Change in your cycle?

If your periods get irregular, it's time to consult your gynaecologist

Shabnam has been concerned for the past 2 months. She is 41 years old and has always had very regular periods. Surprisingly, in the past two months she has had irregular bleeding. She called her mother this morning for advice. Should she go and see a gynaecologist? Is this something to be worried about? Women usually settle into a specific pattern of periods by the time they are in their early 20s. They are accustomed to that pattern and get very concerned if there is any change. It is normal for a period to last from 1-7 days. Counting from the first day of one period to the first day of the next period, an average cycle lasts about 28 days, but it can be longer or shorter. If the cycle is longer than 35 days or shorter than 21 days, it is considered abnormal. When the menstrual period is not regular, when bleeding lasts longer than normal, is heavier than normal, or when bleeding patterns change, it is called abnormal bleeding. Bleeding between periods, bleeding after intercourse, or spotting anytime in the menstrual cycle is also abnormal. This requires a check up with a gynaecologist because abnormal bleeding has a number of causes. CausesDuring puberty, and for the first few years after a girl begins to have periods (around 9-16 years of age), it is common to have irregular cycles because the system is still immature. This usually settles down without intervention. Between the ages of 35 and 45, it is very common to have changes in the pattern of periods. This happens because in some cycles, the normal process of ovulation gets missed. Closer to menopause, which is commonly around the age of 50, it is normal to skip periods or for the bleeding to become lighter or heavier. Uterine fibroids and polyps, both of which are non-cancerous growths in the uterus, can cause irregular bleeding. Certain types of cancers, such as cancer of the uterus, cervix, or vagina can also be first suspected because of abnormal bleeding. Medical conditions like thyroid hormone imbalance can also occasionally cause irregular bleeding. What is causing the abnormal bleeding? When a woman develops abnormal and irregular bleeding, and if the examination of the uterus reveals no abnormality, the gynaecologist will usually prescribe medications for a short time to regulate the periods, especially in younger women. If a cause other than hormonal imbalance is suspected, she might be investigated further. Ultrasound scan is the commonest investigation and is used to locate any abnormal growth in the uterus, like fibroids or polyps. Fibroids are the commonest benign (non-cancerous) growths in the uterus and almost 40 per cent of women will have them on an ultrasound examination. They may not necessarily be the reason for the abnormal bleeding. When the fibroid is pushing on the lining of the uterus or growing into it, then it can cause heavy bleeding. A hysteroscopy may be done in some women, especially in the postmenopausal age group. In this procedure, a thin telescope-like device is inserted through the vagina and cervix to view the inside of the uterus. Dilatation and curettage (D & C) is also a common procedure where the opening of the cervix is dilated and the tissue inside the uterus is gently scraped out. This tissue is then examined under the microscope for any microscopic abnormalities. TreatmentTreatment for abnormal bleeding will depend on many factors, including the cause, the woman's age, and the pattern and severity of the bleeding. Medications or surgical procedures may be offered. The commonest problem that women face is heavy bleeding. If there is no other abnormality, the best medications to control the bleeding are tranexamic acid and mefenamic acid. These medications reduce the flow by as much as 50-80 per cent when taken every month during the periods. Birth control pills or progesterone (a kind of hormone) may be prescribed to regulate the periods. They also may improve other symptoms like pain during periods. Different drugs may be prescribed if getting pregnant is the priority. A new kind of intrauterine device is available which contains a hormone. In women with heavy bleeding which is not controlled with tablets, this can be inserted into the uterus for 5 years and can reduce the bleeding by 70-80 per cent. It effectively avoids hysterectomy in many women. Hysteroscopy can be used to remove polyps or fibroids inside the uterus that are causing the bleeding. Endometrial ablation also is used to treat abnormal uterine bleeding. This treatment uses electricity, laser, heat, or freezing to destroy the lining of the uterus. Hysterectomy (removal of the uterus) is a procedure that may be used only when other forms of treatments have failed or are not an option. GITA ARJUN

(The author is a Chennai-based obstetrician and gynaecologist with a special interest in women's health issues)

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