Problems with Menstruation

Normal Menstrual Flows

About once a month, women of childbearing age normal menstruate for 4-6 days, losing between 25 and 60 cc of blood. The blood is dark in color and mixed with mucous, inflammatory exudate, and cellular debris, representing the shed lining of the uterus.

Day #1 of the menstrual cycle is designated as the first day of the menstrual flow. At approximately Day #14, one or the other ovaries releases an egg (ovulation), an event which may or may not be perceived by the woman. With ovulation, some women notice brief abdominal cramping while others do not. Some women notice a small amount of pink vaginal discharge or spotting, while others do not. Some women notice a significant, brief, increase in cervical mucous secretions (evidenced in vaginal discharge) but others do not.

Following ovulation, progesterone, the other female hormone (other than estrogen) is produced in significant quantities. Progesterone has a number of functions, but in the normal menstrual cycle, continues to be produced by the ovary for 10-12 days. Following the abrupt fall in progesterone, a new menstrual flow is triggered, starting several days after the drop in progesterone.

Cramps

Menstrual cramps (dysmenorrhea) are among the most common of menstrual cycle symptoms. They may be mild, moderate or severe, and may not be consistent from one cycle to the next. They are usually midline and suprapubic. The cramps are waxing and waning in character but a constant dull ache is also common. The pain may radiate into the back or upper anterior thighs.

The cramps typically begin a day or two prior to the menstrual flow and are usually resolved before the menstrual flow has finished, although there is considerable person-to-person variation.

Simple cramps usually respond well to simple measures. Any of the nonsteroidal anti-inflammatory agents (Ibuprofen, naproxen, etc.) can be effective, but sufficiently high doses are most effective. A loading dose of ibuprofen, 800 mg PO can be started a day prior to the anticipated onset of cramps. This is followed by 600 mg PO every 8 hours for as long as the cramps persist. If you wait until cramps have already begun to start the NSAIDs, they will not be as effective, but may still prove useful.

Regular  exercise has been demonstrated to reduce the frequency and severity of menstrual cramps, probably through the release of internal beta-endorphins.

More severe menstrual cramps usually respond very well to BCPs. Possibly through blocking of ovulation and also perhaps by the reduction in amount and duration of bleeding, BCPs are a first-line treatment for significant dysmenorrhea. Any of the low-dose, monophasic BCPs can be employed for this purpose. Significant relief should be expected after the first BCP-induced flow and additional improvement over the next 6 months may continue.

For those women with severe cramps whose symptoms are not improved with BCPs, continuous BCPs may provide the solution. In this case, the BCPs are taken without letup (continuously) and there is no menstrual flow at all. Without a menstrual flow, menstrual cramps are inhibited. For these women, gynecologic consultation while in garrison is probably wise to evaluate such patients for the possible presence of endometriosis.

Breast Pain

For some women, cyclic breast pain and tenderness (mastodynia or cyclic mastalgia) accompanies the later portions of the menstrual cycle. Typically for several days preceding the menstrual flow, the breasts of these women enlarge, become lumpy, tender to touch, and produce a generalized aching. The nipples may become extremely sensitive and very uncomfortable. This condition is sometimes called fibrocystic breast disease, fibrocystic breast changes, or cyclic mastalgia.

Very mild cases of mastodynia can be treated with mild analgesics and reassurance. The more severe forms respond well to a number of medication; The simplest of these is BCPs.

After starting low-dose, monophasic BCPs, the cyclic breast pain is usually immediately improved to some extent. In the months and years to come, the breasts usually become progressively less lumpy, less tender and less uncomfortable. BCPs are a very effective long-term treatment for this problem.

Also effective is the use of Danazol. Unfortunately, Danazol (800 mg/day) is expensive, not often available in operational settings, and has many significant side effects (unwanted hair growth, deepening of the voice, weight gain, clitoral hypertrophy, and others), which limit its' usefulness.

If these medications are unavailable, probably any medication which disrupts ovulation, such as Lupron, or DEPO-PROVERA, will be reasonably effective in stopping the cyclic breast pain that is so annoying to some women.

Midcycle Pain

Midcycle pain ("mittelschmerz") is the pain that can accompany ovulation. Typically occurring on about Day #14, the pain is unilateral, may occur on either side, and lasts for a few hours to a day or two.

It is not known why this ovulatory pain is so disabling to some women, is minor in other women, and not even felt by still other women.

The treatment of mild cases is usually reassurance and oral analgesics during the pain. For more significant symptoms, BCPs generally work very well at inhibiting ovulation and preventing the pain. Other alternatives include any medication which would interfere with ovulation, such as DEPO-PROVERA, or Lupron. The latter two, while effective, often have so many other side effects that the treatment is worse than the problem.

Acne

Acne is caused by a combination of hereditary predisposition (genetic factors) and stimulation of skin glands by male hormones. Both men and women produce both male and female hormones, but men mainly produce male hormones and women mainly produce female hormones.

In the second half of the menstrual cycle, particularly as menstruation is approaching, there is a fall in the amount of estrogen (female hormone), although the small amount of male hormone remains more or less constant. This results in a relative increase in the influence of the small amount male hormone present. In the susceptible woman, this will lead to increased acne just before the menstrual flow.

BCPs are usually effective in treating this. In fact, BCPs are usually helpful in treating acne in general, primarily because of the suppression of ovarian function. Since the ovaries produce about a third of all male hormone in women, this drop in male hormone levels is often sufficient to lead to improvement in acne.

Occasionally, (uncommonly) the BCPs aggravate the acne, and in these cases, the BCPs should be switched or stopped altogether. While some evidence suggests that Ortho-Cyclen and Demulen 1/35 may be more effective against acne than the other BCPs, good results can likely be obtained from any of them.

Headaches

Headaches may accompany the menstrual cycle and present in a number of ways.

Menstrual migraine headaches are common and temporarily disabling. They usually occur just before the onset of a menstrual flow or during the first day. They are triggered, in susceptible individuals, by the sudden drop in hormones accompanying the premenstrual phase. Good success in treating menstrual migraines can usually be achieved through the use of BCPs:

• In some cases, low-dose monophasic BCPs are effective at suppressing the menstrual migraines.

• In some cases, the 7 days "off" BCPs each month is too long and the accompanying hormone changes trigger the headaches. These women do well for a few days during their "off" week, but then develop headaches at the end of the week. For these women, shortening the "off week" to only 3 days will frequently provide them relief from their menstrual migraines. There is still a change in hormones, but about the time the menstrual migraine is going to begin, the reinstitution of the BCPs prevents the migraines from starting.

• In some cases, it will be necessary to go to continuous BCPs to achieve good migraine suppression.

• In some cases, BCPs are not effective in controlling the menstrual migraines and other treatments must be used.

Sinus headaches may be more pronounced during the days leading up to the menstrual cycle, due to changes in hormone levels and their impact on sinus mucosa and fluid retention. These headaches have their focus of pain in the paranasal sinuses which become sensitive to direct digital pressure, and also by the indirect pressure of putting the head down between the knees. In addition to the usual methods of treating sinus headaches (analgesics, decongestants, antihistamines, antibiotics, as appropriate), cyclic symptoms can often be controlled by BCP suppression of ovulation.

Tension or stress headaches may also worsen or improve, depending on the menstrual cycle. In these cases, hormone changes or fluid retention may play a role in the development of such headaches in susceptible individuals. BCPs can often improve these headaches, although occasionally, the BCPs may aggravate them. A therapeutic trial of BCPs is often undertaken.

Fluid Retention

The fluid retention just prior to menses usually amounts to a pound or less of extracellular fluid collected in the dependent extremities and to a lesser degree in the breasts.

Mild to moderate degrees of fluid retention are usually tolerated with reassurance while more dramatic forms are often treated. BCPs, by blocking ovulation and the accompanying hormonal changes are very effective at blocking the fluid retention elements of bloating.

Alternatively, any diuretic can be used and generally has very dramatic, though very temporary effects. Used every other day for a few days, diuretics in reasonable doses will generally keep fluid retention to a minimum, but with some risk of salt imbalance. Used more frequently or for longer periods of time, the risks of electrolyte imbalance increase. In operational settings, the risks of diuretic therapy very often are greater than any potential benefits in other than very extreme cases.

Abdominal Bloating

Progesterone has a quieting effect on smooth muscle contractility. Largely for this reason, gastrointestinal function usually slows to some degree during the second half of the menstrual cycle.

While most women do not notice the change, a few will notice bowel sluggishness, constipation, increased gas production and abdominal dissension. While this is not dangerous, it can be annoying. When combined with the natural tendency in many deployed settings to intentionally dehydrate (avoiding the problem of urination), constipation can become a quite significant problem.

BCPs can block this change in gastrointestinal function by virtue of the inhibition of ovulation and the hormone changes that go along with ovulation. Increasing dietary fiber and fluid intake can also be helpful. In extreme cases in operational settings, bulk laxatives or bowel stimulants may prove necessary.

Depression and Irritability

It is not known why some women, as they approach their menstrual flow, experience these mood changes. For most women, these symptoms are either very mild or absent, while others have moderate or severe symptoms. For them, the symptoms may begin around the time of ovulation and persist until the menstrual flow has begun. For others, the mood changes are limited to a day or two preceding the menstrual flow.

About 80% of women with moderate to severe premenstrual mood changes will obtain significant relief from BCPs. The blocking of ovulation seems to be the key element as very low dose pills or progestin-only pills do not seem to have the same effect.

If BCPs are not available or the patient is not a good BCP candidate, any medication which blocks ovulation will likely have the same effect. Unfortunately, some of these medications (Lupron, DEPO PROVERA, Danazol) have depression and irritability as potential side-effects, so the patient must be closely watched.

Anti-depressant medications (Prozac, etc.) are also about 80% effective in improving the mood changes associated with the premenstrual syndrome. These are not, however, the same 80% who benefit from BCPs, so for BCP failures, a therapeutic trial of antidepressant medication may be considered. Whether such a trial is appropriate in an operational setting should be individually determined.

Home