Menstrual Disorders By Dr Joseph Ugboaja

This is a topic that has continued to pose challenges to the women and their physicians alike. We will start with 4 case illustrations to show the varied modes of presentation of menstrual disorders. It is important to discuss and understand menstrual disorders as they may associate with serious health conditions such as cancers. They may also, as we will see be associated with difficulty in achieving pregnancy. We will introduce the discussion by looking at some case scenarios.

Case 1: Mrs AO, a 40 year old secondary school teacher who presented to the gynaecology clinic with a 2 year history of heavy menstrual flow that has been progressive. The increased flow is associated with passage of clot and feeling of faintness following each menstrual episode. Although the menses has remain regular at 29-30 days, the duration of flow has increased to 7-9 days as against 4-5 days and she now uses 3 packs of pads as against 1 pad she normally used. Clinical evaluation at the hospital showed that she has uterine fibroids for which she had surgery.

Case 2: The second patient is Mrs BC, a 26 year old banker that presented with irregular menstrual periods. Sometimes, she will go up to 6 months without having her menstruation. She has been married for 3 years but has not been able to get pregnant. Although the duration and flow was normal, she t not predict when the next menses will come. Clinical evaluation showed that Mrs BC has anovulation secondary to polycystic Ovary Syndrome for she was commenced on drugs to stimulate ovulation and she subsequently conceived.

Case 3: Mrs TC, a 34 year old business woman who complained about a progressive reduction in her menses of 3 years duration. Her normal menstrual cycle was a regular 28 day cycle with 4 days duration of good flow. But following a surgery for uterine fibroid 4 years earlier, she noticed a progressive reduction in the volume and days of flow. At the point of her visit, she only menstruates for a day and may not even finish half pack of pads for each episode. After ultrasound and hysteroscopy, she was found to have uterine synaechia (adhesion bands) for which she had hysteroscopic adhesiolysis which restoration of normal menstrual flow.

Case 4: Mrs AE, A 70 year old retired farmer was brought to the hospital by the daughter with complaints of vaginal bleeding. Her last normal menses was about 20 years previously. There was an associated foul smelling vaginal discharge, pelvic pain and difficulty with urination. Clinical evaluation showed a fungating mass at the cervix. A biopsy was taken and histopathological evaluation showed carcinoma of the cervix.

Discussion
The above case scenarios depict some of the common presentation of abnormalities in menstruation in our environment. We will start the lesson by understanding the basics of menstruation and menstrual cycle. So what is menstruation and how does it come about?

At the beginning of each menstrual cycle in a woman, there is some form of ‘pilling up’ of the innermost part of the womb called the endometrium under the influence of increasing estrogen levels in the blood produced by the growing ovarian follicles. As the follicles grow bigger, they produce more estrogen, which in turn stimulates endometrial growth. This ‘endometrial ‘pilling up’ stops when the follicle ruptures during the process of ovulation. At this point, the resultant corpus luteum (formed from the remnants of the ruptured follicle) starts the secretion of another hormone called progesterone which causes the decidualization of the endometrium in readiness to receive an embryo, in case the released egg has been fertilized. If there is no implantation, the corpus luteum dies after a while and there will be shedding of the prepared endometrium as it is no longer supported by the hormones. This shedding of the endometrium is what is seen as the ‘menstrual flow’. From the above, it can be seen that normal menstrual flow is dependent on the interplay of hormones (estrogen and progesterone) produced by the ovaries as well as the integrity of the innermost lining of the womb (uterus)- the endometrium.
Therefore, disorders of menstruation can arise from poor ovarian regulation as well as local issues within the womb that either increases or reduces the surface area of the endometrium.
What do we mean by menstrual abnormalities/disorders?
Before discussing abnormalities, it will be good to understand the normal menstrual pattern. Normal menstrual cycle is cyclical (21-35days), predictable and lasts about 4-5 days with moderate flow (< 80mls with no clots). It may be associated with pain, but usually the pain subsides after the initial days. Abnormalities in menstruation, therefore can occur either in the length/regularity of cycle or duration and volume of flow. These deviations are caused by different gynaecological conditions and have varied health implications. We shall look at some of them a little bit in depth. Let’s start with the Disorders of volume/ duration of flow. The commonest abnormality here is Menorrhagia which refers to an increased volume of menstrual flow of > 80 mls or duration of more than 7 days. It is usually associated passage of clots, use of more pads and feeling of weakness or faintness following each menstrual episode. The condition is caused by lesions within the (uterus) womb which includes uterine fibroids, endometrial polyps, endometrial hyperplasia and cancer among other things. Uterine fibroid as we saw in the 1st case scenario (Mrs AO) is the commonest cause of menorrhagia in our environment and must be excluded in all women who have menorrhagia. The other abnormality in volume/duration of flow is Hypomenorrhea which refers to a situation of reduced menstrual flow which is usually progressive and may lead to entire ceasation of menses in some cases. The condition is most commonly caused by intrauterine adhesions as was seen in the 3rd case scenario (Mrs TC). Intrauterine adhesions are usually caused by some surgeries or infections that involved the lining of the womb causing some form of scarring that reduces the surface area of endometrium for shedding.
The next form of abnormalities is disorders of cycle length or regularity. The normal menstrual pattern is cyclical and predictable and comes every 21-35 days and therefore, menstrual cycle that comes outside this range and cannot be predicted is referred to as an irregular menstrual cycle. It is important to note that a menstrual cycle that varies within this range does not qualify as irregular cycle.
The commonest form of disorder under this category is Oligomenorrhea which refers to a cycle length of more than 35 days but less than 6 months. Sometimes, a woman can go as far as 6 months without having her menstruation. This condition is usually associated with absence of ovulation (anovulation) as seen in the 2nd case scenario (Mrs BC). The commonest cause of anovulation is polycystic ovary syndrome (PCOS), which must be ruled out in all case of infertility associated with irregular cycle. PCOS responds well to ovulation induction agents and procedures. The less common condition is Polymenorrhea which refers to cycle lengths shorter than 21 days. It usually suggests early period of ovarian failure as may be seen in the early perimenopausal phase.
The other abnormalities worth mentioning are intermenstrual bleeding and postmenopausal bleeding. Intermenstrual bleeding refers to vaginal bleeding or spotting that occurs in between normal menstruation. This indicates some lesions either in the womb (uterus) or the mouth of the womb (cervix) which may include polyps, cancers etc. Any woman who complains of intermenstrual bleeding must be assessed to rule out these lesions. Postmenopausal bleeding refers to vaginal bleeding after the onset of menopause and it is ominous.(we shall discuss menopause at a later class). At menopause, there is complete ceasation of ovarian function and therefore, menstruation. Therefore, any vaginal bleeding occurring at that phase of life is abnormal and serious and must be reviewed as most of them will indicate the presence of cancer of the genital tract, notably cancer of the cervix. This is demonstrated in the 4th case scenario (Mrs AE).
What do I do when I notice abnormal menstruation?
What you need to do is to present to a doctor preferably a Gynaecologist for consultation. This is important in order to find out the cause of the abnormal bleeding (as there are many gynaecological conditions that can present with abnormal menstruation) and also to manage you properly.
How does the doctor know the cause of my abnormal menstruation?
At presentation, the doctor will ask you some questions bordering on your symptoms. These questions will seek to define your menstrual history both presently and prior to the problems so as to define the change or alteration. Depending on the main symptom, other questions will be asked to pinpoint the likely cause. This will be followed by physical examination to further elucidate the possible cause of the problem. The examination will include general physical examination and abdominal examination. The physical examination will be concluded with a bimanual pelvic examination.
After the examination, some ancillary investigations will be done and will normally include ultrasound scan, PCV(to determine your blood level), urinalysis to test for glucose and protein in urine and sometimes hysteroscopy.
How will I be treated if I have abnormal menstruation?
The treatment for abnormal menstruation is dependent on the cause. As we have seen from the 4 case scenarios, the causes are varied. Uterine fibroids, endometrial polyps, uterine adhesions are all treated by surgery with restoration of normal menses. Irregular menstruation which usually occurs within the context of infertility is treated by ovulation induction. In summary, the treatment is according to the cause.
Conclusion
Abnormal menstruation or uterine bleeding is a serious gynaecological condition that requires expert evaluation and management. Women experiencing such symptoms need to visit a physician, preferably a gynaecologist for proper evaluation and management.
I wish you a fruitful and wonderful week ahead. See you next week!

ABOUT THE AUTHOR
Dr Ugboaja Joseph is an Obstetrician & Gynaecologist by training and currently Chairman, Medical Advisory Committee of Nnamdi Azikiwe University Teaching Hospital, Nnewi and Director, Clinical services, Research & Training as well as chairman, Taskforce on Covid-19 of the hospital. He holds Postgraduate fellowships in Obstetrics & Gynaecology of National Postgraduate Medical College, Nigeria (FMCOG), West Africa College of Surgeons (FWACS) and International College of Surgeons (FICS). He joined the Hospital management in 2014 as the deputy CMAC, a position he held for 4 years. He was subsequently appointed the CMAC in 2017 for the initial tenure of 2 years which ended in 2019. He was reappointed in 2019 for the final tenure of 2 years as the CMAC of the hospital. His tenure as the CMAC of the hospital brought a lot of innovative changes and improvement in services under the leadership of the CMD, Prof AO Igwegbe. These include the formation of the NAUTH Research Society; the Quality improvement committee; the Clinicopathologic series; the Cancer Society; Laboratory Quality Management system as well as the introduction of the Annual NAUTH Scientific Conferences.
Dr Ugboaja has attended several workshops, trainings and conferences on Strategic leadership and healthcare management including those organized by the administrative college of Nigeria (ASCON). He is a Associate of the Institute of Management Consultants of Nigeria.(IMCON). He believes in transformational leadership and also believes, strongly that leaders should be altruistic, inspiring, motivational, transparent and accountable.