Many anxious women have come to me over the years. Usually it is because their teenage daughters fail to start menstruating, bleed continuously once they start, have excessive bleeding, or have periods that appear unexpectedly off schedule. Sometimes it is for themselves, because after many years of clockwork menstruation everything suddenly goes haywire.
Menarche occurs at a certain age (between 10-17 years), when the pituitary gland in the brain releases FSH (follicle stimulating hormone). This is followed by the release of LH (luteinizing hormone). These hormones act on the ovary producing the hormones oestrogen and progesterone and also releasing an egg (ovum). If pregnancy does not occur, then the egg released by the ovary dies, hormone levels drop and bleeding occurs. This cycle repeats regularly. Menstruation stops (menopause) when the ovary stops responding to these pituitary hormones.
The length of a cycle (the first day of bleeding) may be anywhere from 21 days to 35 days. The duration of the bleeding may be from 2-7 days. Each woman is different, and what is normal for one may be quite different from another. The important thing is that the cycles must be consistent, regular and typical for that person. At menarche the immaturity of the pituitary gland can make periods irregular. This usually settles down in two to three years. Near menopause, the ovaries become unresponsive to FSH and LH. The cycles become scanty, infrequent, irregular and finally cease altogether.
Ovulation sometimes does not occur (anovulation). The periods become infrequent and irregular though the flow may be light or heavy. This can be normal at menarche and menopause. PCOS (polycystic ovarian syndrome) remains one of the commonest causes affecting 10-20 per cent of the women of child-bearing age. At other times it may be because the pituitary gland is releasing excess amounts of a hormone called prolactin. It is also affected by a lack or excess of thyroid hormone, uncontrolled diabetes, eating disorders resulting in a BMI (weight divided by height in meter squared) less than 18 or more than 30 and some medications (drugs for epilepsy and psychosis).
If ovulation occurs regularly, the cycles are usually on time, but the bleeding can be prolonged and excessive. This reduces the days between cycles. It can occur in menarche because of hereditary bleeding disorders - the commonest of which is von Willebrand disease - a genetic deficiency in some other clotting factor, platelet disorders, leukemia or advanced liver disease. In older women, it is more likely to be due to structural abnormalities in the uterus like fibroids and polyps.
The reason for abnormal bleeding can usually be determined with a general physical examination, blood tests, and ultrasound evaluations. Hysteroscopy (looking inside the uterus) or laproscopy may also be required.
If there is a specific treatable cause for the bleeding then tackling that will cure the problem. More often, a few months of hormonal treatment will work. Surgical removal of fibroids or polyps, or ablation of the uterine cavity or embolisation of the uterine artery supplying the fibroid can also be done.
Dr Gita Mathai is a paediatrician with a family practice at Vellore and author of Staying Healthy in Modern India. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in
