Features of Menstruation
Onset of Menstruation (Menarche)
The first menstruation, called the menarche, typically occurs between the ages of 12 and 13 years. Menarche generally occurs 2 to 3 years after initial breast development (breast budding). A higher body mass index (BMI) during childhood is associated with earlier puberty and menarche. Environmental factors and nutrition may also influence the age at which menstruation begins. There is a global historic trend for earlier age at menarche that manifested over the last two centuries.
Length of Monthly Cycle
The average menstrual cycle duration is about 28 days but anywhere from 21 days to 35 days is considered normal. Cycles tend to be longer during the teenage years and they also lengthen when a woman reaches her 40s. Cycle length is most irregular around the time that girls first start menstruating (menarche) and when women stop menstruating (menopause).
Duration of Periods
Most women bleed for around 3 to 5 days but a normal period can last anywhere from 2 to 7 days.
Normal Absence of Menstruation
Normal absence of periods can occur in any woman under the following circumstances:
· Menstruation stops during pregnancy. Some women continue to have irregular bleeding during the first trimester. This bleeding may indicate a miscarriage and requires immediate medical attention.
· When women breast-feed they are unlikely to ovulate. After that time, menstruation usually resumes, and they are fertile again. However, women may be fertile even if they don’t menstruate and some women may be fertile while breast feeding. So it’s always wise to use contraception even while breast feeding.
· Perimenopause (transition to menopause) starts when the intervals between periods begin to lengthen, and it ends with menopause itself (the complete cessation of menstruation). Menopause usually occurs at about age 51, although smokers often go through menopause earlier.
Menstrual Disorders
There are several types of menstrual disorders. Problems can range from heavy, painful periods to no periods at all. There are many variations in menstrual patterns, but in general women should be concerned when periods come fewer than 21 days or more than 3 months apart, or if they last more than 10 days. Such events may indicate ovulation problems or other medical conditions.
Dysmenorrhea (Painful Cramps)
Dysmenorrhea is severe, frequent cramping during menstruation. Pain occurs in the lower abdomen but can spread to the lower back and thighs. Dysmenorrhea is usually referred to as primary or secondary:
· Primary dysmenorrhea. Cramping pain caused by menstruation. The cramps occur from contractions in the uterus and are usually more severe during heavy bleeding.
· Secondary dysmenorrhea. Menstrual-related pain that accompanies another medical or physical condition, such as endometriosis or uterine fibroids.
Menorrhagia (Heavy Bleeding)
Menorrhagia is the medical term for significantly heavier periods. Menorrhagia can be caused by a number of factors.
During a normal menstrual cycle, the average woman loses about 1 ounce (30 mL) of blood and changes her sanitary products around 3 to 5 times per day.
With menorrhagia, menstrual flow lasts longer and is heavier than normal. The bleeding occurs at regular intervals (during periods), but may last more than 7 days, and menstrual flow soaks more than 5 sanitary products per day or requires product change during the night. Clot formation is common. Menorrhagia is often accompanied by dysmenorrhea because passing large clots can cause painful cramping.
Menorrhagia is a type of abnormal uterine bleeding. Other types of abnormal bleeding are:
· Metrorrhagia. Also called breakthrough bleeding, refers to bleeding that occurs at irregular intervals and with variable amounts. The bleeding occurs between periods or is unrelated to periods. Spotting or light bleeding between periods is common in girls just starting menstruation and sometimes during ovulation in young adult women.
· Menometrorrhagia. Refers to heavy and prolonged bleeding that occurs at irregular intervals. Menometrorrhagia combines features of menorrhagia and metrorrhagia. The bleeding can occur at the time of menstruation (like menorrhagia) or in between periods (like metrorrhagia).
· Dysfunctional uterine bleeding (DUB). A general term for abnormal uterine bleeding that usually refers to extra or excessive bleeding caused by hormonal problems, usually lack of ovulation (anovulation). DUB tends to occurs either when girls begin to menstruate or when women approach menopause, but it can occur at any time during a woman’s reproductive life. This term is not often used by most gynecologists.
· Other types of abnormal uterine bleeding. Include bleeding after sex and bleeding after menopause. Postmenopausal bleeding is not normal and can be a sign of a serious condition.
Amenorrhea (Absence of Menstruation)
Amenorrhea is the absence of menstruation. There are two categories: primary amenorrhea and secondary amenorrhea. These terms refer to the time when menstruation stops:
· Primary amenorrhea. Occurs when a girl does not begin to menstruate by age 16. Girls who show no signs of sexual development (breast development and pubic hair) by age 13 should be evaluated by a doctor. Any girl who does not have her period by age 15 should be evaluated for primary amenorrhea.
· Secondary amenorrhea. Occurs when periods that were previously regular stop for at least 3 months.
Oligomenorrhea (Infrequent Menstruation) and Hypomenorrhea (Light Menstruation)
Oligomenorrhea is a condition in which menstrual cycles are infrequent, occurring more than 35 days apart. It is very common in early adolescence and does not usually indicate a medical problem. Light or scanty flow is also common in the first years after menarche and before menopause.
When girls first menstruate they often do not have regular cycles for several years. Even healthy cycles in adult women can vary by a few days from month to month. Periods may occur every 3 weeks in some women, and every 5 weeks in others. Flow also varies and can be heavy or light. Skipping a period and then having a heavy flow may occur; this is most likely due to missed ovulation rather than a miscarriage.
Premenstrual Syndrome (PMS)
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 typically do not start until at least day 13 in the cycle, and resolve within 4 days after bleeding begins.
Women may begin to have premenstrual syndrome symptoms at any time during their reproductive years, but it usually occurs when they are in their late 20s to early 40s. Once established, the symptoms tend to remain fairly constant until menopause, although they can vary from cycle to cycle.
Risk Factors
Age plays a key role in menstrual disorders. Girls who start menstruating at age 11 or younger are at higher risk for severe pain, longer periods, and longer menstrual cycles.
Women who are approaching menopause (perimenopause) may also skip periods. Occasional episodes of heavy bleeding are also common as women approach menopause.
Other risk factors include:
· Weight. Being either excessively overweight or underweight can increase the risk for dysmenorrhea (painful periods) and amenorrhea (absent periods).
· Menstrual Cycles and Flow. Longer and heavier menstrual cycles are associated with painful cramps.
· Pregnancy History. Women who have had a higher number of pregnancies are at increased risk for menorrhagia. Women who have never given birth have a higher risk of dysmenorrhea, while women who first gave birth at a young age are at lower risk.
· Smoking. Smoking can increase the risk for heavier periods.
· Stress. Physical and emotional stress may block the release of luteinizing hormone, causing temporary amenorrhea.
· Exercise. Intensive athletic training is linked with late menarche and amenorrhea or oligomenorrhea.
Complications
Anemia
Menorrhagia (heavy menstrual bleeding) is the most common cause of anemia (reduction in red blood cells) in premenopausal women. A blood loss of more than 80 mL per menstrual cycle can eventually lead to anemia. Most cases of anemia are mild. Nevertheless, even mild-to-moderate anemia can reduce oxygen transport in the blood, causing symptoms such as fatigue, lightheadedness, and pale skin. Severe anemia that is not treated can lead to heart problems.
Osteoporosis
Amenorrhea (absent or irregular menstrual periods) caused by reduced estrogen levels is linked to osteopenia (loss of bone density) and osteoporosis (more severe bone loss that increases fracture risk). Because bone growth is at its peak in adolescence and young adulthood, losing bone density at that time is very dangerous and early diagnosis and treatment is essential for long-term health.
Osteoporosis is a condition characterized by progressive loss of bone density, thinning of bone tissue, and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency, or advanced age. Regular weight-bearing exercise and strength training, and calcium and vitamin D supplements, can reduce and even reverse loss of bone density.
Infertility
Some conditions associated with heavy bleeding, such as ovulation abnormalities, fibroids, or endometriosis, can contribute to infertility. Many conditions that cause amenorrhea, such as ovulation abnormalities and PCOS, can also cause infertility. Irregular periods from any cause may make it more difficult to conceive. Sometimes treating the underlying condition can restore fertility. In other cases, specific fertility treatments that use assisted reproductive technologies may be needed.
Quality of Life
Menstrual disorders, particularly pain and heavy bleeding, can affect school and work productivity and social activities.