Normal Menstruation: The intervals of menstrual cycle the duration of flow and volume of flow remain relatively constant during reproductive years.
Normal Hormone Cycle:
1. 1st part cycle- estrogen halts flow and promotes endometrial proliferation
2. After ovulation- progesterone stops endometrial growth
3. No pregnancy occurs- the corpus luteum regresses, progesterone falls and endometrium sheds = period.
Common Issues & Reasons for Bleeding in no particular order
1. Iatrogenic/ Meds/ Hormone Imbalance
IUD– both normal and nonhormonal can cause heavy and irregular periods, especially within first 6 months of placement.
Hormonal birth control – Oral contraceptives, Estrogen, Progesterone. Sometimes can lengthen periods, usually the first few months after starting new medication. Fix-can change brands or change to higher dose estrogen.
Anovulatory Cycles
Early Menopause - can cause light periods for several months, seeming like it will not stop.
Thyroid (hypo or hyper) – can cause light periods for several months, seeming like it will not stop.
Hyperprolactinemia
Cushing’s Disease
PCOS – cysts affect hormone levels and fertility
Adrenal Dysfunction/ Tumor
Stress (emotional or from excessive exercise)
2. Infection
a. Endometriosis- tissue lining the uterus can swell and bleed with hormone changes. Also can cause pain and other complications.
b. Cervicitis
3. Benign Pelvic Pathology – can cause heavier and longer periods
a. Uterine Fibroids = muscular, usually benign tumors.
b. Endometrial Polyp- red growths on lining of uterus.
c. Cervical polyp
d. Leiomyoma
e. Adenomyosis
4. Pregnancy- light bleeding or spotting especially early in pregnancy.
a. Ovulation – spotting can last longer than usual
b. Complications of Pregnancy: Intrauterine pregnancy, Ectopic pregnancy (usually
painful), spontaneous abortion, gestational trophoblastic disease, placenta previa.
c. Miscarriage – causes bleeding and spotting for a few weeks.
5. Trauma
a. Laceration
b. Foreign Body
6. Perimenopause= pre-menopause. Periods can be less or more frequent as well as shorter or longer then typical.
7. Cancer – abnormal bleeding between periods or after intercourse.
a. Cervical = HPV is a type of cervical cancer.
b. Endometrial
c. Ovarian
8. Systemic Disease
a. Hepatic Disease- Liver
b. Renal Disease- Kidney
c. Coagulopathy
d. Thrombocytopenia
e. Von Willebrand’s Disease- rare but common blood disorder. You typically bleed for
5+ min after a cut or 10+ min w nosebleed and have frequent & easy bruising.
f. Leukemia
9. Dysfunctional uterine bleeding (DUB)- secondary to anovulation in premenopause vs endometrial hyperplasia or carcinoma with perimenopause. **The rest of this article talks about DUB** DUB usually related to hormone imbalance:
a. Estrogen breakthrough bleeding – excess estrogen stimulates endometrium to proliferate in an undifferentiated manner. With insufficient progesterone to provide structural support, portions of endometrial lining slough at irregular intervals. The usual progesterone-guided vasoconstriction and platelet plugging do not happen, this profuse bleeding.
b. Estrogen withdrawal bleeding – sudden decrease in estrogen levels, such as surgery or stop of hormonal therapy, or just before normal ovulation in menstrual cycle. Typically self limited and doesn’t recur if estrogen levels remain low.
c. Progesterone breakthrough bleeding – when progestereone to estrogen ratio is high, ex progesterone only contraceptive methods. The endometrium becomes atrophic and ulcerated b/c loss of estrogen and is prone to request irregular bleeding.
Initial testing
Lab work including: Thyroid (TSH, T4 and T3), Complete blood Count (CBC, platelet count) and Ferritin (Fe), Complete metabolic panel (CMP). Swab for Chlamydia/ Gonorrhea. Preg test (HCG). Hormones (Estrogen, Testosterone, FSH, LH, DHEA). PAP
Pelvic (PAP & Cultures) & Transvaginal Ultrasound (look for Pathology including: hyperplasia or carcinoma). If Endometrial stripe <5mm = atrophic endometrium. If > 5mm- get biopsy/ hysterectomy & refer.
Pregnancy test
Normal Exam BUT– premenopausal still bleeding
Ovulatory- Menorrhagia – Eval for bleeding disorder – Biopsy or US to exclude uterine pathology.
Ovulatory Polymenorrhagia- Eval for Luteal phase defect – OCP (oral contraceptives) or Clomiphene (serophene).
Ovulatory- Oligomenorrhea- Progesterone withdrawal every 3 months, OCT or Clomiphene induction.
Ovulatory- Intermenstrual bleeding – IUD? If yes- remove. If no- Cervical pathology?- If yes-treat, if no - bleed at ovulation? If yes- begin observation if No OCP.
Anovulatory- Adult- Get TSH & prolactin – if normal – Check for hypothalamic disorder (stress, eating disorder, high level exercise) – If yes- OCP or clomiphene. If No – Consider PCOS w chronic anovulation (LH, FSH, DHEA-s, Free Testosterone on day 3 of cycle).-->OCP, Progesterone withdrawal every 3 months or clomiphene for ovulation induction. **All causes of anovulation represent a progesterone-deficient state.
*There’s no progesterone if on OCP (bc suppress ovulation) or before ovulation, so you need to test about a week before your period actually comes. The more progesterone, the better. It’s not possible to have “too much” progesterone, except in the case of exogenous supplementation (taking progesterone).
TMT for DUB
Medroxyprogesterone, 10 mg x 10 days, monthly or “depo-Provera” IM 150mg every 3 months)
OCP- Oral contraceptives- Low dose (35μg) if premenopausal. 20μg if peri-menopausal.
Clomiphene, 50 to 150 mg per day on days 5 to 9. - Can induce ovulation in a woman who desires pregnancy.
Perimenopausal- Cyclic HRT – Increase progesterone if early withdrawal bleeding. Increase estrogen dose if intermenstrual bleeding is present.
Postmenopausal – Continuous combined HRT – Increase estrogen &/or progesterone 1-3 months to stabilize the endometrium. If bleeding continues, change to cyclic HRT or use a different type of estrogen.
*Progesterone helps coordinate regular uterine shedding when given as late luteal replacement on days 19-26. Long cycle use of progesterone may reduce menstrual bleeding. Progesterone is the dominant hormone during the secretory phase of menses and is a potent anti-inflammatory agent, limiting endometrial inflammation and protects against endometrial hyperplasia.
** Natural way to create your own Progesterone
1. Be well nourished with calories, protein, carbohydrate, fat, iodine, and zinc.
2. Correct underlying inflammatory issues such as dairy sensitivity, gluten sensitivity, mast cells and histamine issues, leaky gut, thyroid disease, or insulin resistance.
3. Reduce stress.
4. Consider taking ovulation-promoting herbs such as Vitex (chaste tree) or peony.
5. Remember the hundred days to ovulation and play the long game.
* "Natural" progesterone is derived from soybeans or, most commonly, from an inedible wild Mexican yam (Diascorea uillosa).
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