Menstruation is a normal physiological event occurring in a woman in the reproductive years.  Normal menstruation occurring in normal quantities is reassuring to the woman, in spite of the small inconveniences experienced during the period.  Any change from the normal pattern gives rise to anxious moments. The reasons for abnormal bleeding varies according to the age of the patient.  In the years following the first menarche and in the years preceding menopause, there may be disorders of ovulation. Ovulation is the normal process of extrusion of ova in women). In the reproductive years, bleeding may occur in spite of normal ovulation.  Besides these hormonal abnormalities, tumours in the uterus or ovaries could cause excessive or irregular uterine bleeding.

  In the following section, a few of the commonly faced situations are discussed.

Q:What is normal menstruation?

A: Normal menstruation means menstruation occurring once in 28-35 days,  the flow being   moderate in amount for the first 2-3 days and petering out to a complete stop in 7 days time. 

Case example:A young 12 year old girl who has attained menarche (first menstruation) 6 months back comes with bleeding coming on every 15 days.  The flow is not heavy, but it is bothersome and the girl is not able to concentrate in her studies. Does it need medical intervention?

A;Menstruation is a result of the combined efforts of the uterus, the ovaries and the brain.  In the first few years after mernarche, menstruation tends to be a bit irregular, because the body systems are yet to mature.  In due course of time it may mature and regular menstruation may ensue.  Meanwhile there may be signs of anaemia like inability to concentrate, etc.  Taking iron tablets with a good nutritious diet will help in tiding over the situation.  If the menstruation still does not become normal, taking oral contraceptive pills for 3 months will help.  As the flow is not very heavy, probably detailed investigations could be deferred. 

Case example:If the same girl comes with heavy bleeding, what could be the reason?

A: If the bleeding is heavy, then the girl should be evaluated thoroughly.  An ultrasonography should be done to rule out any abnormalities in the uterus or ovaries.  A detailed blood test should be done to rule out any bleeding disorders or abnormalities in the blood cells. If there are any abnormalities detected, treatment should be given to cure the disease.    If every thing is normal, she may need treatment with heavy doses of hormone pills. 

Q: If a woman in the reproductive age group comes with heavy bleeding what could be the reason?

A: In the reproductive group the causes could be

1. Pregnancy related problems.

2. Intrauterine device related problems

3. Hormonal imbalance.

4. Ovarian cysts or uterine fibroids.

5. Pelvic inflammatory disease.

Pregnancy related problems: In a woman in the reproductive age group, unintentional pregnancy and related problems should always be kept in mind.  It is commonly believed that pregnancy will occur only if a woman misses her periods.  But it is quite possible that even without missing her periods, a woman may be harbouring an abnormal pregnancy either in the uterus or even outside the uterus, which is then called an ectopic pregnancy.  Ectopic pregnancies are usually associated with pain in the abdomen. 

Intrauterine device related problems.

Patients using copper containing intrauterine contraceptive devices could have bleeding related to a foreign body reaction to the device.   Usually the first 2-3 months following insertion of the IUD is associated with irregular and excessive periods, but it settles on its own. If it is excessively heavy even after that, medical intervention may be necessary.

As in all age groups, abnormal tumours in the uterus or ovaries should be ruled out. 

Any infections in the uterus or nearby structures (Pelvic inflammatory disease) could also cause abnormal bleeding.  Clinical examination can rule out gross abnormalities.  Ultrasonography is a more accurate method of ruling out abnormalities in the pelvic organs. In women with no structural or pregnancy related abnormalities, any bleeding is called dysfunctional uterine bleeding.  While in the post menarchal or premenopausal women, these abnormalities occur due to disorders in ovulation, in women in the reproductive age group, bleeding occurs in spite of normal ovulation. Quite often they can be cured by non-hormonal medical treatments.

What are the treatment options for dysfunctional uterine bleeding in women who have completed child bearing?

D&C: In women who have completed childbearing, when medical treatment fails, a small procedure called D&C (Dilatation and curettage) may be done.  It involves widening the opening of the uterus and putting in a curette and scraping the inner surface of the uterus. This inner lining of the uterus is called the endometrium.  The endometrium which is thus taken out is submitted for testing in a pathological laboratory to make sure there is no malignancy in it.  This procedure besides being diagnostic to rule out malignancy may also be curative. Bleeding may completely stop after this.  D&C is usually done as a day care procedure and need not involve admission to the hospital.

Medicated intrauterine devices: Intra-uterine devices medicated with a hormone called progesterone are placed in the uterus. The advantage of this IUD is that it is a simple procedure and avoids the complications of surgical procedures.  The disadvantage is that it is a bit costly (Around Rs.7500). Although the cost may seem to be a bit high for the average patient, it is certainly worth trying specially in cases where surgery or anaesthesia poses a risk to the patient.  

Endometrial Ablation:  In dysfunctional uterine bleeding the irregular or excessive and prolonged bleeding is caused by irregular shedding of the inner lining of the uterus called the endometrium.  This lining can be destroyed using many modalities like heat, electricity, laser, microwaves etc. Theses procedures could be a boon to the woman with DUB with risk of surgery or anaesthesia.   

Thermal ablation: A rubber device is introduced into the uterus and a hot solution is passed into the rubber balloon.  The heat of the solution is transmitted across the rubber balloon on to the lining of the uterus which is desiccated.  This is done in many centers using company made rubber balloons, passing the solution at a set temperature and pressure. The cost of therapy using company made devices may be around Rs.5000-Rs7000.  The author has been doing this procedure using boiling water and ordinary urinary catheters which have a rubber balloon near one end.  The cost of therapy comes down to Rs.2000.  80% of patients who undergo the procedure are relieved of their complaints.  Most of them attain normal menstruation or decreased menstruation.  Very few attain stoppage of menstruation.  It is done as a day-care procedure and can be done under local anaesthesia and sedation or under mild general anaesthesia. Immediately following the procedure there may be uterine cramps which settles with antispasmodics and some may have profuse watery discharge for a month or so. 

Hysterectomy:  If medical treatment and D&C fails, another option is removal of the  uterus.  Uterus being of normal size, can be removed through the vaginal route.  Pain after surgery is minimal, and in uncomplicated cases the hospital stay may be limited to 3 or 4 days.  Hysterectomy being a major surgery should be reserved for cases where all other means of controlling bleeding fails.  Since vaginal hysterectomy is not a very morbid procedure,& there is a 100% possibility of cure, some doctors do not wait to try methods like medicated intrauterine devices or endometrial ablation before going in for hysterectomy. However, it must be remembered that hysterectomy is certainly associated with more complications compared to the non surgical treatment modalities.  In India where there is no insurance cover for most patients, the cost of these procedures may seem prohibitive to some patients, and probably that is another reason why hysterectomy is preferred in many patients with dysfunctional uterine bleeding.  Personally, in a patient with no pain associated with bleeding & with no fibroids the author would suggest thermal ablation and if that fails, advice the patient to go in for hysterectomy.    

Normal women have small white organs called ovaries placed by the side of the womb.   They are normally about half a lemon in size and are responsible for the production of hormones called oestrogen and progesterone in the body. They extrude human eggs or ova every month by a process called ovulation.  Sometimes the follicles which harbour these ova get filled with a watery fluid or even blood .  This gives rise to what are called ovarian cysts.  They are basically membranous sacs in the ovary filled with fluid.  More often than not, these ovarian cysts are harmless and could be left alone.  But there are situations where surgical intervention will be needed.  

The various types of ovarian cysts generally found are described below:

Harmless functional cysts:

  Due to the routine use of ultrasonography for a myriad of conditions, ovarian cysts are normally found in many women.  They could be harmless cysts which are called ‘’functional cysts”.  They normally appear and disappear by themselves.  By and large simple cysts that are less than 5-6 cm in size do not need any intervention. A repeat ultrasonography after 3 months may show disappearance of the cyst.  If the cyst persists, it is better to have the cyst removed surgically by a procedure called ovarian cystectomy.

Twisted ovarian cysts:

Sometimes the cysts turn around or undergo a twist, so to say.  This is usually associated with intermittent abdominal pain,.  The pain is usually more in certain positions, like turning on to one side.  Sometims it may be accompanied by vomiting.

   A twisted ovarian cyst, if left alone, will have a jeopardised blood supply and this will lead to gangrene of the ovary.  So whenever there is acute pain in the abdomen and an ovarian cyst is diagnosed, the woman is subjected to surgery, usually ovarian cystectomy. It can be done laparoscopically in places there are facilities to do the procedure or by open surgery.. If surgery is delayed and the ovary has undergone gangrene, the ovary will have to be  sacrificed.  

Endometrioma:

Sometimes the ovarian cyst is filled with dark, chocolate coloured fluid, which is old blood.  This is caused in women who suffer from a disease called endometriosis.  In endometriosis, a tissue called endometrium, which normally lines the uterus,is found in places outside the uterus.  The uterus, normally sheds this endometrium outside at the time of menstruation.  Instead, if the endometrium is found in the abdomen , the woman is said to have endometriosis.  A collection of endometrium along with blood, in the ovary, which enlarges to  form a cyst, is called an Endometrioma or Chocolate cyst.  If it occurs in women who do not have children, it may cause infertility.  The ideal treatment for endometrioma is laparoscopic ovarian cystectomy,

 Endometriomas,  in  spite of  very good  surgery  do  tend  to  recur,  as, the  basic disease  Endometriosis,with  retrograde menstuation, where the menstrual blood goes retrograde into the abdomen, is not cured.  Repeated ovarian cystectomies in such patients will lead to loss of precious ova. Infertile patients with recurrence of endometrioma should think in terms of undergoing  procedures like Artificial Reproductive Technonlogy  instead of  undergoing repeated surgeries.

Benign ovarian tumours: Sometimes ovarian cysts are caused by noncancerous benign tumours like serous cystadenoma, mucinous cystadenoma, etc.  These cysts  do not regress and need surgical removal.  The cyst can be removed by cystectomy through laparoscope or open surgery.  Once removed , there is not much chance of recurrence.

Dermoid   cysts:  Sometimes, the ovarian cyst is filled with many tissues like hair, teeth, bone, fatty sebacious material, etc.  These are called Dermoid cysts.  These are called germ-cell tumours.  Usually this occurs in the younger age group.  Treatment is by cystectomy. There is very little chance of recurrence.  In one  study, after Dermoid resection, 3.4% patients were seen to have a recurrence within the study period of 6 years.  Dermoids could also occur bilaterally and there is a small risk of malignancy in untreated patients.  It is possible to get pregnant even after removal of Dermoids.

Malignant ovarian cysts: Malignant ovarian cysts usually occur bilaterally, although it could also occur unilateally.  Ultrasonogram in such patients show solid elements in the ovarian cysts, besides the usual fluid that is seen in non-cancerous cysts.  Tumour markers like CA -125 are raised in such patients.  This could be detected by testing the blood.  Special ultrasound examination like colour Doppler ultrasonography can show increased blood flow in the cyst.  

If the cyst is malignant, in young patients, in some particular cases, it may suffice to remove only the affected ovary.  In most cases, in the older age group the uterus along with both the ovaries will have to be removed .  Open surgery is the preferred  modallity of surgery in these patients.  

 Indications for surgery in ovarian cysts:

1. The cyst  persists after 3 months;   Persistent ovarian cysts could be caused by benign ovarian tumours and need removal.

2. The cyst  is associated with pain or increase in size: Pain could be due to a twist in the ovary, which may lead to loss of blood supply to the ovary and subsequent death of the ovary. 

3. Endometrioma: A common cause for ovarian cysts is an endometrioma.  In this condition, menstrual blood collects over the ovary, finally ballooning it into a blood filled sac. This is called an endometrioma and the blood inside the sac is usually old blood. 

4. Cancerous cysts:   Cancerous cysts usually have solid components besides the usual liquid contents of simple ovarian cysts.  These differences could be detected by ultrasonography.  A special type of ultrasonography called colour doppler ultrasonography could detect the presence of increased blood flow in the ovary suggestive of malignancy in the ovarian cyst.

Some blood tests like CA125 levels could also be useful in the detection of malignancy. 

Ovarian cysts in pregnancy: 

Ovarian cysts may occur during pregnancy.  If seen in the first 3 months it could be a functional cyst and could be left alone.  If severely symptomatic, immediate surgery may be needed. Otherwise, doctors wait till the 4th month to see if the cyst disappears.  If it persists, ovarian cystectomy may be done

Laparoscopic ovarian cystectomy is possible in pregnancy and is safe in pregnancy in experienced hands. We have done 4 cases of laparoscopic ovarian cystectomy in pregnancy in our unit and all of them had good obstetric outcome.  

  Disappearance of cysts:

Clinical situation: A 14 year old school girl gets mild abdominal pain off and on for 2 days and it became severe one day.  She visited her physician who suspected an ovarian cyst and referred her to a gynaecologist.  An ultrasonoram showed a 6 cm cyst. The girl was advised an emergency laparoscopic surgery to remove the cyst.  But the girl had her school examination the next day and she refused to undergo surgery.  Meanwhile, her mother solicited divine intervention from god to see that nothing went wrong with her daughter.  2 days later the pain disappeared and the girl decided not to go back to her doctors.  What could be the reason? Had the doctor advised unnecessary surgery? Was it divine intervention indeed?

A:  An ovarian cyst that is not associated with any discomfort could be left alone.  But when there is severe pain associated with the cyst, it is ominous.  Severe pain in the presence of an ovarian cyst could be due to a twist in the ovarian cyst. The twist could jeopardize its blood supply and lead to permanent damage to the ovary.  This is why when a patient who has severe pain in abdomen is found to have an ovarian cyst, emergency surgery is advocated.  But instead of twisting, sometimes the cyst may simply burst and this will relieve the pain.  If that happens, there is a happy ending and a scenario that is described about the 14 year old girl in the question above follows.  However, no doctor can prophesize whether the severe pain is a prelude to a twist in the ovary or portends rupture of the cyst. Doctors with high expertise in sonography can, with the help of a color Doppler sonography detect the twist in the ovary.  But in the presence of severe pain, generally doctors play it safe and ask for an emergency surgery to be on the safe side even if the twist is not seen on ultrasonography.  Generally, a twisted ovarian cyst is accompanied by other symptoms like vomiting, pain while passing urine, etc. If these symptoms are present, it is more helpful to clinch the diagnosis of a twisted ovarian cyst.