MENSTRUAL / POLYCYSTIC DISEASES


Normal Menstrual Cycle
Common menstrual Disorders
Polycystic Ovarian Syndrome (PCOS)
Menopause


WHAT IS A NORMAL MENSTRUAL CYCLE?
The menstrual cycle is a biological result of a complex interaction between the reproductive system and the endocrine (hormone producing glands) system. This interaction is dedicated to the maintenance of the productive function and an appropriate hormonal balance in women. Any menstrual irregularity is symptom of a problem lurking somewhere in the two systems (reproductive and endocrine).

Normal may vary from person to person but in general a period every 24-32 days, lasting 3-7 days, average loss 30cc to 60cc, about 80% blood loss occurs in first two days.

The terms menstrual disturbance and menstrual abnormality refer to any change in menstrual flow or interval occurring in a postmenarchal, premenopausal female, which represents a significant variation in that individual.

Menstrual disturbance is a sign rather than a disease, and it should be remembered that pregnancy is the most common cause of change in the menstrual cycle or interval. In contrast, the term menstrual disorder refers to abnormal changes in menses arising from gynecologic causes other than pregnancy.

COMMON FEMALE MENSTRUAL DISORDERS
Any change in the menstrual pattern of a female would be broadly called as menstrual disorder
Amenorrhea - absence of periods
Primary amenorrhea - No periods since the age of puberty (no periods even after attaining 16 years of age).
Secondary amenorrhea - regular periods absent for at least three cycles wherein the individual earlier had regular cycles.
Dysmenorrhea - Painful periods or severe menstrual cramps. Uterine contractions occur during all periods, but in some women these cramps can be frequent and very intense. In such cases the condition is known as dysmenorrhea. This condition affects almost more than 50% of all post pubescent women.
Oligomenorrhea - Unusually infrequent periods. It is very common in early puberty and not usually worrisome, medical advice is needed only if periods occur at an interval of less than 20 days or more than 38 days.
Dysfunctional uterine bleeding - Excessive bleeding with an unknown cause.
Hypomenorrhea - Unusually light periods.
Polymenorrhea - Unusually frequent periods.
Postmenopausal bleeding - Bleeding that occurs after menopause.

PREMENSTRUAL SYNDROME (PMS): Physical and psychological symptoms that occur before the start of a period. Premenstrual syndrome (PMS) is a set of physical, emotional, and behavioral symptoms that occur during the last week of the luteal phase (a week before menstruation) in most cycles. The symptoms should typically resolve within four days after bleeding starts and not start until at least day 13 in the cycle. Women may begin to experience premenstrual syndrome symptoms at any time during their reproductive years. Once established, the symptoms tend to remain fairly constant until menopause, although they can vary from cycle to cycle. About 100 different symptoms have been identified with the premenstrual phase.

The cause of premenstrual syndrome is not known but severe symptoms have been shown to be responsive to lifestyle changes. Getting exercise several times a week, eating a balanced diet, getting adequate sleep, and reducing or eliminating caffeine and alcohol are some of the changes most often recommended. Medical treatment may also help.

Evaluation is usually made by history and symptoms; there are no specific physical findings or laboratory abnormalities.

POLYCYSTIC OVARIAN SYNDROME (PCOS)
PCOS is a health problem that can affect a woman’s menstrual cycle, fertility, hormones, insulin production, heart, blood vessels and even appearance.

If your hormones don't work in the normal way, your ovaries might end up making too many eggs. Those eggs turn into many cysts. These cysts are like little balloons filled with liquid or fluid-filled sacs. PCOS often begins in the teenage years and usually requires longer treatment duration. Even women in their childbearing years can suffer from it. An estimated 5 to 10 percent of women between 16-40 years of age have PCOS.
PCOS is the most common hormonal reproductive problem in women of childbearing age.

SIGNS & SYMPTOMS OF PCOS:
Infrequent or absent menstrual periods, and/or irregular bleeding.
Infertility or inability to get pregnant because of anovulation.
May or may not have many small cysts in their ovaries.
High levels of male hormones, also called androgens.
Increased growth of hair on the face, chest, stomach, back, thumbs, or toes acne, oily skin, or dandruff (due to androgens).
Pelvic pain.
Weight gain or obesity, usually carrying extra weight around the waist.
Male-pattern baldness or thinning of hair.
Type 2 diabetes (because of hyperinsulinaemia).
High blood pressure.
High cholesterol.

Why do women with Polycystic Ovarian Syndrome (PCOS) have trouble with their menstrual cycle?
The ovaries are two small organs one on each side of the uterus secreting female hormones the most important being estrogens. A woman's ovaries have follicles, which are tiny sacs filled with liquid that hold the eggs. These sacs are also called cysts. Each month about 20 eggs start to mature, but usually only one becomes dominant. As the one egg grows, the follicle accumulates fluid in it. When that egg matures, the follicle breaks open to release the egg so it can travel through the fallopian tube for fertilization. When the single egg leaves the follicle, ovulation takes place.

In women with PCOS, the ovary doesn't make all of the hormones it needs for any of the eggs to fully mature. They may start to grow and accumulate fluid. But no one egg becomes large enough. Instead, some may remain as cysts. Since no egg matures or is released, ovulation does not occur and the hormone progesterone is not made. Without progesterone, a woman’s menstrual cycle is irregular or absent. Also, the cysts produce male hormones, which continue to prevent ovulation.

In girls with PCOS, the ovaries produce higher than normal amounts of androgens, and this can interfere with egg development and its release. Some of the eggs develop into cysts, which are little sacs filled with liquid. Instead of being released during ovulation, as an egg is during a normal menstrual cycle, the cysts build up in the ovaries and may become enlarged. Because of the way the cyst production interferes with the menstrual cycle, it's common for girls and women with PCOS to have irregular or missed periods.

After menopause the level of male hormones reduces but even with falling male hormone levels, excessive hair growth continues, and male pattern baldness or thinning of hair continues and may get worse after menopause.

MANAGEMENT OF PCOS
Because of the affect on a woman’s menstrual cycle, it is often necessary to have some help in regulating and managing periods. One way of regulating menstruation is by losing weight, something which can be difficult for women with PCOS but not at all difficult at Jalan’s Health & Diabetes Care Centre. Women looking to get pregnant may experience infertility issues necessitating the use of infertility treatments in order to conceive.

Because no exact cause for PCOS is known, a cure for PCOS is currently not available allopathically but here homeopathy comes to your rescue. At Jalan’s Health & Diabetes Care Centre we have successfully treated cases of PCOS and delivered results in a period of 1-3 months. In some cases though, women with PCOS might require long-term management. Losing weight might be necessary.

MENOPAUSE
Menopause is the time of cessation of ovarian function resulting in permanent amenorrhea. It takes about 12 months of amenorrhea to confirm that menopause has set in, and therefore it is a retrospective diagnosis. Climacteric is the phase of waning ovarian activity, and may begin 2 to3 years before menopause and continue for 2 to 5 years after it. Climacteric is thus a phase of adjustment between the active and inactive ovarian function and occupies several years of a women’s life, and involves physical, sexual and psychological adjustments.

Age
Menopause normally occurs between the age of 45 and 50 years; the average age being 47 years. It is not uncommon however to see a women menstruate well beyond the age of 50. This delayed menopause may be related to good nutrition and better health. Late menopause is also common in women suffering from uterine fibroids and those at the risk for endometrial cancer. Menopausal age is directly associated with smoking and genetic disposition. Smoking induces premature menopause i.e. menopause setting before the age of 40.

Pathophysiology
During climacteric, ovarian activity declines. Initially ovulation fails, no corpus luteum forms, and progesterone is not secreted by the ovary. Therefore the premenopausal menstrual cycles are often anovulatory and irregular. Later graffian follicle also fails to develop, estrogenic activity is reduced, and endometrial atrophy leads to amenorrhea. Cessation of ovarian activity and fall in the oestrogen level as well as inhibin levels cause a rebound increase in the secretion of FSH and LH by the anterior pituitary gland.

Menopausal urine has become an important commercial source of gonadotropin (hMG).
With further advancing years, gonadotropin activity of the pituitary gland also decreases and a fall in FSH level eventually occurs.

Anatomical Changes
The genital organs undergo atrophy and regression.
The ovaries shrink and their surfaces become grooved and furrowed.
The plain muscle in the fallopian tube undergoes atrophy, cilia disappear from the tubal epithelium, and the tubal plicae are no longer prominent.
The uterus becomes smaller through atrophy of its plain muscle.
It is common for the endometrial glands to dilate before menopause sets in and cystic glandular hyperplasia reported in some premenopausal women cause metropathia haemorrhagica, with irregular heavy bleeding.
The cervix becomes smaller and its vaginal portion is represented by a small prominence at the vaginal vault.
The vaginal fornices gradually disappear, vagina becomes narrow and its epithelium becomes pale, thin and dry and gets easily infected causing senile vaginitis.
The vagina atrophies and the vaginal orifice narrows and this can cause dyspareunia (painful intercourse).
The skin of the labia minora and vestibule becomes thin pale and dry. The pubic hair is reduced and becomes grey.
The red patches seen around the urethra and introitus are caused by senile vulvitis and a urethral caruncle may be produced.
The pelvic cellular tissue become lax and the ligaments that support the uterus and vagina lose their tone, and predispose to prolapse of genital organs.
The skin wrinkles and hair may grow around the chin and lips.Arthritis, osteoporosis of the vertebral bones, upper end of the hip joint, and wrist are all related to oestrogen deficiency after menopause.

Menopausal symptoms
Early features of menopause

Hot flushes
Sweating
Insomnia
Headache
Psychological
Cancer phobia
Irritability, depression
Lack of concentration
Progressive diminution in the amount of blood loss during menstruation
Gradual increase in the spacing between periods
Palpitations
Increase or decrease in sexual desire
Recurrent urinary tract infections
Stress incontinence
Dryness of vagina


Investigations
History of various symptoms
General examination-include blood pressure recording, palpation of the breasts, weight,
Pelvic examination- Pap Smear
Blood sugar, lipid profile, ECG
Mammography, pelvic ultrasound
Bone density study. DEXA is a quick test with less radiation
Oestrogen (E2) level, FSH to decide on the need of hormone replacement therapy (HRT).