Menstruation – having periods – is part of the female reproductive cycle and for many, painful, irregular or other symptoms are part of life. Here, CK resident Obstetrician & Gynaecologist, Dr Gary Swift demystifies and explains some common complaints.
Women commence having periods when hormone centres in the base of the brain mature and send signals to the ovaries at puberty. Menarche (first menstruation) is usually the last of the five stages of puberty and occurs on average at 12 years of age in Australia and similar Western Countries.
The oocytes (eggs) which have populated the ovaries of baby girls during the 20th week of pregnancy respond to the FSH stimulation from the pituitary gland. The eggs are in a dormant state. A batch of eggs starts to mature each month, secreting estrogen as they grow and the dominant or lead follicle eventually is released, available for fertilization. All this is designed for reproduction to perpetuate the species.
The first two years after menarche are often unpredictable until regular ovulation occurs. For some girls a regular pattern doesn’t establish and this may be due to genetic or environmental factors or a common condition called Polycystic ovaries (PCOS).
Painful periods may be due to Primary Dysmenorrhea (sensitivity to prostaglandin hormones produced in the endometrial lining) or sometimes medical conditions such as Endometriosis.
Heavy periods (Menorrhagia) in young women may be hereditary, associated with infections, endocrine disturbance, or occasionally related to disorders in the clotting system such as Von Willebrand’s disease or Haemophilias. Most cases will be in the absence of definable pathology and termed “Idiopathic” or “Dysfunctional”. In older women fibroids, adenomyosis and cancers and precancerous conditions need to be considered.
Many women endure such symptoms until they are prescribed the oral contraceptive pill in the late teens or early twenties. Thereafter “periods” are actually “withdrawal bleeds” at the direction of the contraceptive pills. These bleeds will tend to be light and predictable hence the attraction as well as the prevention of unwanted pregnancy. Other medical management options also exist including oral and injectable progesterones and the Mirena IUCD ®. Surgical options are reserved for women who have usually finished their families and vary according to the underlying cause.
When women cease contraceptive pills and embark on pregnancy, periods will generally resume the pre-pill pattern as oral contraceptives don’t change any fundamentals they just put things in a holding pattern.
Most anxieties about the pill and adverse effects on fertility are untrue “wives’ tales”. The pill does not deplete egg supply, alter egg quality or change fertility in any way. It protects against uterine and ovarian cancer in the longer term.
When attempting pregnancy 85% of healthy couples should be pregnant within 12 months of regular cycles and intercourse and 93% within two years. Beyond this the monthly chance of pregnancy falls to 2-3% and it is after the 12 month mark in women under 35 years of age a fertility evaluation is recommended to exclude at least the three common causes of infertility: male factor, ovulation defects and tubal/peritoneal abnormalities. Over 35 the recommendation for timing investigation shortens to 6 months due to the relentless negative effect of age on monthly chance of pregnancy.
When pregnancy occurs, ovulation and the menstrual cycle stops. Pregnancy hormones block the stimulation and release of eggs. This suppression persists through pregnancy and into the phase of breast feeding.
If women don’t breast feed, pregnancy hormone (BhCG) disappears from their bodies within two weeks and the ovulatory mechanisms resume. It is therefore possible to conceive again four weeks after birth if lactation is suppressed. This is the reason that contraception is discussed prior to discharge from hospital ideally or at least at the six week check.
Women who choose to breast feed are under the influence of a hormone called Prolactin which suppresses ovarian stimulation initially. As a rough guide half the women who breast feed won’t resume ovulation and be fertile until they wean their babies. The other half will have a variable and often unpredictable return of periods usually from three months onwards. This group is offered progesterone based contraception such as the Minipill or Mirena of which neither will interfere with breast milk quality or quantity.
Once breast feeding is complete periods will return to their normal pattern between children unless altered by contraceptives. The conditions then that impact on periods to make them heavy and/or painful will depend partly on age and genetic predisposition or the presence of other pathology.
Fibroids are benign tumours which grow in the uterine muscle, causing enlargement and distortion and potentially affecting menstrual flow depending on their size and position relative to the endometrial cavity. They are almost unheard of in teens, rare in 20s but become increasingly more common in the 30s with 40% of women over 40 having at least one fibroid (with or without symptoms). They grow in the presence of estrogen and regress after the menopause unless HRT is taken. Some women with fibroids require surgery to remove them for symptoms of heavy bleeding or pelvic pressure. Conservative surgery is available however many women still require removal of the uterus (hysterectomy).
Adenomyosis is the other significant condition which causes increasingly painful and heavy periods from mid 30s onwards. The endometrial lining cells get buried in the deeper layers of the uterine muscle so each month there is bleeding into the muscle which causes pain and distortion of the shape of the uterus. This disease may respond to the progesterone containing IUD (Mirena) or oral progesterone therapy but may require hysterectomy if symptoms are severely impacting on quality of life.
There are other causes of menstrual disturbance and many causes with no identifiable pathology (Dysfunctional Uterine Bleeding). Procedures such as hysteroscopy and curettage may be required to rule out cancer and PAP smears should always be checked.
Where hysterectomy is required the Gold Standard now is “keyhole” or laparoscopic surgery. This approach is suitable for all but very large uteruses in experienced hands and results in short hospital stays (usually 48 hours) and more rapid return to normal duties and much less pain than traditional open surgery.
Ultimately in the presence or absence of bleeding problems periods will cease when a woman passes though the menopause. This means she has effectively run out of eggs which can be stimulated to grow and release. This corresponds with low estrogen hormone production causing a plethora of symptoms (the subject of another article) and occurs at an average age of 51.7 years in Australia with a range of 40-60 years.
As a general rule any symptoms of concern should be directed to your GP and appropriate treatment, discussion or referral may be arranged.
Dr Gary Swift is an Obstetrician & Gynaecologist who specialises in many of the treatments to manage period problems. He has been in private practice at Pindara Hospital since 2000 and is a highly qualified laparoscopic surgeon.
For more information give us a call at 07 5564 6017