Co-authored and medically reviewed by Dr. Bolarinwa E.S
For most females of childbearing age, a common source of worry is irregular periods (menstruation). The fact that only 15% of women have a normal 28-day menstrual cycle gives credence to the claim that for most women, the menstrual cycle does not follow a predictable pattern. Hence, it is okay to be worried when one experiences irregular periods because they are tell-tale signs that all is not perfectly well in the body system. The good news, however, is that you are not alone, and solutions for irregular periods now abound at your finger tips. This is the more reason one should not ignore the signs because the earlier one begins to tackle the root cause of an irregular period, the higher the chances that it will be treated effectively.
In this article, we highlight the following concepts of menstruation:
- the normal menstrual cycle and its physiology
- signs of irregular periods (menstruation) with associated symptoms
- possible causes of irregular menstrual cycles and how they can be diagnosed
- different management modalities of the differentials of abnormal menstrual cycles.
- Home remedies to regulate your cycle
Menstruation is the cyclical process of discharging blood and endometrial tissue from the uterus between puberty and menopause in women who are not pregnant. It entails the shedding of superficial layers of the endometrium with subsequent repair in preparation for re-growth from the basalis layer. Women usually experience about 400 menstruation between the start of menstruation (menarche) and the end of menstruation (menopause).
A normal menstrual cycle begins to count from the first day of a period to the first day of the next period with the volume of blood totaling to about 20 – 80ml.
This could last for 3-7 days. Even though the seemingly perfect menstrual cycle is believed to be 28 days, as earlier stated, only 15% of women have that. The menstrual cycle of most healthy females ranges between 21 and 35 days. The normal menses can be summarized as a ‘breakdown, remodeling and repair’ process.
However, the actual events that lead to break down are predominantly local events that are precipitated by a fall in steroid hormones at the end of the cycle. Local factors involved are: lysosomes, metalloproteinases and endothelin (vasoconstrictive agents).
What are Irregular Periods?
In simple terms, an irregular period (menstrual cycle) is when one’s menstrual cycle is longer than 35 days or becomes very inconsistent. This is also known as Abnormal Uterine Bleeding (AUB) or Oligomenorrhea.
Medically speaking, irregular periods encompass any alteration in the normal menstrual flow pattern. The alteration may take the form of the following:
- Excessive flow
- Prolonged flow
- Intermenstrual bleeding
- Variation or inconsistency in period dates
Whichever is the case, it is pertinent not to ignore the signs and symptoms of these anomalies. Although, it is important to note that if these symptoms occur at the start of puberty or towards the beginning of menopause, seeking for treatment may not be very necessary.
Symptoms of Irregular periods
There are many reasons females experience irregular periods. Some of these symptoms
- Menorrhagia: heavy or prolonged menstrual flow. Commonest gynecological complaint and commonest indication for hysterectomy. Between ages 16 to 45, incidence 30%
- Hypomenorrhea- unusually light menstrual flow
- Cryptomenorrhea- hidden menses
- Metrorrhagia- regular intermentrual bleeding
- Polymenorrhea-too frequent menses occurring at <21days interval
- Hypermenorrhea- excessive regular menstrual bleeding
- Menometrorrhagia- prolonged menses with intermenstrual bleeding
- Oligomenorrhea- menses at intervals of > 35 days
- Contact bleeding (postcoital bleeding)
- Post menopausal bleeding
Causes of Irregular Periods
There are a plethora of reasons women experience irregular periods ranging from weight to lifestyle. The leading cause of irregular periods in women is hormonal imbalance especially an imbalance in estrogen and progesterone production. Other hormone influences that impact on the menstrual cycle include endocrine disorders such as thyroid disease, adrenal disease and prolactin disorders.
However, it does not end there. Matter of fact, a lot more factors contribute to the chances of having irregular periods like physical and emotional stress, or significant weight loss.
Medically, the causes of irregular periods can be grouped into two:
Organic causes which have identifiable roots and non-organic causes which have no identifiable reason.
For organic causes, root reasons for the irregular period may include local disorders like:
- Endocervical polyps
- Endometrial polyps/hyperplasia
- Pelvic Inflammatory Disease (local inflammatory response and altered ovarian function)
- Endometrial cancer
- Cervical cancer
- Hormone producing tumors (granulosa-theca cells of the ovary)
- Trauma (e.g postcoital laceration)
- Rare-arteriovenous malformations of the uterus
It could also be from systemic disorders such as:
- Disorders of haemostasis- especially in teenagers. Von Willebrand’s dx, ITP, deficiencies of factors II,V,VII,XI
- Liver disorders
- Medication-steroid hormones, contraceptive pills and injectables, neuroleptics, anticoagulants and cytotoxic drugs.
Some pregnancies can also lead to irregular periods as a result of:
- Miscarriage, ectopic pregnancy, Gestational trophoblastic disease (GTD), Postpartum hemorrhage (PPH).
Home Remedies to Regulate Irregular Periods (menstruation)
As earlier noted, not all irregular periods are caused by hormonal imbalance. Sometimes, inculcating some lifestyle changes can bring a lasting solution to a menstrual problem. These science-backed remedies have proven to help many women get their cycle back on track.
In case you are having irregular periods, try out the tried and tested home remedies listed below:
1. Healthy Weight:
Some menstrual irregularities are caused by rapid weight gain. Ovulation is very important in menstruation and it can be affected by weight gain. Therefore, in case you are overweight, one smart way to regulate your period is by losing some weight.
You can learn more from our article on Smoothies for Weight Loss for easy and sweeter ways of losing one’s weight.
Also note that losing a lot of weight can equally result in irregular periods. So, depending on where you fall in – either underweight or overweight – endeavor to maintain a healthy weight.
If you suspect that the irregularity in your period may be caused by your weight, Consult a Doctor on KompleteCare to advice you on the ideal weight that you need as well as the best way to achieve that weight.
2. Consume Ginger:
Among the many benefits of ginger is its ability to help minimize the quantity of blood lost during menstruation. From time immemorial, women have added ginger to their tea or foods to help treat prolonged and painful periods. This wonder spice contributes to alleviated other related symptoms of menstruation such as anxiety and mood swings.
Read more Health Benefits of Ginger.
3. Drink Grape Juice:
Grape fruits contain a lot of healthy vitamins such as vitamin C, beta-carotene, quercetin, lutein, lycopene and ellagic acid which combine to help correct irregular periods. All you have to do is to take a glass of grape juice every morning and watch the irregular period come back on track.
Clinical Management of Irregular Periods
- History-description of pattern, estimated blood loss, presence of other cyclical symptoms, reproductive history, contraceptive use, cervical smear and sexual history.
- The gold standard for objective assessment of menstrual blood loss is by the ALKALINE HAEMATIN method.
- Vital signs, height and weight
- General examination- stigmata of systemic diseases
- Abdomen- liver enlargement, pelvic masses (irregular or symmetrical), lymph nodes
- Breast- masses, nipple discharge
- Vulva and vagina
- Speculum examination of the cervix, pap smear, ECS, MCS
- Rectal examination
- Full blood count- PCV, platelet count, WBC
- Serum BHCG
- Thyroid function test
- Mid-luteal progesterone level (ovulation> 30nmol/L)
- Serum androgen level
- Prolactin level
- Coagulation screen/bleeding time
- Liver function test
- Renal function test
- Transvaginal ultrasound (gold standard for PCOS)
- Transabdominal ultrasound for women who are not sexually active
- Doppler ultrasound
- Hysteroscopy (performed in the proliferative phase of menstrual cycle)
- It is an integral component of evaluating AUB, particularly in women> 35 years or young women with chronic anovulation. It provides a direct histological evaluation of the endometrium.
- Aspiration curettage
- Hysteroscopy and direct biopsy
- Dilation and Curettage
- Treatment depends on the mode of presentation and the age group of the patient.
- In acute conditions- resuscitate, correct anaemia and arrest ongoing bleeding.
- High dose estrogen intravenously-25mg conjugated every 4 hours.
- Haemodynamically stable, oral conjugated estrogens 2.5mg every 4-6 hours for 14-21 days.
- Once bleeding stopped, medroxy progesterone acetate 5mg OD/BD X 7-10/7
- Hormonal treatment
- Combined oral contraceptive
- Danazol (isoxazol derivative of 17& ethinyl testosterone)
- GnRH analogues- buserelin, naferelin, goserelin, should not be used for more than 6 months
- Gestrinone- 19 testosterone derivative
- Levonorgestril- releasing IUCD
- Antifibrinolysis- a.tranexamic acid Contraindicated in thromboembolism and reduced level of antithrombin III.
- Ethamsylate- increases capillary wall strength + antifibrinolytic effect.
- Antiprostaglandins- Ibuprofen, naproxen, mefenamic acid, flufenamic acid,meclofenamic acid
- Antiprogestational agents-RU 486,synthetis 19-norsteroid with antiprogestogen activity. Inhibits ovulation and disrupts the endometrium
- Dilation and Currettage
- Endometrial resection and ablation- diathermy, laser, radiofrequency-induced ablation and thermal balloon ablation.
- Myomectomy- 15% risk of hysterectomy
- Hysterectomy- TAH, subtotal, vaginal, laparoscopic- assisted vaginal hysterectomy
Conditions for combined hysterectomy + BSO
- Co-existing ovarian pathology
- Family history of ovarian, breast or bowel cancer
- Age > 45 years
- Perimenopuasal or menopausal symptoms
- History of severe pain
- Severe premenstrual syndrome
Criteria for optimal results with endometrial ablation
- Older patients
- Uterus < 10/52
- Proliferative phase
- Pretreatment with danazol or a progestogen
- No endometriosis or adenomyosis
Dysfunctional Uterine Bleeding (DUB)
Irregular uterine bleeding unrelated to structural abnormalities of the uterus or the endometrial lining is a diagnosis of exclusion made after structural causes of bleeding and chronic medical diseases have been ruled out.
It occurs more commonly in the first 5 years after menarche and in the perimenopausal period.
About 50% of menorrhagia are attributed to DUB.
20% are adolescents, 50% aged 40-50 years
Most cases of DUB(85%) are due to failure of ovulation caused by alteration in the neuro-endocrinological function.
Dysfunctional Uterine Bleeding is classified into two broad categories:
- Anovulatory DUB which mostly occurs in women of reproductive age and characterized by irregular cycle. It has been noted to be most common in obese women.
- Ovulatory DUB which often affects women in ages 35 to 45. It is characterized by heavy regular/painful menses resulting from insufficient progesterone by corpus luteum.
- It is largely unknown
- Dysfunction of the Hypothalamic-pituitary-ovarian (HPO) axis
- Cyclic ovarian stimulation of the endometrium is lost. Constant non-cycling estrogen levels that stimulate endometrial growth. Proliferation with periodic shedding causes the endometrium to outgrow its blood supply. This leads to break down and sloughing off.
- Persistent corpus luteum cyst and luteal insufficiency (ovulatory)
Diagnosis of Dysfunctional Uterine Bleeding
- Patient history
- Absence of ovulatory temperature changes
- Low serum progesterone level
- Report of endometrial sampling in older women
Depends on the age of the patient.
- Adolescent/ young women
Oral contraceptive pills
- Premenopausal/ older women
Proper evaluation- hysteroscopy, endometrial biopsy.
Hysterectomy (coexisting endometriosis, myoma, prolapse)
- Psychological stress
- Haemodynamic instability
- Chronic anaemia
- Endometrial hyperplasia
In a nutshell,
Irregular menstrual cycles or periods is a common gynaecology presentation that has a significant impact on the many women of child bearing age as it can affect patient’s daily routine, reproductive career and general health. A careful history, detailed examination and relevant investigation is essential to making a proper diagnosis and treatment which will improve the patient’s quality of life. It is important to pay attention to one’s body changes and report menstrual alterations early for effective treatment. For most women, a simple lifestyle change can do the trick of correcting irregular menstruation such as maintaining a healthy weight, eating ginger or drinking grape juice every morning.
- Disorders of the menstrual cycle, Gynaecology by Ten Teachers, Seventh Edition, 2000
- Complications of Menstruation; Abnormal Uterine Bleeding, Current diagnosis and treatment, Obstetrics and Gynaecology, Tenth Edition,2007
- Abnormal Uterine Bleeding, Comprehensive Gynaecology in the tropics, kwawukume etal, February 2005
- Abnormal Uterine bleeding, A guide for the patient, American Society for Reproductive Medicine, 1996
- Abnormal Uterine Bleeding, Journal of the American College of Obstetricians and Gynaecology
Dr. Bolarinwa E. S is a physician of family medicine in National hospital, Abuja, Nigeria.