Normal menstruation and common menstrual problems

Menstrual problems are commonly seen in adolescents.

Normal menstrual cycle consists of three phases-Follicular phase, which consists of the first 14 days, Ovulatory phase (mid cycle) and Luteal phase which extends from 16-28 days.

During the follicular phase a hormone from the hypothalamus called Gonodotropin Releasing Hormone (GnRH) acts on the pituitary gland resulting in the release of Follicle Stimulating Hormone (FSH) and Leutenizing Hormone (LH). Under the influence of FSH and LH a dominant follicle develops in one of the ovaries.

The maturing follicle produces estradiol which leads to proliferation of the lining of the uterus to prepare it to receive the Zygote in case fertilization takes place. Estradiol also causes decrease in FSH secretion and increase in LH secretion.

The rising LH level stimulates production of progesterone by the follicle. Progesterone in turn leads to increase in levels of LH and FSH. The increase in LH is more marked than that of FSH. This happens at the mid cycle and is called as LH surge, which results in rupture of follicle and release of ovum.

During luteal phase LH and FSH levels decline. The corpus luteum continues to secrete progesterone. Both estrogen and progesterone prepare the uterus for the development of fetus. If pregnancy does not occur the corpus luteum becomes inactive, the levels of estrogen and progesterone decrease and the inner lining of the uterus is shed as menstrual flow about 14 days after ovulation.

Amenorrhea

Amenorrhea is failure to have menstrual bleeding when it should normally occur. It can be either primary or secondary. Primary amenorrhea is failure to attain menarche (first menstrual bleeding) by the age of 14 years if secondary sexual characteristics have not appeared. If secondary sex characteristics have appeared then the age limit is accepted as 15 years.

The term constitutional delay is used when the onset is delayed or the rate of progression of puberty is slow in the absence of any abnormality.

Secondary amenorrhea is the lack of menstrual bleeding for at least 3 cycles after regular cycles have started. Under certain circumstances earlier investigation may be required for example when pregnancy is suspected, or there are some other physical abnormalities.

Primary amenorrhea may be due to anatomical abnormalities, chromosomal disorders and chronic illness.

Common causes of secondary amenorrhea are pregnancy, stress and Polycystic Ovary Syndrome (PCOS).

Dysmenorrhea

This term refers to pain associated with menstruation and is a very common complaint among teenage girls. It is of two types primary and secondary. In primary dysmenorrhea there is no associated disease and clinical examinations normal.

Secondary dysmenorrhea is associated will some diseases involving the pelvic organs and clinical examination usually reveals some abnormality.

Primary dysmenorrhea is much more common than secondary dysmenorrhea. It usually starts with the onset of menstrual flow or just before and lasts for about two days. If usually does not start until several months after menarche when cycles become ovulatory.

More help for menstrual problems

The pain is situated in the lower abdomen and may radiate to lower back and thighs. Sometimes the pain is associated with nausea, vomiting, diarrhea and increased frequency of urination. The pain is attributed to a substance called prostaglandin which causes contraction of uterus.

Treatment: If the pain is mild applying a heating pad on lower abdomen or warm bath may be enough to relieve the pain.

In moderate to severe pain an anti-inflammatory drug may be used. Ibuprofen 400-800mg up to 3 times daily or Naproxen 250-500mg 2 times per day may be given. Commercial preparations containing either of these along with paracetamol and smooth muscle relaxants are available and are very effective is severe pain.

Secondary dysmenorrhea is commonly due to infection or a condition called endometriosis. In the latter condition tissue from the endometrium (inner lining of the uterus) gets implanted outside the uterus.

Secondary dysmenorrhea requires gynecological evaluation and investigation to find out the cause. Treatment depends on the cause appropriate antibiotics for infection and hormonal suppression or surgery for endometriosis.

Premenstrual syndrome (PMS)

This refers to a group of physical and psychological symptoms occurring during the luteal phase of menstrual cycle and relieved by the onset of menses. The complaints include emotional instability, depression, anxiety, irritability and impulsivity, sense of bloating, breast tenderness, fatigue and changes in appetite.

The exact cause is not known. This is more common is adult women but adolescents can also suffer from this. Hormonal imbalance is suspected.

Several drugs have been tried for this condition with variable results. Oral contraceptive pills and anti-inflammatory drugs have been tried. Sertraline is another drug used for this condition.

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