Menstrual disorders: Types, Causes, Symptoms, Risk factors and Prevention

Menstrual disorders definition

Menstrual disorders are the problems related to a woman's normal menstrual cycle that are found to be associated with physical or emotional issues that interfere with the regular menstrual cycle, causing pain, unusually heavy or light bleeding, and missed periods.

The menstrual cycle may be defined by its length, regularity, frequency, and pattern of menstrual blood loss. Irregularity in the pattern and amount of vaginal bleeding of uterine origin often indicates a sign of pathology or an abnormality in the function of the hypothalamic, pituitary, and ovarian axis.

Menstruation is an essential natural phenomenon for every female and occurs throughout the reproductive years, starting from adolescence to menopausal age. The average menstrual cycle lasts about five days. It includes the regular shedding of the endometrium every 28 + 7 days in response to female hormones, with an average blood loss per cycle, usually about 60 milliliters.

Regular menstrual cycle repeats once in every 21–35 days with duration of 2–8 days. Any disturbances in the pattern of menstruation may eventually affect the female physical and mental health (psychological health), which in turn hampers the quality of life.

Types of menstrual disorders

Types of menstrual disorders may range from no periods to heavy, painful periods. There may be variations in menstrual patterns, but in general, females should be concerned when fewer than 21 days or more than three months apart. If they last more than ten days, such conditions may indicate ovulation problems and other common medical conditions. The following are some of the common menstrual disorders:

• Amenorrhea
• Primary amenorrhea
• Secondary amenorrhea
• Abnormal uterine bleeding
• Oligomenorrhea
• Polymenorrhoea
• Hypermenorrhea
• Hypomenorrhea
• Metrorrhagia
• Menometrorrhagia
• Perimenopausal bleeding
• Dysmenorrhea
• Primary dysmenorrhea
• Secondary dysmenorrhea
• Premenstrual syndrome
  

Amenorrhea (Absence of menstruation)

Having no menstrual bleeding for 90 days or longer is called amenorrhea; it can be classified as primary and secondary according to the onset:

• Primary amenorrhea: The onset of menstruation in females, known as menarche, usually occurs at the age of 12.5. Primary amenorrhea refers to the absence of menses (menarche) initiation by age 16.
• Secondary amenorrhea: It refers to the discontinuation of menses (menstrual bleeding) after the onset of menarche.

In this condition, the woman has normal periods, but they suddenly stop for three months or longer.

Abnormal uterine bleeding

Menorrhagia or abnormal uterine bleeding refers to prolonged or heavy bleeding that lasts more than seven days where the duration of periods is>8 days (> five pads/ day fully soaked) and may caused by uterus problems or hormone problems.

The International Federation of Gynaecology and Obstetrics (FIGO) and the American Congress of Obstetricians-Gynaecologists have endorsed PALM-COEIN to classify abnormal uterine bleeding (AUB) based on structural and non-structural causes. This system has replaced the following traditional terms, which are not commonly used now.

• Oligomenorrhea: Inconsistent and irregular menstrual blood flow in a woman. If a female reports four to nine menstrual cycles in a year or a length of menstrual period greater than 35 days, then it is termed oligomenorrhea.
  
• Metrorrhagia: It refers to the increased duration of menstrual flow after seven days and continues with the cycle.
  
• Menometrorrhagia: It refers to prolonged bleeding that occurs at irregular intervals.
  
• Polymenorrhoea: It is a form of abnormal uterine bleeding, where the cycle repeats about once every eight days (> five pads/ day fully soaked).
  
• Hypomenorrhea: It refers to regular menstruation occurring at normal intervals but with abnormally low bleeding. (Duration of periods <2 days and slight loss of blood < pad/day).
  
• Hypermenorrhea: It refers to regular menstruation occurring at normal intervals but with abnormally excessive bleeding, over 90 ml.
  
• Perimenopausal bleeding: Perimenopause is a natural process of a woman caused when the ovaries gradually stop working. It is the stage leading to the last menstrual period called menopause.  During this phase, ovaries get smaller and make less oestrogen, and there will changes in the menstrual cycle and hormone levels.

For most women, menopause may occur between 45 and 55 years of age and vary from person to person. Perimenopause lasts 4 to 6 years on average. However, for some people, it may last up to 10 years before menopause, and for others, only a year.

Dysmenorrhea (Painful cramps)

This condition refers to the severe, frequent cramping or pain during menstruation that is characterized by crampy lower abdominal pain that can spread to the lower back and thighs and may be associated with vomiting, nausea, and diarrhoea. Dysmenorrhea is usually classified as primary or secondary.

• Primary dysmenorrhea: It is usually defined as cramping pain in the female lower abdomen

        occurring at the onset of the menstrual cycle in the absence of any identifiable pelvic disease.

• Secondary dysmenorrhea: It is usually referring to painful periods (menses) resulting from pelvic pathology such as endometriosis.
  

Premenstrual syndrome

Premenstrual syndrome (PMS) is an occurrence of physical and physiological changes just before the onset of menstruation or a combination of symptoms that many women get about a week or two before their period.

• Generally, symptoms occur in the 1-14 days before the beginning of the menstruation.
• After the start of menstrual bleeding, the woman feels well.
• The combination of changes occurs regularly, frequently, or in every cycle.
• Premenstrual syndrome causes the woman distress and may cause other problems.
  

Amenorrhea is not life-threatening; however, the loss of the menstrual cycle has been associated with a high risk of hip and wrist fractures, with a 1.5-3% prevalence of amenorrhea in the female population during their reproductive years. Whereas primary amenorrhea is relatively uncommon, secondary amenorrhea is frequent in women of reproductive age.

The prevalence of Abnormal uterine bleeding (AUB) is reported to be 17.9% in India. Any woman of reproductive age may develop AUB. However, AUB usually occurs at the beginning and end of the reproductive years.

Up to 1/3rd of women may experience abnormal uterine bleeding in their lives, with irregularities most commonly occurring at menarche and perimenopause, where 20% of abnormal uterine bleeding cases happen in adolescents and as many as 50% of women aged 40-50 experience AUB. Of these cases of AUB, about 90% are due to menstrual periods when ovulation does not occur.

The prevalence of dysmenorrhea is 80% in adolescents and may vary between 16% and 91% in individuals of reproductive age, with severe pain observed in 2% to 29% of individuals. Additionally, dysmenorrhea can cause up to 12% of monthly absences from work or school.

The prevalence of premenstrual syndrome (PMS) has been reported as 20 to 32% in premenopausal women and 30-40% in the reproductive female population. The estimated prevalence of PMS in India is 43%, as most studies have been done on adolescent and college-going females.

A study revealed a high prevalence of heavy menstrual bleeding in perimenopausal age, with the highest occurrence between the ages of 45-50 years and ranging from 5% to 70%. Its association with abnormal uterine bleeding is not clear.

Causes of menstrual disorders

It is important to understand the menstrual cycle to recognize irregularities that may arise due to various factors such as hormonal fluctuations, anatomical abnormalities, lifestyle factors, and underlying health conditions. The following are the causes of menstrual irregularities according to their types:

Amenorrhea

• Primary amenorrhea
• Chromosomal or genetic abnormalities
• Problems with the hypothalamus or pituitary gland in the brain
• Secondary amenorrhea
• Natural causes
• Medications and therapies
• Hypothalamic amenorrhea
• Gynaecological conditions
• Thyroid problems
• Pituitary tumours

Abnormal uterine bleeding

• PALM (structural causes)
• Polyp
• Adenomyosis
• Leiomyoma
• Submucosal myomaOther myoma
• Malignancy and hyperplasia
• COEIN (non-structural causes)
• Coagulopathy
• Ovulatory dysfunction
• Endometrial
• Iatrogenic
• Not yet classified

Dysmenorrhea

• Primary dysmenorrhea
• Chemical imbalances
• Secondary dysmenorrhea
• Medical conditions

Premenstrual syndrome

• Hormone fluctuations
• Genetics 
• Changes in chemicals in the brain
• Calcium or magnesium deficiency
  

Amenorrhea (Absence of menstruation)

Amenorrhea may happen as a natural part of life, such as pregnancy or breastfeeding, and sometimes indicates a sign of another health problem rather than a disease, including polycystic ovarian syndrome (PCOS) or infertility. The below-mentioned are the some of the common causes of primary and secondary amenorrhea’s:

Causes of primary amenorrhea:

Primary amenorrhea (failure of menstrual periods to occur by age 16) may happen due to two leading causes:

• Chromosomal or genetic abnormalities: These abnormalities can stop the natural functioning of the ovaries. 
• Problems with the hypothalamus or pituitary gland in the brain: These problems in the women's brain interrupt the normal balance of hormones that can prevent periods from starting. Conditions such as eating disorders, extreme physical or psychological stress, excessive exercise, or a combination of these factors also disrupt the normal functioning of the pituitary gland or hypothalamus, delaying the onset of menstruation.

Rarely, physical problems such as missing reproductive organs or blockage of reproductive                        passageways lead to primary amenorrhea. Missing portions of the female reproductive tract may cause disruptions in the endocrine system and merge with hypothalamic or pituitary issues to prevent menstruation.

Causes of secondary amenorrhea:

Secondary amenorrhea (missing menstrual periods for three months in a row or not having periods for at least six months after menstruating normally) may result from different causes, such as:

• Natural causes
• Pregnancy (most common cause)
• Breastfeeding 
• Menopause
• Medications and therapies: Some specific medications and therapies may cause a woman to stop having her period. This can include the drugs that prevent birth, including injectable contraceptives and hormonal intrauterine devices. Additionally, some medications such as antidepressants and antihypertensives, as well as radiation and chemotherapy treatments for hematologic cancer (including bone marrow, blood, and lymph nodes) and gynaecologic cancer, can destroy the cells that produce oestrogen and eggs in the ovaries.
• Hypothalamic amenorrhea: This condition happens due to the stoppage or slow release of the hormone that starts the menstrual cycle by the hypothalamus.
• Gynaecological conditions:  Especially, those that direct to or result from an imbalance of hormones may also have secondary amenorrhea as a major symptom.
• Polycystic ovary syndrome (PCOS)
• Fragile X-associated primary ovarian insufficiency (FXPOI)
• Thyroid problems: The thyroid gland produces certain hormones that control a woman's metabolism and play a role in puberty and menstruation. Underactive (hypothyroidism) or overactive (hyperthyroidism) can cause menstrual abnormalities, including amenorrhea.
• Pituitary tumours: The pituitary gland controls hormone production, affecting many bodily functions, including the reproductive cycle and metabolism. Usually, most of the tumours on the pituitary gland are benign (noncancerous). However, they interfere with the body's hormonal regulation of menstruation.
  

Abnormal uterine bleeding

In nonpregnant women of reproductive age, causes of abnormal uterine bleeding may be classified as structural or non-structural to help identify the cause and to guide treatment. The PALM-COEIN classification system may be used for the structural (PALM) and non-structural (COEIN) causes of abnormal bleeding.

PALM-COEIN classification system

PALM (structural causes): 

• Polyp: They are the abnormal growths within the lining of the uterus
• Adenomyosis: This is a gynaecologic condition characterized by endometrial tissue (tissue that lines the uterus) that grows into the uterus wall (myometrium).
• Leiomyoma (uterine fibroid): These benign (non-cancerous) tumours originate in smooth muscle cells of the myometrium.
• Malignancy: Malignancy refers to presence of the cancerous cells

COEIN (non-structural causes):

• Coagulopathy: It is a bleeding disorder that is characterized by the inability of blood to coagulate or clot
• Ovulatory dysfunction: Irregular, infrequent (less than nine per year) menstrual periods or absent ovulation affecting menstrual cycles 
• Endometrial: Abnormalities or irregularities in the endometrial lining of the uterus.
• Iatrogenic: Menstrual disorders induced unintentionally by a health care professional (physician) or surgeon or by medical treatment or diagnostic procedures.
• Not yet classified: Abnormal uterine bleeding can occur for reasons that do not fit into any specified categories.

Abnormal uterine bleeding due to ovulatory dysfunction (AUB-O) is the common cause of non-structural abnormal bleeding. Causes of ovulatory dysfunction include PCOS, pituitary disorders, premature menopause (primary ovarian insufficiency), poor nutrition, extreme physical or emotional stress, and changes that occur around puberty or during the years before menopause occurs and the one year after perimenopause.

Perimenopause bleeding

A variety of conditions may cause abnormal bleeding in women between adolescence and menopause (called perimenopausal women). Abrupt changes in the levels of hormones at the time of ovulation may cause vaginal spotting or small amounts of bleeding.

Unpredictable or erratic bleeding can also occur in perimenopausal women who use the methods to prevent birth. Some women do not ovulate regularly and may experience unpredictable heavy or light vaginal bleeding. Some women who ovulate regularly experience bleeding between periods and excessive loss of blood during their menstruation. The most common causes of such bleeding are uterine adenomyosis, uterine fibroids, or endometrial polyps.

Other causes of AUB in premenopausal women include:

• Pregnancy
• Infection or inflammation of the endometrium or cervix
• Cancer or precancer of the endometrium or cervix
• Clotting disorders such as the use of anticoagulant medications, platelet abnormalities, or problems with clotting factors
• Medical illnesses include hypothyroidism, liver disease, or chronic renal disease.

Dysmenorrhea

Premenstrual syndrome

The cause of premenstrual syndrome is not clear. It seems to be associated with hormone fluctuations in the women's body. Changes in chemicals in the brain may also play a role in causing PMS.

• Hormone fluctuations: Progesterone and oestrogen levels are not steady during the menstrual cycle and may affect other hormones, including aldosterone (which regulates salt and water balance). Excess aldosterone may cause bloating and fluid retention. Some females are more sensitive to the hormonal fluctuations. 
• Genetics: Some women may have a genetic makeup that makes them more vulnerable to premenstrual syndrome.
  
• Changes in chemicals in the brain: Serotonin levels may tend to be lower in females with premenstrual syndrome. Serotonin is a chemical substance that helps nerve cells communicate and is thought to help regulate the mood of woman.
• Calcium or magnesium deficiency: A deficiency of calcium or magnesium may contribute to PMS.

The cause of the PMS may involve many factors including genetics, genomics, developmental exposures or comorbidities; however, the exact mechanism of this condition is poorly understood.

Symptoms of menstrual disorders

Risk factors of menstrual disorders

Menstrual disorders are a range of conditions that affect a woman's menstrual cycle. They can cause irregular periods, heavy bleeding, painful periods, or absent periods. Here are some risk factors for menstrual disorders:

• Hormonal Imbalances: Hormones play a vital role in regulating the menstrual cycle. Imbalances in estrogen, progesterone, and other hormones can disrupt the menstrual cycle and lead to menstrual disorders.
• Weight: Being significantly underweight (low weight) or overweight can affect hormone levels and ovulation, leading to irregular periods or amenorrhea (absence of periods).
• Diet and Exercise: Poor diet or Unhealthy diets and lack of exercise can contribute to hormonal imbalances and weight issues, both of which can increase the risk of menstrual disorders.
• Chronic Medical Conditions: Certain medical conditions, such as polycystic ovary syndrome (PCOS), endometriosis, and uterine fibroids, can all contribute to menstrual disorders.
• Medications: Some of the medications, such as birth control pills, certain antidepressants, and blood thinners, can affect menstrual regularity or bleeding patterns.
• Stress: Chronic stress can disrupt hormone regulation and lead to irregular periods or amenorrhea.
• Age: Periods are often irregular in the first few years after menstruation begins (menarche) and in the years leading up to menopause.

The following are some of the predisposing factors that increases the risk of menstrual disorders according to their types.

• Amenorrhea: Risk factors for amenorrhea include excessive exercise, eating disorders, obesity, a family history of amenorrhea or early menopause, and genetic changes.

• Abnormal uterine bleeding: AUB may occur in different conditions. It may occur in pregnancy, secondary to haemostatic disorders, pathology of the genital tract, infections, systematic diseases, endocrine disturbance, obesity, stress, and extreme exercise, may account for all disrupted normal ovulatory function, and may be considered as preventable risk factors for AUB.

• Perimenopausal bleeding: Perimenopausal woman may experience various menstrual irregularities during their period due to variations in hormones, which are physiological or due to pathological changes. In perimenopause, AUB is often part of normal physiology, and there may be some bothersome signs and symptoms. Noncancerous findings such as endometrial polyps and myomas increase with women’s age, leading to more abnormal uterine bleeding in the perimenopause.

      In perimenopause women, ovulation is not regular, and insufficient or absent progesterone may                lead to premature and irregular shedding of the endometrium. Continuous stimulation of oestrogen        in the endometrium results in heavy and long-lasting bleeding. In women with less oestrogen, there          is no stimulation of the endometrium, leading to amenorrhea. Although the AUB is part of normal              physiology in perimenopausal women, it is not always the case and should not be assumed. In rare            cases, bleeding abnormalities are not normal and may indicate signs of cancer.

• Dysmenorrhea: Associated risk factors for dysmenorrhea may include age (commonly) up to 30 years, menarche at a younger age, smoking, longer and heavier menstrual cycles, nulliparity, and previous caesarean section with incomplete scar healing. Other risk factors for dysmenorrhea include heavy menstrual loss, irregular menstrual cycles, sexual abuse, menarche before 12 years of age, sterilization, and clinically suspected pelvic inflammatory disease.

• Premenstrual syndrome: As per many researchers, it was found that interpersonal relationship stress, biological factors including genetics, length of menses and pregnancies, and lifestyle exposures such as dietary habits, physical exercise, or stimulants may be potential risk factors for premenstrual syndrome.
  

Complications of menstrual disorders

Menstrual disorders can cause a range of physical and emotional complications that can significantly impact a woman's quality of life. Here's a breakdown of some potential complications of menstrual disorders:

• Anemia: This is a common complication of heavy menstrual bleeding (menorrhagia). It happens when the body doesn't have enough red blood cells to carry oxygen effectively. Symptoms include fatigue, weakness, shortness of breath, and pale skin.
• Iron Deficiency: Heavy bleeding can drain iron stores in the body, that can lead to iron deficiency anemia. This can worsen fatigue and other symptoms of anemia.
• Infertility: Some menstrual disorders, such as PCOS and endometriosis, can affect ovulation or implantation, making it difficult to get pregnant.
• Increased Risk of Endometrial Cancer: Although uncommon, prolonged periods of irregular bleeding or anovulation (lack of ovulation) can increase the risk of endometrial cancer, a cancer of the uterine lining.
• Pelvic Pain: Endometriosis, a condition where endometrial tissue grows outside the uterus, can cause severe pelvic pain during menstruation and throughout the cycle. Uterine fibroids, benign tumors in the uterus, can also cause pain and pressure.
• Mental Health Concerns: Irregular periods, heavy bleeding, and chronic pain can all contribute to emotional distress, anxiety, and depression. Premenstrual dysphoric disorder (PMDD), a severe form of PMS, can significantly impact mood and daily functioning.
• Impact on Daily Life: Menstrual disorders can disrupt daily activities and routines due to pain, fatigue, and unpredictable bleeding patterns. This can affect work, school, social activities, and overall well-being.

The following are some complications that are commonly seen in the menstrual disorders as per their type.

• Amenorrhea: Amenorrhea is not a dangerous condition; however, the loss of the menstrual cycle has been associated with a high risk of hip and wrist fractures, bone thinning, declining fertility, and premature ovarian failure. Other complications of this condition include the risk of cardiovascular diseases such as high blood pressure, risk of osteoporosis, aging, and menopause. Women with amenorrhea have low oestrogen resulting from impaired hypothalamic–pituitary–ovarian axis, leading to anovulation and hypoestrogenism.

• Abnormal uterine bleeding: The complications of long-term abnormal uterine bleeding may include infertility, anaemia, and endometrial cancer. Acute abnormal uterine bleeding hypotension, shock, and even death may occur if prompt treatment and supportive care are not initiated.

• Premenstrual syndrome: Complications of premenstrual syndrome may include behavioural problems and school absence and are also associated with an increased risk of bulimia nervosa (eating disorder and a serious mental illness) and future hypertension.

• Dysmenorrhea: If the dysmenorrhea is untreated, it may lead to hyperalgesia priming (an injury that induces a chronic pain), which increases the risk of chronic pelvic pain.

Early diagnosis and treatment of menstrual disorders is crucial to prevent complications and improve a woman's quality of life.

Diagnosis of menstrual disorders

The diagnosis of menstrual disorders may vary based on underlying conditions. It includes the following:

Amenorrhea

It may occur due to several different conditions. A systematic assessment, including a detailed history, physical examination, and laboratory evaluation of selected serum hormone levels, may usually identify the underlying cause.

• Primary amenorrhea: Suppose the patient is older than 16 and has never had a period. In that case, the gynaecologist will do a thorough medical history and physical exam, such as a pelvic exam, to check if the patient is experiencing other signs of puberty. Depending on the findings, other examinations may be ordered to determine the cause of primary amenorrhea.
• Secondary amenorrhea: If the patient is sexually active, the gynaecologist will likely order a pregnancy test and will also recommends a complete physical exam, including a pelvic examination. Contacting the gynaecologist as soon as possible is recommended if the patient doesn’t get a period.

Other tests for amenorrhea include:

• Thyroid function test
• Ovary function test
• Androgen test
• Hormone challenge test
• Chromosome evaluation
• Ultrasound 
• Computed tomography
• Magnetic resonance imaging (MRI)
• Hysteroscopy
  

Abnormal uterine bleeding

Investigations of abnormal uterine bleeding include pregnancy testing, if indicated, and a CBC (complete blood count) with ferritin. Coagulopathy might be ruled out when menorrhagia occurs at the beginning of menarche, and there is no obvious pelvic disease.

Additional tests might be done based on clinical suspicion, such as:

Other examinations such as ultrasonography also suggested to look for ovarian or uterine disease and endometrial biopsy. If possible, transvaginal ultrasound may perform on days 4 to 6 of the menstrual cycle. In women who are experiencing premenopause, there is no known correlation between endometrial thickness seen on the imaging scan and endometrial disease.

Perimenopausal bleeding

The diagnostic examination of abnormal uterine bleeding in perimenopausal women includes clinical examination (bimanual and speculum), PAP smear, and ultrasonography. Both hysteroscopy and ultrasonography are complementary in the case of AUB, and simultaneous biopsy confirmed the diagnosis. Hysteroscopy may be reserved for the suspicious cases of endometrial pathology on ultrasound and all instances of metrorrhagia, menometrorrhagia, and postmenopausal bleeding.

Dysmenorrhea

To diagnose dysmenorrhea, a gynaecologist evaluates the medical history and does a complete physical and pelvic exam. Other tests may include:

• Ultrasound
• Magnetic resonance imaging (MRI)
• Laparoscopy
• Hysteroscopy

Premenstrual syndrome

There is no particular test for PMS or PMDD. To be diagnosed with PMS or PMDD, a female must have physical symptoms, including breast tenderness, bloating, and mood changes such as sadness and crying. These symptoms must happen before the menstrual period (and disappear after the onset of the period).

Blood tests are not needed for PMS diagnosis. However, a blood count may be recommended to screen for other medical conditions that cause fatigue, such as anaemia. Thyroid function tests may detect hypothyroidism or hyperthyroidism, both of which have similar symptoms to PMS and PMDD. A gynaecologist may request to record the symptoms daily for two complete menstrual cycles to diagnose the symptoms of PMS.

Treatment of menstrual disorders

Management of menstrual disorders depends on several factors and varies as per the condition that a patient is facing; the following are the treatment methods that might be recommended for the different menstrual irregularities:

Amenorrhea

The treatment for amenorrhea varies depending on the underlying causes:

• Health status 
• Goals of the woman

If lifestyle factors cause primary or secondary amenorrhea, a gynaecologist may suggest changes in the areas below:

• Weight
• Stress
• Level of physical activity

For primary amenorrhea, based on the age and results of the ovary function test, healthcare providers may recommend watchful waiting. Primary amenorrhea, caused by genetic or chromosomal problems, may need surgery.

Secondary amenorrhea treatment depends on the cause and may include medically or surgically or a combination of the two.

Common medical treatments for this condition include treatments that control the birth or other types of hormonal medicines, medications to help relieve the symptoms of PCOS, and oestrogen replacement therapy.

Abnormal uterine bleeding

Based on the PALM–COEIN acronym for cases of chronic AUB, specific treatment options for some categories are listed below:

• Polyps will be treated through surgical resection.
• Adenomyosis is treated via hysterectomy, but rarely adenomyomectomy is recommended.
• Fibroids (Leiomyomas) can be treated medically or surgically depending on the patient’s desire for fertility, medical comorbidities, pressure symptoms, and distortion of the uterine cavity.
• Medical management options include an IUD (intrauterine device), GnRH agonists, and NSAIDs. Surgical options include endometrial ablation or hysterectomy and uterine artery embolization.
• Malignancy or hyperplasia can be treated with surgery or palliative therapy (radiotherapy).
• Coagulopathies leading to abnormal uterine bleeding can be treated with antifibrinolytics or antidiuretic hormones.
• Ovulatory dysfunction will be treated through lifestyle modification in women with PCOS, obesity, or other conditions.
• Endocrine disorders are corrected using appropriate medications. However, endometrial disorders have no specific therapy, as the mechanisms are not clearly understood.
• Iatrogenic causes of abnormal uterine bleeding may be managed based on the offending drug or drugs.
• Antibiotic is used to treat endometriosis and uterine arteriovenous malformation (AVM) with embolization.

Dysmenorrhea

The following are the treatment options for period pain:

• Prostaglandin inhibitors (NSAIDS)
• Oral contraceptives (ovulation inhibitors)
• Hormonal treatments
• Vitamin supplements
• Diet changes
• Regular exercise releases the endorphins (natural chemicals) that relieve pain
• Endometrial resection (a procedure to remove the lining of the uterus)
• Endometrial ablation (a procedure used to damage the uterus lining)
• Hysterectomy (surgical removal of the uterus).

Premenstrual syndrome

Conservative treatments may be recommended first for PMS patients, including regular exercise, relaxation techniques, and vitamin and mineral supplementation. These treatments help relieve symptoms in some women and have few or no side effects. If these treatments do not provide sufficient relief, prescription medication may be considered a second option. The best medications for PMS or PMDD are selective serotonin reuptake inhibitors (SSRIs).

Prevention of menstrual disorders

Menstruation is a natural phenomenon in female reproduction. It is not possible to avoid it; however, irregularities can be prevented by following some of the preventive measures to avoid the painful symptoms:

• Maintaining a healthy lifestyle: Increased BMI, short sleep, sedentary lifecycle and vigorous physical activity can contribute to the risk of menstrual disorders. Maintaining the following healthy lifestyle modifications may help the woman to avoid the menstrual disorders.
• Ensure adequate rest and sleep 
• Following good dietary habits
• Avoiding junk food and poor energy intake
• Avoid smoking
• Limit the alcohol consumption
• Regular screening: It is recommended to consult a gynaecologist regularly to evaluate the reproductive health of women and to diagnose any abnormalities related to menstruation and other reproductive problems, which helps to give the treatment promptly.
• Managing other conditions: Other medical conditions such as diabetes, anaemia, infections, and tumours must be managed to decrease the risk of menstrual disorders.
• Following prescribed drugs: Regularly taking the medicines as prescribed by gynaecologists for underlying diseases such as PCOS, endometriosis, fibroids, and thyroid disorders may help to decrease the risk of menstrual disorders.
  

Frequently Asked Questions (FAQs) on Menstrual disorders

How do I know if my cycle is normal?

Normal menstrual cycle ranges from 21 to 35 days long, with an average of 28 days. Menstrual periods usually last from 5 to 7 days. Any changes in the normal menstrual cycle may be a cause for concern. A change in the cycle could be a period more often or less often, no period at all, heavier or lighter bleeding than usual, or spotting between periods.

How is menstrual disorder treated?

Treatments for menstrual disorders often vary depending on the type of irregularity in the menstruation and certain lifestyle factors, including that the woman is desiring to get to conceive.

Menstrual irregularities occur due to an ovulatory bleeding (absent periods, infrequent periods, and irregular periods), treated by using cyclic progestin, oral contraceptives, and management of an underlying disorder that is inducing the menstrual problem, including counselling and nutritional therapy for an eating disorder.

Treatment for menstrual disorders that are due to ovulatory bleeding (heavy or prolonged menstrual bleeding), including insertion of a hormone-releasing intrauterine device (IUD), use of various medications or (NSAIDS) non-steroidal anti-inflammatory medications. If the cause of menstrual disorder is structural or if medical management is not effective, then the surgical removal of polyps or uterine fibroids, hysterectomy, endometrial ablation, and uterine artery embolization may be considered.

Can an endocrinologist help with menstrual disorders?

As per the available evidence in research studies, oligomenorrhea (cycles longer than 35 days) is the most common menstrual disturbance among endocrine disorders that the endocrinologist can help.

However, for conditions related to menstruation, the gynaecologist examines the women and gives appropriate treatment.

When is bleeding is not normal?

Heavy bleeding is not considered normal and may need treatment if the patient experiences:

• The period lasts more than seven days, 

• Feeling dizzy or faint,

• Family history of blood clotting problems, 

• Changing the pad more than once every 1 to 2 hours.

What should I know about bleeding disorders?

Bleeding disorders are problems with how a person's blood clots. In girls and women, heavy periods do not automatically mean that a person has a bleeding disorder. The most common bleeding disorder is Von Willebrand disease. It runs throughs family. If the patient has a problem with blood clotting, it is recommended to talk with healthcare professions for screening of bleeding disorder.

What causes menstrual irregularities?

Menstrual irregularities can be caused by a variety of conditions, such as hormonal imbalances, pregnancy, infections, diseases, trauma, and certain medications.

How many women are affected by menstrual irregularities?

Menstrual irregularities occur in an estimated 14% to 25% of women of reproductive age. Estimates of the number of women with menstrual disorders may differ by the cause or nature of the irregularity. For instance, if a woman experiences severe cramps, she might be considered on the list of women with endometriosis rather than on the list of women with menstrual irregularities.

How do healthcare professionals diagnose menstrual irregularities?

Diagnosis of menstrual irregularities depends on the type of condition that a female is experiencing. A gynaecologist diagnoses menstrual disorders using a combination of multiple tests, including medical history, blood tests, physical examination, endometrial biopsy, hysteroscopy, saline infusion sonohysterography, ultrasonography, etc.

What are the symptoms of menstruation?

The main sign of menstruation is bleeding from the vagina. Other symptoms including menstrual cramps in abdomen or pelvis, lower back pain, bloating and sore breasts, headache, fatigue, mood swings, and irritability.

Department of Gynecology