menstrual bleeding irregularities


Menstruation (menstrual bleeding) is the shedding of the layer covering the inner lining of the uterus with the hormonal effect. In women, menstruation continues throughout the reproductive age, starting with puberty and ending at menopause.

In newborn girls, the inner layer of the uterus may swell and shed in the first 1.5 months due to estrogen and progesterone hormones coming from the mother, that is, the placenta. Again in this period, the discharge has increased in the baby girl and the external genital organs have a raised appearance. After this period, there is no hormonal effect until puberty. Most of the genital bleedings that may occur in childhood are caused by foreign body escaping inside. Although rare, benign or malignant tumors may cause bleeding during this period.

At the beginning of the reproductive age, messages begin to arrive in the brain from the hypothalamus to the pituitary, the center of all hormones. The pituitary also begins to stimulate the follicles (liquid-filled cysts that secrete estrogen hormone and contain eggs) in the ovaries, which are ready until this age. Underdeveloped follicles secrete testosterone, a male hormone. Under the influence of these hormones, breasts begin to grow in adolescent girls, and then hair growth in the genital area and armpits increases. One year after the breasts start to grow, the first menstruation will be seen (menarche). Menarche is usually between the ages of 9-14. In the first two years after menarche, the inner layer of the uterus will shed irregularly with the effect of estrogen secreted from the follicles. Menstrual bleeding can be early or late and can last for weeks.

After about two years, the follicles with a diameter of 2-2.5 cm will crack, remove the egg and leave their place to the corpus luteum, which we call the yellow body. Progesterone hormone will be secreted from the corpus luteum for 14 days. Regular menstrual bleeding will begin with the effect of first estrogen and then progesterone. It is worth emphasizing that menstrual bleeding comes 14 days after ovulation. In menstrual cycles with ovulation, it is natural that premenstrual symptoms such as chest tightness and swelling in the abdomen and menstruation begin to be slightly painful due to the effect of progesterone. Regular menstrual bleeding is every 28 days and is normal between 21-35 days. Bleeding for 2-7 days (average 3-5 days) is natural. The amount of bleeding is 50 ml (between 20-80 ml). Normally, menstrual bleeding is clot-free because substances that prevent clotting are secreted in the uterus. As the amount of bleeding increases, these substances will become insufficient and clots will begin to appear.

Bleeding irregularities may be due to hormonal causes. To explain the hormonal causes, starting from the hypothalamus, respectively; We can list the causes originating from the pituitary and ovaries. All the reasons that affect the brain and psychological structure (air change, fatigue, stress, weight gain, exercise) can affect the menstrual order. Hormones affecting the pituitary are also among the causes that affect the menstrual cycle. For example, the hormone prolactin, which provides milk from the breast, is among the most common causes of delaying menstruation, apart from breastfeeding. We all know that thyroid diseases (goiter) cause menstrual irregularities. Again, the effect of adrenal diseases, which are controlled by the pituitary, on the menstrual cycle is undeniable. We know that many drugs and hormones that affect these tissues also affect the menstrual order. Although rare, it should not be forgotten in the differential diagnosis of brain and pituitary tumors. When we look at the ovaries; We see that polycystic ovary syndrome is the disease that most affects the menstrual cycle. In this syndrome, which affects 1/5 of the population, the diagnosis can be easily made by seeing more than ten follicles with a diameter of 3-5 mm in both ovaries lined up in the form of pearls by ultrasonography. These underdeveloped follicles will secrete testosterone and estrogen. The follicle will not develop enough to release an egg every month, so there will be no corpus luteum and progesterone hormone. For this reason, in these cases, menstruation will be delayed and there will be irregular bleeding with the effect of estrogen only. In these cases with high testosterone levels, the rate of hair growth will also be higher. These cases are usually overweight and prone to diabetes. In the period when they want a child, these cases should be supported with ovulation-reinforcing drugs and they should be advised to lose weight.

Some benign and malignant ovarian tumors that secrete hormones may cause bleeding irregularities.

As can be seen, hormonal-related bleeding irregularity is due to the shedding of the inner layer of the uterus with the effect of estrogen not met with progesterone. In cases of bleeding irregularities that occur only a few times, drugs containing progesterone can be used for short-term treatment, starting 10-14 days before menstruation. If the complaints continue, the root cause should be investigated. If there is no medical problem in long-term menstrual irregularities without any organic pathology, the best therapeutic drugs are birth control pills.

Every birth control pill contains synthetic estrogen and progesterone. The pills are excreted from the body within 24 hours. It should be used for 21 days and a break for seven days. The inner lining of the uterus will swell and shed less and regularly. Therefore, menstrual blood loss and menstrual pain will decrease. With the effect of progesterone, it will reduce the risk of intrauterine cancer by 50% by suppressing the uterine membrane that swells only with the effect of estrogen. Hormones that mix with the blood from the pill will prevent the formation of eggs by preventing the formation of follicles in the ovary by blocking the signals coming from the pituitary for 24 hours. When the pill is forgotten even for one day, this pressure will disappear, and the risk of eggs and pregnancy will arise. In addition, the risk of cysts formed by follicles that cannot crack under the effect of the pills will decrease by 75%, and ovarian cancers will be seen 50% less. Benign uterine tumors, which we call fibroids due to estrogen hormone, will be 30% less common. Protection against ovarian and intrauterine cancer will continue for another 25 years after use. It is worth emphasizing that birth control pills can be used without interruption for years until menopause, except for those over the age of 35 who smoke excessively, those with high blood pressure and diabetes, those at risk of thrombosis and coagulation.

Bleeding irregularities of organic origin can occur in the vagina, cervix, uterine canal and intrauterine canals. Tears due to trauma in the vagina may rarely cause simple cysts to bleed. Vaginal cancers are very rare and occur in advanced age. Changes in the cervix can often cause bloody discharge and bleeding after sexual intercourse. Rashes on the cervix, which we call ectopia, are usually benign. But it is definitely recommended to do a pap smear test. Early sexual intercourse, smoking and some sexually transmitted HPV virus models increase the risk of cervical cancers that occur at a young age. Women of reproductive age should have regular pap smears every year. If there is no additional risk factor, they should have a smear every three years after three years in a row.

The moles in the mouth of the uterus, which we call polyps, are also causes of bloody discharge. Polyps can be found at the cervix or inside the uterus. Although not malignant, they should be removed by curettage.

Changes that we call hyperplasia of the inner layer of the uterus under the influence of estrogen are among the most important causes of organic bleeding irregularities coming from the uterus. The inner layer of the uterus is cleaned by abortion, and when the pathological diagnosis is simple hyperplasia, it can be treated for three months by giving only progesterone-containing drugs. Three months later, the success of the treatment and the disappearance of hyperplasia are confirmed by abortion again. Since the risk of intrauterine cancer will increase in the future in ongoing or atypical hyperplasia, it should even be considered that the uterus may need to be surgically removed. Fibroids in the inner layer of the uterus are also the main cause of irregular bleeding. In fibroids in the muscle layer of the uterus, they can prolong and increase the amount of bleeding by affecting the contraction of the uterus.

In addition, some drugs and bleeding-coagulation disorders are among the organic causes that will disrupt the bleeding pattern.

Bleeding due to hormonal irregularities is prolonged and regular bleeding in the form of early or late shedding of the inner lining of the uterus. There is no definite order in organic bleedings, the bleedings may be rali, they may be in different amounts and irregularities.


Menstrual bleeding will be long and excessive in those who use intrauterine devices. Drugs called prostaglandin inhibitors will reduce bleeding blood loss by 50%, but the number of bleeding days will remain the same. If the intrauterine device slides down, bloody discharge will be seen more. With the intrauterine device containing progesterone, there will be long bloody discharges and irregular bleeding at the beginning, after a certain period of time, the bleeding will decrease and start to be delayed. Again, in subcutaneous implants and three-month injections containing only progesterone, menstrual irregularities will be seen in the first six months, and then there will be menstrual delays for months. Menstrual delays and menstrual irregularities are less common in those who use estrogen+progesterone-containing birth control pills, monthly injections, and vaginal rings. Menstrual bleeding is less in these women. Not all menstrual irregularities will be seen in those who use contraception. Regardless of the method we use, bleeding irregularities that may occur in the first three months can generally be considered normal.

In the pre-menopausal period, the follicle in the ovary will decrease, and dysfunctional bleeding will reappear under the influence of only estrogen (in some months, without ovulation, corpus luteum and progesterone), as in the adolescence period. The use of progesterone, estrogen+progesterone may be sufficient for more frequent bleeding. When it recurs, hyperplasia and other changes should be excluded by sampling with curettage from the uterus. There may be delays in menstrual bleeding during this period, no additional treatment is required, but since there may be sporadic ovulation, the risk of pregnancy should be ruled out and precautions should be taken with contraceptive methods.

Pregnancy and ectopic pregnancies must be ruled out, even if bleeding occurs at any stage of the reproductive age. A woman who has not had a menstrual period for a year can be diagnosed with menopause. The average age of menopause is between 48 and 52 years. There are no follicles in the ovaries, no eggs, no children, no estrogen, no menstruation. Up to 50% of cases of bleeding occurring one year after menopause will result in intrauterine cancer. For this reason, sampling must be done from the uterus with curettage. Thinning (atrophy) of the vaginal tissue due to estrogen deficiency in menopause is the main cause of bloody discharge in this period. It can be easily treated with local ointments containing estrogen. I wish all women not to experience the uneasiness of menstrual irregularity…

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