Menstrual bleeding is defined as recurrent regular bleeding in sexually mature women. The most common vaginal canals other than menstrual bleeding are bleeding due to menstrual irregularity. The first menstrual bleeding is a signal that a woman is now sexually mature, and this first bleeding is called menarche in medicine.
The average age of menarche is 12 years (normal between 10 and 14 years). Every woman experiences about 400 menstrual periods during her sexual maturity. Bleeding in the first years is irregular and there is usually no ovulation. The last menstrual bleeding is around the age of 50 and this is called menopause.
Cycle length and onset of menstruation:
Cycle time is the time between two menstrual bleedings and starts from the first bleeding day and continues until the next bleeding day. Menstrual bleeding normally lasts 4 to 6 days; severity varies from person to person. Every woman loses an average of 60-80 ml of blood during her menstrual bleeding. The most intense day of bleeding is the second day of menstruation. Menstrual blood does not clot because it contains fibrinolytic enzymes that keep the blood liquid. The other part of the blood circulation is not affected by this condition.
Menstrual bleeding continues in each cycle only if there is no pregnancy. In other words, the absence of menstrual bleeding may indicate that there is a pregnancy in the middle. Flowing menstrual blood disrupts the physiological order of the vagina. Microbes that cause inflammation and infections can easily pass through the vagina. For this reason, it is recommended to be more careful in cleaning and avoid sexual intercourse during menstruation.
The mechanism of the hormones that cause menstrual bleeding in a woman’s body is a very complex issue. This order includes the brain, a part of the brain called the hypothalamus, a hormone gland called the pituitary, the ovaries and the uterus (womb).
Relaesin (that is, releasing) hormones (GNRH = Gonadotropin releasing hormones) are produced in the hypothalamus. This hormone is one of the most important hormones for a normal menstrual cycle. These relaesing-hormones cause Gonadotropin hormones to form in the pituitary. Gonadotropin hormones: FSH that is follicle stimulating hormone, LH that is Luteinizing hormone and Prolactin. (Hormone that ensures milk production during pregnancy and postpartum milk production)
With the effect of FSH in the ovaries, the follicle in which the egg cell is located matures until ovulation occurs. Estrogen production is also increased for this event. The increased amount of estrogen hormone provides further maturation, growth and change in the structure of the follicles in which the egg cell is located. This maturation period is from day 1 to day 12 or day 14 in a normal 28-day cycle.
LH (Luteinizing Hormone) reaches its high values just before ovulation and ovulation takes place on the 12th, 14th days. The mature follicle bursts, the egg cell comes out and is captured by the fallopian tube (tubes). The ovulation event is felt by some women as a slight pain in the abdomen. Under normal conditions, one egg is released for fertilization each month. The follicle closes immediately after ovulation.
Yellowish pigment cells accumulate in the empty space left by the egg cell. Therefore, this follicle is called yellow object (Corpus luteum). The process from the formation of the corpus luteum to the onset of the next menstrual period is called the luteal phase. It starts from the ovulation event and continues until the 28th cycle day. Progesterone is produced in the corpus luteum. This hormone causes the body temperature to increase by 0.3-0.6 degrees. (Measurement of body temperature as a method of protection is based on this) The most important task of progesterone is the protection and maintenance of pregnancy.
In the absence of pregnancy, the corpus luteum disintegrates and progesterone production stops. This causes bleeding in the uterus. The mucosal layer of the uterine wall, which is prepared for a possible pregnancy, is expelled by bleeding. This is the last phase of menstrual bleeding. After the end of the bleeding on the uterine wall and the healing of the wound, the proliferation phase begins and the uterus prepares itself for a possible pregnancy. If there is no fertilization, this layer is thrown out again in the form of bleeding and this continues.
Spot-shaped Dirty Bleeding
This type of bleeding is brown in color and usually occurs just before the onset of menstruation, in the middle of the cycle or at the time of ovulation. This bleeding can have many causes. For example: such as an injury to the mucosal layer and a short luteal phase. A detailed anamnesis is made by the doctor.
The frequency of such bleedings is asked when a child is desired. Anatomical causes are investigated in gynecological examination. When there is a suspicion of a hormonal disorder, hormones are checked in the blood or urine. Patients may be asked to note the frequency of bleeding, the severity of pain, the presence of breakthrough bleeding, and the time of ovulation for several months.
Interim bleeding is any type of bleeding that comes from the vagina except menstrual periods. Intermediate hemorrhages are usually brown. There can be many reasons for this:
. Cycle problems : hormonal causes
. Ovulation (ovulation) bleeding: This bleeding is very light and harmless, it occurs at the time of ovulation. In a normal cycle, just before ovulation, estrogens suddenly drop. This sudden change in hormones can cause bleeding.
. Bleeding while taking contraceptive pills: It is common during the use of contraceptive pills, which have a very low amount of estrogen.
. A damaged vein: Blood from an injured vein is usually light red in color. Such bleeding can occur, for example, after sexual intercourse. In this type of bleeding, it is useful to consult a doctor.
. Bleeding after menopause: Menopausal women should take any vaginal bleeding seriously. The doctor should be consulted and the cause of bleeding should be explained.
. Implantation bleeding: There may also be a small bleeding during the implantation of the embryo on the uterine mucosa. Under normal conditions, this is so slight that it is not noticeable.
Irregularities in Menstrual Bleeding
Irregularities in menstrual bleeding may occur as irregularities in the length, intensity or frequency of bleeding.
Severe, prolonged bleeding
More than 80 ml of blood per day is lost in heavy and prolonged menstrual bleeding, which is called menorrhagia in medical language. Menstrual bleeding is not only heavy but also prolonged. It takes 8-10 days. Serious ailments such as anemia can occur with menorrhagia. Causes are usually of organ origin. For example Myomas, Polyps, Carcinomas or ovarian tumors.
Only 10% are caused by hormonal problems, problems with the blood-producing organs or high blood pressure. Organic problems can be detected in the gynecological examination. In addition, blood tests such as hemoglobin, iron level and platelets are also performed. If there are hormonal problems, hormone tests are done in the blood or urine.
The frequency, severity, length, pain, if any, intermittent bleeding and ovulation time of menstrual bleeding experienced by the patient in the last months should be noted. Treatment is applied according to the cause. Operative treatment is often inevitable. Fibroids and polyps are treated with surgery or medication, regardless of their location and size. Drugs that increase the contraction of the uterus support the reduction of bleeding.
If there is no organic problem, hormonal treatment is applied and hormone drugs called gestagen are generally used. If a child is not considered, protection drugs called contraceptives are used.
Removal of the uterus may also be considered if all therapeutic attempts fail and bleeding is causing severe anemia.
Very Severe Bleeding
It is also called hypermenorrhea in medical language. Bleeding that is heavy but does not last long. More than 15 pads are used per day and usually large blood clots are removed. These blood clots can cause pain. The reason for this painful menstrual bleeding is the insufficient fibrinolytic potency that normally prevents blood from clotting. In 80% of cases, there are organic problems in the uterus or adnexa.
The main causes are fibroids, polyps, ovarian tumors and carcinomas, weakness in the uterine muscles as a result of frequent births, bending in the uterus, weakness in the uterine muscles and loss of elasticity. In 15% of cases, the problem may be hormonal. Hormonally, the reason is usually the persistence of the follicle or the delayed expulsion of the uterine mucosa, which develops due to the timely destruction of the corpus luteum. Causes such as blood coagulation problems (hemorrhagic diathesis), decreased thrombocyte count, fibrinolysis or high blood pressure are less common.
The history (medical questioning) made by the doctor is very important. Especially physical development, puberty, cycles, family history, genetic predisposition and other metabolic diseases should be questioned thoroughly. Possible anatomical causes are investigated in the gynecological examination. Weight, body proportions, body hair growth, development of sexual symptoms, mental development, and physical factors are also important details to be investigated. When hormonal problems are suspected, blood or urine hormone tests are performed. Complete blood count, blood coagulation values, and blood pressure are also tests that should be done.
First, the cause is treated. If the cause is anatomical, it is corrected operatively. For blood-related problems, experts are consulted on the subject. Medicines to support the contraction of the uterine muscles are used, rest and cold compresses applied to the abdomen may also be beneficial. If there is no organic reason and the child is not wanted, contraceptive contraceptive drugs may be useful. In cases where there is no organic problem, the severity of bleeding can also be reduced with hormone preparations.
Less Than Normal Menstrual Bleeding
In medical language, it is called hypomenorrhea. Menstrual bleeding lasts 2-3 days and is in the form of spotting. Such irregularities usually occur in the premenopausal period or in overweight women. The reason is usually disruptions in ovarian functions. Hormone production has decreased and slowed down. This causes the uterine mucosa to form a thinner layer. As a result, menstrual bleeding is also less.
Other causes are local vascular effects (rapid narrowing of the opened vessels), high-dose Gestagens may cause less bleeding.
Diagnosis is made by detailed anamnesis and gynecological examination. Hormone analyzes will also help in diagnosis. In some cases, endoscopic examination of the uterine wall may be requested. It is a condition that generally does not require treatment. Only if the child is desired, hormone therapy is started.
More Than Normal Menstrual Bleeding
In medical language it is called polymenorrhea. Menstrual bleeding occurs less than 25 days later and there are usually no other menstrual complaints. There is hormonal imbalance during the cycle. The maturation phase of the follicle is shortened. Egg maturation normally takes 2 weeks, here this time is shortened.
Corpus luteum phase is shortened. Normally, after ovulation, the remaining follicle transforms into the corpus luteum and produces the hormone Progesterone for 2 weeks. If fertilization has not taken place, the corpus luteum disappears. If the corpus luteum disappears prematurely, less progesterone is produced and menstruation begins earlier. Both phases are shortened. There was no ovulation.
Polymenorrhea can usually be seen at the beginning of puberty or at the beginning of the menopause. But extremely stressful situations can also cause polymenorrhea.
The diagnosis can be started with the measurement of basal body temperature. In this way, it can be understood whether the corpus luteum is destroyed before its time. The measurement of ferritin, which is the storage iron in the blood, should also be made absolutely. Frequent and heavy bleeding causes iron deficiency anemia in most women. If it is not planned to have children for treatment, birth control pills are used. If the luteal phase is shortened, it is used from the 12th day of the cycle. Gestagens can prolong the cycle. This irregularity can often resolve spontaneously, especially when the cause of its occurrence is eliminated. Ensuring healthy living conditions plays an important role in recovery.
Rare Menstrual Bleeding
In medical language, it is called oligomenorrhea. The duration and severity of menstrual bleeding are normal, but the time between two periods is prolonged. This break may take 35–45 days. This interval can be of different length each time, sometimes difficult to distinguish from amenorrhea. Oligomenorrhea is usually caused by loss of function in the ovaries due to hormonal problems. The luteal phase is prolonged: oligomenorrhea may occur if ovulation does not occur, as at the onset of puberty and menopause.
Or the ovaries do not respond to central impulses, namely FSH and LH-hormones. Other causes may be thyroid gland diseases (hypo- or hyperthreosis), overproduction of the hormone Prplactin, or excess of androgen hormones can also cause oligomenorrhea. Is there a previous history of frequent miscarriage in infrequent menstrual bleeding? This too should be investigated. If the child is not wanted, it is generally a condition that does not require treatment. If it is planned to have a child, hormone preparations that will affect the cycle may help the bleeding to return to its normal rhythm.
Complete Cessation of Menstrual Bleeding
In medical language, it is called amenorrhea. It is the most common menstrual problem. There are two types of amenorrhea:
. Primary amenorrhea: If there is no menstrual bleeding after the age of 15, primary amenorrhea is mentioned.
. Secondary amenorrhea: menstrual bleeding started normally during adolescence; If there is no period for more than three months, it is said to be secondary amenorrhea.
There is also “post contraceptive-amenorrhea” as a separate form in amenorrhea. Approximately 1-2% of women using birth control pills do not have menstrual bleeding for at least 3 months when birth control pills are discontinued.
Primary amenorrhea: Its causes are diverse and serious. The most common cause (30%) is genetic errors and chromosomal abnormalities.
In 20% of primary amenorrhea, the cause is a defect in the genital organs: a lack of ovaries or a vagina, a lack of a uterus or the presence of an atretic uterus can be the cause. Most of the time, the hymen is completely closed, preventing the bleeding from going outward. In 15%, there may be hormonal problems in the pituitary or ovaries. 10% have problems in extra genital endocrine organs. (For example, adrenal glands, thyroid gland, etc.) If menstruation has not occurred until the age of 16, the situation should be investigated urgently.
Secondary amenorrhea: The first thing that comes to mind when menstruation stops in women who have reached sexual maturity is pregnancy. It can be easily understood with these tests. In addition, menstrual bleeding is physiologically interrupted during breastfeeding and menopause periods. In amenorrhea occurring in other cases, all organs related to menstrual bleeding should be considered. This situation, which is more common today than before, can be encountered in intense physical-psychological stress situations, as well as excessive weight loss after excessive sports activities, wrong diets or amenorrhea can be seen in nutritional disorders called anorexia nervosa. All these reasons are seen in 60% of secondary amenorrhea.
They are problems encountered in only 30% of secondary amenorrhea. Problems with excess prolactin production and ovarian function: such as polycystic ovary syndrome, tumors, premature aging, or damage to the ovaries after radiation therapy or chemotherapy. In only 7% of cases, the problem may be in other endocrine organs. In 5% of cases of secondary amenorrhea, the cause may be in the womb. (For example, incorrect abortion practices, thinning of the mucosa before menopause.)
Various hormone tests, detailed gynecological examination and anamnesis are used to investigate the causes and treat the cause. If the cause is loss of function in the ovaries, recovery depends on how long the problem has been going on and how much function loss there is. Spontaneous recovery can be seen in 20-25% of cases. Success is achieved in 40-60% of treatment.
Menstrual Bleeding with Severe Pain
It is called dysmenorrhea in medical language. It is known that one out of every five women suffers from dysmenorrhea. It is possible to distinguish such complaints as primary and secondary dysmenorrhea.
Primary dysmenorrhea: It progresses with prolonged uterine contractions. The reason was determined as the overproduction of Prostaglandin F 2 in the endometrium (inner layer of the uterus). Complaints often lead to psychological problems.
Secondary dysmenorrhea: The cause here is a disease called Endometriosis. In endometriosis, the endometrial cells that break off from the endometrium, which is the inner layer of the uterus, during menstruation, settle in other organs and places. Bleeding occurs in these areas with each menstrual bleeding. But fibroids or spiral or previous gynecological surgeries can also cause these painful complaints.
In dysmenorrhea cases, complaints such as fatigue, back pain, nausea, vomiting, constipation, diarrhea, headaches, migraine, loss of appetite, heart palpitations, and abdominal pain are common. Abdominal pains are severe colic-style pain. There is tenderness in the breasts. Psychological problems such as decreased self-confidence, irritability and depression are common. Complaints begin a few days before menstruation and reach their peak on the first day of menstruation. In young girls, underdeveloped genitalia and the presence of a narrow cervical canal may also be the cause of these pains.
Here, too, treatment is applied for the cause. Strong pain relievers and cramp solvers are used. Apart from this, the use of gestagen in certain periods of the cycle and the use of birth control pills if the child is not desired may also be beneficial. In some cases, psychological support with relaxation techniques may be required.
The search for menstrual cramps may be in the form of an increase in the frequency of menstruation, a decrease below the lower limit of 21 days, or a prolongation of the menstrual period or an increase in the amount of bleeding. In all three cases, anemia and complaints related to anemia occur in women due to blood loss (fatigue, irritability, loss of appetite, palpitations, etc.).
First of all, it is necessary to look at the gynecological examination with ultrasound in order to find the cause of excessive bleeding. Frequent menstruation is usually caused by hormonal disorders. In excessive and prolonged bleeding, benign tumors such as uterine fibroids, intrauterine polyps, disorders in the blood coagulation mechanism, intrauterine devices (spiral) inflammation can be seen. Long bleeding after a missed period may suggest a pregnancy loss and an ectopic pregnancy. Sometimes, there is no problem that we can see as a result of the examination.
In such cases, it is useful to take tissue from the uterus and show it to pathology and have it examined.
Revealing the cause of bleeding and treating the cause is the most effective and correct treatment. Despite all very rare tests, the cause of excessive bleeding cannot be found. At that time, we can protect the woman from excessive blood loss by placing appropriate drugs or a hormonal spiral that reduces bleeding.
The simplest definition of premenstrual syndrome (PMS) is that a few of more than 100 complaints are seen in the premenstrual period and this period continues with a completely symptom-free period. The most common complaints are abdominal swelling 7-10 days before menstruation, tension, irritability, breast tenderness, pain, crying spells depression, fatigue, increased thirst and appetite, various degrees of edema. It is not possible for a person to have all the symptoms at once. Diagnosis is made by periodic observation of complaints.
Complaints are intermittently related to the menstrual cycle, starting one week before the period and ending with the onset of menstruation.
Treating My PMS
The first step is to convince both the patient and the physician that this problem is temporary. The only tool used in diagnosis is keeping a menstrual calendar. With the contributions of other observers such as family members, it is necessary to record the problems in the period at least 3 months, 10 days before the period, their effects on work and lifestyle, and the period when the complaints completely disappeared after these troubled days. PMS is not a simple disease, but rather a combination of different problems.
that PMS has a psychological basis; we believe that it is biologically, psychologically and sociologically related to the menstrual cycle. This is perhaps a learned response. This response is perhaps an event triggered by hormonal changes. Hormonal changes can affect sensitivity and mood instability. Changes in lifestyle are effective in the treatment of complaints.
A change in diet, exercise, work or social activities, instead of controlling the life conditions of the person, providing the control over one’s own life allows to get through this period more harmlessly. In the treatment plan, the drug is selected for the elimination of periodic complaints.
The Effect of Stress on Menstrual Bleeding
The menstrual cycle is achieved by stimulating the ovaries with hormones secreted from the brain and by the regularity of this warning and the ovaries responding to this warning.
Besides many factors that affect the regular functioning of the brain (Hypotalamus Hypophysis) and ovaries, stress also plays an important role. Unfortunately, one of the intense stresses experienced is the exam stress experienced by our children and girls. Due to exam stress, anxiety and worry, the hypothalamus region of the brain is affected, negatively affecting the release of a number of hormones to be secreted, and menstrual irregularities occur.
Our young girl, who has menstrual irregularities due to stress, and her family often come to us with anxiety. As a result of the examination, there is usually no organic problem. Treatment should be planned according to the type of menstrual irregularity. Especially since excessive and heavy bleeding can lead to anemia and cause fatigue and concentration disorders, they should be treated. Again, in this period, bloating, tension and irritability may be seen due to long-term delays in menstruation, so it is necessary to ensure the menstrual cycle of the young girl with appropriate drugs. The main purpose of treatment should be directed to the cause, that is, learning to cope with stress, or rather not to stress.