Menstruation (Greek Word, men – month) is monthly uterine bleeding outflowing through vagina onto vulva for 4-5 days every 28 days during reproductive life of a women from menarche to menopause. Menses are normal uterine function whereby endometrium prepares to receive pregnancy.

The menstrual cycle of 28 days starts on day of onset of menstruation (day 1) and ends at day 28 on start of next mens.

Menstruation signals that fertilization and embedding of fertilised ovum have not occurred on the preceding menstual cycle. Anovular menstruation is cyclical monthly bleeding from only oestrogen primed endometrium. This occurs for a few years after onset of menstruation (menarche) and before final cessation of menstruation (menopause).

Clinical features

Symptoms

1. Feeling of heaviness and discomfort in the pelvis, lower abdomen and in the small of the back.
2. Feeling of pricking and fullness in the breasts.
3. Frequency of urination and constipation.
4. Feeling of lassitude, irritability, and headache. Above symptoms vary in severity from individual to individual. Rarely, bleeding from nose may occur as vicarious menstruation' since blood viscosity falls at mens.

Signs

1. Sudden drop in temperature of about 1 degree F but with individual variations.
2. Pulse rate and blood pressure tend to drop.
3. Gain in weight occurs during premenstrual fortnight upto about I Kg. due to retention of water and salt; it occurs in about half of women. There is loss of weight with the onset of flow.
4. Menstrual loss (mens). The vaginal menstrual bleeding mainly arterial, partly venous is a dark reddish liquid (not clotted) blood with shed endometrial tissue bits. The discharge has disagreeable smell due to the secretion of vulvar sebaceous glands and decomposition of blood elements. Menstrual blood is deficient in prothrombin, and fibrinogen but rich in calcium. Microscopically, it contains red cells, large number of leucocytes, vaginal epithelium, cervical mucus, fragments of endometrium with macrophages, histiocytes, mast cells and bacteria, Menstrual discharge also contains cholesterol, oestrogen, lipids and prostaglandins. Menstrual blood from the endometrium clots in the uterine cavity by its thromboplastic property. The clots are dissolved by the fibrinolysins released from the endometrium. Fibrin degradation products therefore circulate in increased amount during menstruation. Clots are passed when mens¬trual bleeding becomes excessive.

Interval and Duration

The menstrual cycle lasts on an average twenty eight days. A deviation of 2 to 3 days can be frequently encountered. The extremes of 21 and 35 days interval may also be found. In any woman's menstrual life, the interval can vary. The usual duration is three to five days with essentially normal extremes of two and seven days. Every woman needs sex education in this normal range of menstrual pattern so that she does not suffer from miseducation on normal menstrual pattern taken as menstrual irregularity.

Blood Loss

The average total blood loss during menstruation has been estimated as 35 ml (range 5 60 ml); average loss of iron was found as 12 mg. A rough clinical estimate is that normally not more than three fresh pads are necessary in the twenty four hours two during the day and one at night, thus requiring total 12 15 pads during a rnens. This loss widely varies and becomes greater in women living in warm climate than those living in cold climate.

Management

Proper education on mens is important. She should be educated that menstruation is not the drainage of noxious substance from the body but a normal manifestation of womanhood. During menses, she should carry on her usual activities including daily bathing, playing games. Personal hygiene is maintained by changing regularly sanitary pads. Intravaginal tampons can be used by the married provided she does not forget to leave it behind. Healthy couple can have sexual intercourse during menses. Postponement or advancement of menstruation. This becomes at times necessary for important social reason like marriage. This is not to be advocated on flimsy ground. The hormone therapy employed is the following:

1. Progesterone norethisterone one tab. thrice daily starting from 20th day of menstrual cycle till beyond the date of postponement.
2. Oestrogen progestogen contraceptive pills, two a day is started from the 20th day. Menstrual flow is expected 2 to 3 days after the treatment is suspended. Menstruation can be pre¬maturely brought by starting hormone therapy from 5th day of mens for 14 days, The therapy is (a) Oestrogen ethinyl oestradiol 0.05 mg. t.d.s. or (b) Oestrogen progestogen oral pill once daily. Anovulax menstrual flow is likely to begin within 2 3 days of the cessation of therapy.

Play of sex hormones from hypothalamus in brain, anterior pituitary gland, ovary causes menstrual bleeding from uterine endometrium.

Steps are-

1. In the brain, hypothalamus acts as switch to endocrine mechanism of menstruation and starts the process by secreting gonadotrophin releasing hormone (GnRH) or (LHRH) by peptidergic neuron. The latter is controlled by aminergic neuron. Environment influences menstruation via cerebral cortex and hypothalamus.

GnRH flows down from hypothalamus via pituitary portal vessels to

↓

2. Anterior pituitary gland (gonadotroph cells) liberating follicle stimulating Hormone (FSH) and Luteinising hormone (LH) in blood circulation to initiate growth of ovarian follicles in both ovaries.

↓

Ovarian Cycle. Ovarian follicles (20 in number) are grown in a menstrual cycle in three steps.

(a) ovarian Follicles are grown from primordial follicles. A single graarian follicle matures and becomes dominant by effect of FSH while other follicles undergo atresia.

(b) Oestradiol is secreted by maturing ovarian follicle in the circulation → stimulates hypothalamus and anterior pituitary to cause surge of LH and FSH hormones in blood (Positive feed back) on day 12 of menstrual cycle.

(c) Ovulation (discharge of ovum from ovary) occurs on day 14 of menstrual cycle. Corpus luteum (yellow body) is formed in the shell of mature graafian follicle ovulation due to LH effect.

Corpus luteum remains mature From day 19‑26, degenerates on day 27 and 28 if no pregnancy occurs in menstrual cycle'. Plasma prolactin (from anterior pituitary) rises (luring luteal phase and appears to maintain corpus luteum. Copious progesterone hormone., some oestradiol and inhibin (peptide hormone) are secreted by corpus luteum. Oestradiol causes luteolysis while inhibin depresses FSH.

Uterine cycle

(a) Proliferative phase

Oestradiol from ovarian follicles causes proliferative changes in uterine endometrium (day 7‑14). All the endometrial tissue elements of I mm thick proliferate. Prior to start of proliferative phase, repair phase. runs with mens bleeding and ends by 48 hours after mens.

(b) Secretory phase. Progesterone (from corpus luteum) causes secretary changes in endometrium (day 15‑26) to receive fertilised ovum for embedding. Glycogen appears as subnuclear vacuoles in endometrial gland followed by secretion of glycogen and mucus on the lumen of gland. Glands become Corkscrew . Endometrial vessels become coiled, stroma becomes vascular and oedernatous. Endometrium thickens to 5 mm into three layer (a) superficial compact layer with neck ot'glands (b) spongy layer with dilated glands (c) basal layer in contact with myometrial layer.

Stage of regression occurs in secretory endometriurn on day 27 to 28.

(c) Menstrual bleeding phase occurs for 4‑5 days after day 28 of the cycle due to shedding away of endometrial bits and bleeding from endometria I bed. Necrosis and shedding of endometrial bits extend from region to region during first 2 days of menses. Bleeding occurs as (a) capillary bleeding with or without the formation of subepithelial haematoma (b) venous haemorrhage and (c) diapedisis.

Menstrual phase is caused by withdrawal of oestradiol and progesterone support to endometrium.. FSH rises again to start another, cycle.

Cause of menstrual bleeding. Exact cause is still obscure. The sequence of events are :

Withdrawal of oestrogen and progesterone due to degeneration of corpus luteum →rapid shrinkage and regression of secretory endometrium overcoiling of endometrial spiral arterioles → stasis of circulation in the functional layer of endometrium → necrobiosis of vessels. Prostaglandins elaborated by endometrium also cause vasospasm of spiral vessels → ischaemic necrosis of bit of endometrium suppfied by spiral artery → relaxation of spiral vessel bleeding from spiral vessel end. These vascular changes are described by Markee (1940)

In the shedding process clotting and fibrinolysis at bleeding site occur so that unclotted dark red blood with endometrial tissue bits are discharged for 4‑5 days. Dating of endometrium. Endometrium is dated from its histological appearance particularly during secretory phase e.g. prenuclear vacuoles ‑ 16th day, basal nuclei, secretion in gland lumen ‑ 20th day.

Menstrual Disorders

For every day of every month, there seems to be a different word to describe the way a woman's body changes during "that time of the month." Whether there's too much or too little bleeding, pain and bloating, or mood swings, menstrual disorders can mess with a woman's mind as well as her physical wellbeing. Luckily, according to the American College of Obstetricians and Gynecologists (ACOG), many symptoms of menstruation can be managed, and many disorders can be treated.

The cycle

The monthly menstrual cycle, according to the National Women's Health Information Center (NWHIC), is how a woman's body prepares for the possibility of pregnancy. A girl, according to NWHIC, usually starts menstruating when she is about 12 years old. NWHIC says a cycle can range from 23 to 35 days, but on average is usually 28 days. During this cycle, an egg, released from an ovary, travels down the fallopian tubes towards the uterus. The uterus has been preparing for this by building up a lining of extra blood and tissue. If the egg is fertilized by a sperm cell, the fertilized egg will attach itself to the uterine wall marking the beginning of pregnancy. If the egg is not fertilized, the thick uterine lining and extra blood will be shed through the vaginal canal. That expulsion of blood and tissue is what is commonly called a period. A period, according to ACOG, usually lasts between three and seven days. After the period ends, the cycle begins all over again.

Some common menstrual disorders include:

• Amenorrhea (lack of periods)
• Dysmenorrhea (painful periods)
• Menorrhagia (heavy or lengthy periods)
• Metrorrhagia (spotting)
• Premenstrual Syndrome

Below you'll find information on all these issues.

Amenorrhea

If a woman's regular periods stop at any age, or a teenager fails to develop a menstrual cycle, she may have amenorrhea. ACOG says the most common reason for a missed period is pregnancy, and suggests taking a pregnancy test. ACOG says several other reasons for missed periods include:

• illness
• sudden change in weight
• eating disorders
• extreme exercise
• hormone irregularities
• certain medications
• stress or emotional trauma such as the death of a spouse or close family member

ACOG advises that you see your health care provider if you haven't had a period by age 16, or if you miss periods frequently.

While exercise is important for our health and well being, it can also pose some medical problems for teenage girls and women. According to the American Academy of Pediatrics (AAP), female athletes can be at risk for menstrual disorders such as amenorrhea. AAP says if this is the case, menses may be delayed until age 16, there may be fewer menstrual cycles or periods may occur after the 35th day of a cycle, rather than the 28th day, which is considered average. Part of the problem, according to AAP, may stem from the athlete burning too many calories, and not eating enough. AAP stresses that menstrual dysfunction is not a normal result of exercise and can cause a decrease in bone mineral density.

Dysmenorrhea

Painful periods can be put in two different groups, according to FDA:

• primary dysmenorrhea
• secondary dysmenorrhea

Primary dysmenorrhea will usually start within three years of a girl's first period. FDA says it will last one or two days a month, and can continue through menopause. Primary dysmenorrhea is believed to be caused by the normal production of chemical substances called prostaglandins. These prostaglandins make the uterus contract, sometimes so much that the blood supply is cut off for a short time, depriving the uterine muscle of oxygen. That process can cause painful cramping.

Newer pain relievers are helping dull the ache many women feel as their periods begin. Nonsteroidal anti-inflammatory drugs (NSAIDS) have provided much needed relief for many women according to FDA, because they hamper the production of prostaglandin. These medications can be found in prescription form, or over-the-counter. Hormonal medications are sometimes prescribed to help relieve cramping, and FDA says exercise is thought to be of some benefit as it raises levels of the brain's pain relieving chemicals.

Secondary dysmenorrhea, according to FDA, is pain caused by disease. Uterine fibroids, pelvic inflammatory disease and endometriosis all fall into this category. FDA says one indication that disease is causing the menstrual pain is if pain also occurs at other times during the month or during intercourse. You should seek your healthcare provider's advice should you have concerns about any abnormal pain.

Menorrhagia and Metrorrhagia

A heavy flow during periods and/or lengthy menstrual periods could be diagnosed as menorrhagia. Bleeding or spotting between periods is known as metrorrhagia. The two, alone or together, can be called dysfunctional uterine bleeding. This abnormal uterine bleeding may, according to the U.S. Food and Drug Administration (FDA), be caused by a number of different problems:

• hormonal imbalance
• fibroids
• overgrowth of endometrial tissue
• a bleeding disorder called von Willebrand Disease
• cancer
• thyroid abnormalities
• other conditions

Sometimes, according to FDA, there is no identifiable cause for the bleeding.

Once your physician or healthcare provider is able to diagnose the cause of the abnormal bleeding, a treatment program can begin. There are options to discuss with your doctor.

• Medication - FDA says doctors usually start with medications. Some FDA approved estrogens and progestins are used to treat abnormal uterine bleeding.
• D and C - D and C is also known as dilatation and curettage. It is a procedure in which the physician first dilates or opens the woman's cervix and then inserts a thin, spoon-shaped instrument and uses it to scrape (curettage) the lining of the uterus. The American College of Surgeons says D and C can be used to diagnose, or to treat heavy menstrual bleeding. D and C is often combined with a procedure called hysteroscopy, a procedure to look into the uterus through the cervix with a small telescope-like instrument. If fibroids or other abnormal structures are found, they can often be removed with the hysteroscope.
• Hysterectomy - A hysterectomy can, according to FDA, help improve the life of some women who suffer from abnormal uterine bleeding. The surgery, which involves the removal of the uterus, is somewhat common in this country. The Centers for Disease Control and Prevention (CDC) say five out of every 1,000 women have the operation every year. Not all of those procedures are to treat abnormal bleeding however; some are to treat cancers. Experts warn that it should be the last step in finding a way to resolve abnormal bleeding. Removal of the uterus will leave a woman sterile. The surgery may be done conventionally or robotically.
• Endometrial Ablation - FDA calls endometrial ablation, a viable alternative to a hysterectomy. Endometrial ablation, according to FDA, is a minimally invasive surgery using electrical energy, heat or cold to destroy the endometrium (uterine lining). This may minimize the bleeding, but FDA warns the results may last just a decade and the procedure may not be for everyone. FDA does not advise endometrial ablation for women who want to have children. However, it is still possible to get pregnant after endometrial ablation but it would be considered a high risk pregnancy. While complications are rare, FDA says blood loss, accidental damage to internal organs and perforation of the uterus are possible.
• Fibroid treatment - If fibroids are found to be the cause of the heavy bleeding, FDA says there are medications, called gonadotropin-releasing hormone agonists, your physician may prescribe that will temporarily shrink the fibroids. It involves an injection that temporarily stops estrogen production. These medicines can be used for 3 months, six months or even longer if indicated and with proper monitoring. FDA warns that side effects can include loss of bone density and hot flashes. If the fibroids are causing pain and anemia because of heavy bleeding, FDA says there are several surgical options for removing fibroids:

  • Myomectomy - surgically removing only the fibroids.

  • Myolysis - shrinking the fibroids using electric current or a laser.

  • Uterine Fibroid Embolization (UFE) or Uterine Artery Embolization (UAE) - cutting off the blood supply to the fibroids.

  • Hysterectomy - surgical removal of the uterus.

  FDA says no treatment, other than a hysterectomy, can guarantee an end to abnormal uterine bleeding and fibroids.

Premenstrual Syndrome (PMS)

Premenstrual syndrome is not only real, but it's downright bothersome. According to ACOG, 20 to 40 percent of all women suffer symptoms of PMS, which occurs in the last 7 to 10 days of the menstrual cycle. FDA puts these symptoms into four groups:

Group 1

• Breast tenderness
• Swelling
• Weight Gain
• Bloating

Group 2

• depression

• forgetfulness

• crying

• confusion

• trouble sleeping

Group 3

• headaches

• cravings for sweets

• increased appetite

• dizziness

• fatigue

Gropu 4

• nervous tension

• anxiety

• irritability

• mood swings

You are not alone if you happen to suffer from such a problem. There are many women in every country who face this problem. Your chance of vaginal dryness increases once you have your menopause. The main reason for any one to suffer vaginal dryness is mainly due to reduction in estrogen production which leads to the drying and thinning of the vagina wall.

This creates problem in your sex life as there is complete loss of libido. As vagina is not properly lubricated making your sexual intercourse painful and a less pleasurable activity. General feeling at the vaginal area is that of itching and burning which can be very irritating. By lubricating your vagina this problem can be solved. Due to constant soreness any kind of sexual activity becomes more of pain than fun.

Vaginal dryness during and after menopause, is a much known fact. This kind of problem does not concern older women only or those who all are going through menopause. It can be a problem for any women. Some of the common and known causes other than reduction of estrogen level are cancer treatment medication, yeast infection, vaginal bacterial infection, douching and many more.

Reasons due to which estrogen levels fall are

The best thing to do at these times is to see to it that you are always hydrated. Drinking 8-10 glasses of water everyday should be followed religiously. This kind of drinking would help you in the long run. There should be an open communication between the partners which would help you to deal with the issue. Openness about such matters makes the problem very feeble and less important. As this problem can be easily solved by some simple measures at home and if that doesn’t help a doctor can always help.

Some ways to ward off Vaginal Dryness