.

The menses phase —the bleeding phase, which typically lasts from day 1 to day 5, is the time when the lining of the uterus is actually shed out through the vagina if pregnancy has not occurred. Most women bleed for 3 to 5 days, but a period lasting only 2 days to as many as 7 days is still considered normal. Menstrual blood loss more than 80 mls percycle is considered excessive and abnormal.

The follicular phase —this phase typically takes place from days 6 to 14. During this time, the level of the hormone estrogen rises, which causes the lining of the uterus (called the endometrium) to grow and thicken. In addition, another hormone—follicle-stimulating hormone—causes follicles in the ovaries to grow. During days 10 to 14, only one of the developing follicles will form a fully mature egg (ovum).

Ovulation —the fertile phase - this phase occurs roughly at about day 14 in a 28-day menstrual cycle. A sudden increase in another hormone—luteinizing hormone—causes the ovary to release its egg. This event is called ovulation. Some women may experience a sharp pain during mid-cycle due to ovulation.

The luteal phase —this phase lasts from about day 15 to day 28. After the egg is released from the ovary it begins to travel through the fallopian tubes to the uterus. The level of the hormone progesterone rises to help prepare the uterine lining for pregnancy. If the egg becomes fertilized by a sperm and attaches itself to the uterine wall, the woman becomes pregnant. If pregnancy does not occur, estrogen and progesterone levels drop and the thickened lining of the uterus is shed during the menstrual period.

A menstrual cycle calendar is considered to begin on the first day of a period. The average cycle is 28 days long; however, a cycle can range in length from 21 days to about 35 days. Women stop menstruating at menopause, which occurs at about the age of 50. At menopause, a woman stops producing eggs (stops ovulating) and can no longer become pregnant, the body stops preparing the uterus for a possibly pregnancy, and the monthly menses stops.

What is pre-menstrual syndrome?

Due to the changes in the level of sex hormones particularly progesterone level, it is common that women experience the following symptoms:

• Moodiness
• Trouble sleeping
• Food cravings
• Development of cramps
• Bloating
• Tenderness in the breasts
• Light headaches

What is Abnormal Menstruation and Terms used?

Abnormal menstruation is simply means the menstruation that does not follow the order or normal menstrual cycle and may spell a symptom of disease affecting women’s reproductive system.  There are many conditions of abnormal menstruation and it is often referred to using specific medical term as the following:

Menorrhagia ─ heavy menstrual bleeding every month of more than 80 mls per cycle.  If it is not corrected it commonly cause chronic iron deficiency anaemia in women

Dysmenorrhoea ─ severe menstrual pain just before the menstrual begin and usually subsided one or two days after.  Most of the time it is physiological but it is often associated with endometriosis and other uterine pathology

Polymenorrhoea─ frequent period of more than once a month.

Oligomenorrhoea─scanty period or infrequent period of less than 6 times per year.  This is one of the common symptom of polycystic ovarian syndrome in women.

Menometorrhagia haemorhagica─erratic menstrual bleeding and usually very heavy with blood clots and flooding.

Menstrual Calender

It is indeed a good habit to keep record on detail of your period every month on a calendar. Pay attention on the date when the period starts, the pain ─ how severe and how long it last, and the menstrual flow─how heavy it is. Keeping menstrual calendar helps early detection of menstrual abnormality and helps you with pregnancy planning.

When do you need to contact your gynae doctor?

Contact your doctor if:

·         You have not started menstruating by the age of 16

·         You are bleeding between period

·         You are bleeding for more days than usual

·         You are bleeding more heavily than usual

·         You have severe pain during your period

·         You have bleeding after sex

·         You are bleeding after menopause

·         Your period interval is more than 35 days or shorter than 21 days

·         You think you might be pregnant