Menstruation: What the Pattern & Amount of Bleeding Tell Us About Fertility
Regularity and Flow: Women who ovulate regularly tend to menstruate regularly as well. In other words, their menstrual periods tend to occur at fixed intervals that usually range between 26-30 days apart. Women that menstruate regularly but more than 30 days apart often are experiencing dysfunctional ovulation. The greater the intervals between menstruation, the more likely this is to be the case. Women who do not menstruate at all (amenorrhea) are usually not ovulating at all. Those that menstruate greater than 45 days apart (oligoamenorrhea) and those who have no fixed menstrual pattern are either not ovulating, are ovulating irregularly or have completely dysfunctional ovulation.
The normal length of menstruation can vary from one or two days to up to a week or longer in length. Excessive bleeding that occurs in women with regtular menstruation is rfeferred to as menorrhagia) while heavy bleeding in women with irregular menses is known as metrorrhagia.
So what is meant by excessive bleeding? Simply stated, this is defined as bleeding in an amount or duration that is socially unacceptable to the woman. The passage of large clots, a heavy flow of red blood or bleeding that lasts for longer than a week, whether heavy, modest or slight in amount are all examples of what might be socially unacceptable and are thus by definition, examples of menorrhagia.
While cyclical heavy bleeding (menorrhagia) usually only occurs in ovulating women, it is often associated with underlying pelvic pathology such as endometriosis, dense pelvic adhesions, chronic pelvic inflammatory disease and enlargement/engorgement due to fibroids and/or a condition known as adenomyosis (where the uterine lining penetrates and permeates the uterine muscle). However, it can also occur in the absence of pathology. In such cases, it is often due to a breakdown in normal blood clotting (hyperfibrinolysis) within the uterine lining.
Metrorrhagia (irregular heavy bleeding), on the other hand, is most commonly encountered in cases where the woman is not ovulating at all or is ovulating irregularly (e.g. polycystic ovarian syndrome [PCOS]). In such cases with the absence of ovulation, estrogen-induced endometrial growth continues unabated and unantagoniozed by the hormone of of ovulation, progesterone. The result is that breakthrough bleeding occurs.
Some women often experience regular menstruation but the amount of blood flow is very small (hypomenorrhea). This condition may be completely innocuous, but in some cases it is due to the uterine lining having been severely damaged by: a) post-pregnancy inflammation (endometritis), b) overzealous surgical removal of the uterine lining or endometrium by scraping (D&C;) or, c) as a consequence of other surgical interventions such as surgical trauma with the removal of fibroids or a septum from inside the uterus.
Clearly, women who are not ovulating or who are ovulating abnormally will not conceive without help. Thus, when an irregular menstrual pattern or an abnormal amount of bleeding is due to ovulation dysfunction, fertility treatment must be directed at reinstating normal ovulation through the administration of oral or injectible fertility drugs. In cases where heavy or irregular menstrual bleeding is due to pelvic pathology, treatment must be directed at the cause. Uterine polyps, scar tissue and/or fibroids might need surgical remedies while pelvic adhesions and/or endometriosis might require treatment by endoscopy (hysteroscopy/laparoscopy) or through opening the abdominal cavity (laparotomy).
Pain: How does pain with menstruation (dysmenorrhea) impact fertility? Since women who do NOT ovulate, rarely experience premenstrual symptoms such as breast tenderness, bloating and mood changes, the latter being due to the effects of the hormone progesterone, it follows that since metrorrhagia is most commonly encountered in non-ovulating women, it is usually painless.
Most ovulating women will at one or other stage of their lives experience some degree of pain with menstruation. The commonest variety is known as “primary or spasmodic dysmenorrhea”. It occurs in the absence of underlying pelvic pathology, usually affects women who have never been pregnant and are under the age of 30 years. It disappears after pregnancy that has advanced beyond the first trimester and/or after the age of 30 years, whichever occurs first. One uncommon variety of spasmodic dysmenorrhea is associated with the passage of the entire uterine lining in the form of a single cast, which looks like a piece of raw meat. This so-called “membranous dysmenorrhea” is very painful indeed. Treatment involves the use of antiprostaglandin medications such as ibuprofen. The use of a birth control pill by suppressing ovulation will often also alleviate the condition.
“Secondary or congestive dysmenorrhea” is another matter all together. The condition is associated either with pain that begins a few days before menstruation and then disappears with the onset of menstruation, or with pain that begins with the onset of menstruation and gets progressively worse as menstruation progresses and the menstrual pain continues for longer than 48 hours into the menstrual period. The former (pain begining a few days prior to menses and improving with the onset of bleeding) is most commonly seen with chronic pelvic inflammatory disease, pelvic adhesions or adenomyosis while the latter (pain t6hat continues well into menstruation) is more commonly to be encountered with endometriosis or multiple uterine fibroids. Secondary, congestive dysmenorrhea is often accompanied by other symptoms that point to underlying organic disease such as premenstrual positional pain with deep penetration during intercourse (deep dyspareunia). Treatment is through the use of pain killers and/or is directed surgically at the underlying cause.
So what does all this mean when it comes to infertility? Well, since in many cases heavy, prolonged or irregular bleeding points to specific ovulatory or organic causes that require treatment if fertility is to be reinstated, it is important to take a careful history and then follow the clues so as to treat the cause. Appreciation of the above relationships will go a long way towards establishing a rational approach to the diagnosis and treatment of the causes of infertility.