Irregular periods and infertility by Prof Oladapo Ashiru
The regular menstrual cycle is supposed to be between 21 and 35 days. That is, the woman is supposed to have her period every 21 to 35 days. When the period comes more frequently than this, it is referred to as Abnormal Uterine Bleeding.
In 2011, the International Federation of Gynaecology and Obstetrics developed a lucid classification of abnormal uterine and their causes. Abnormal uterine bleeding when cyclical/ovulatory is called heavy menstrual bleeding (HMB); however, it occurs with anovulation called abnormal uterine bleeding with ovulatory dysfunction (AUB-O).
AUB-O and its causes can be a significant cause of infertility. If the woman is constantly bleeding, it can cause infertility simply because the couple will not have sex because of the bleeding. For example, I had a patient whose period lasted a full 17 days. Even though the period was not heavy, it created a problem because it made it impossible for her and her husband to have intercourse. The period would go on for days, clear up for a few days only for the spotting to start again. They were married for six years without getting pregnant.
About 70 per cent of women who do not release an egg during the menstrual cycle have Dysfunctional Uterine bleeding. Their irregular periods are due to a hormonal imbalance between estrogen and progesterone. It is a very significant cause of infertility, making up to 10 per cent of infertility causes.
The American Society for Reproductive Medicine’s 2019 scientific congress on October 16, 2019, held a focus group discussion on irregular periods. Some of the observations are discussed here.
Dr. Wang and his team showed that in terms of the typical menstrual cycle characteristic, irregularity and extra-long cycle length are associated with a higher risk of mortality, according to a study presented at the American Society for Reproductive Medicine’s 75th Scientific Congress and Expo.
In a prospective cohort study, researchers from Harvard and Tongji Medical College in China teamed up to analyse data on 93,775 women, followed for the years 1991 to 2013 as part of the Nurses Health Study II.
Participants described the history of their menstrual cycles for the study, reporting the usual length and regularity at ages 14 to 17, 18-22, and 28-48. The women had no history of cancer, diabetes, or cardiovascular disease at enrolment.
Researchers used statistical methods to determine associations between cycle characteristics and mortality, accounting for relevant confounders, including BMI, race/ethnicity, physical activity, and lifestyle factors.
During 1,729,410 person-years of follow-up, 1679 deaths were recorded, including 828 from cancer and 166 from cardiovascular disease.
Women whose menstrual cycles were always irregular between the ages of 14 and 17 as well as 18 to 22 were 21 per cent and 34 per cent, respectively, more likely to die from any cause than women reporting very regular menstrual cycles in the same age ranges. A similar association is in women with irregular menstrual cycles from age 28 to 48.
Women reporting cycle lengths of 32 and 39 days, or more than 40 days, were also at higher risk of death during follow-up than women whose usual cycles lasted 26 to 31 days.
ASRM Vice President Hugh Taylor, MD, observed, “Irregular cycling could be evidence of an underlying health condition. But these clues are subtle and may not, in themselves, cause much worry. Patients who experience menstrual irregularity should maintain a healthy lifestyle and be alert to health changes.”
The above-quoted study serves as a warning to people who have irregular periods or long cycles to seek immediate medical attention since such processes may be due to underlying conditions.
Regular menstrual periods typically last for five days but can vary between two to eight days. When menstruation first starts, it can take up to 2 years to establish a regular ovulatory cycle. After puberty, most women’s menstruation becomes regular. The length of time between each period is similar, and a cycle is about 28 days on average but can range from 21 days to 35 days.
Menstruation is said to be abnormal if there is an alteration in the time between periods and the volume of the menstruum for example – less than 21 days or more than 35 days apart; missing three or more periods in a row; the menstrual flow is much heavier or lighter than usual; periods that last longer than eight days; periods that are accompanied by pain, cramping, nausea, or vomiting; bleeding or spotting that happens between periods, after menopause, or the following sex.
A woman’s menstrual cycle is controlled by two hormones, estrogen, and progesterone. The levels of these two hormones vary during the month. During the first half of the month, estrogen is high to stimulate the uterine lining’s growth, called the Endometrium, and to recruit eggs to grow in the ovary. When the egg is ready to be released from the ovary (ovulation) for fertilisation around the 14th day, progesterone rises and causes changes in the endometrial lining of the uterus prepare it for pregnancy.
However, if the egg is not fertilised, the progesterone level falls, and the thickened prepared Endometrium is shed as the monthly menses. If estrogen levels are abnormal, there will be no recruitment and growth of eggs.
It will also disturb the production of progesterone, and therefore, the periods will be irregular. In irregular periods, even when a couple has intercourse during the times that the woman should usually be fertile, there may be no fertilised eggs. She is not growing any eggs that can be released. Therefore, irregular periods are the first sign that there may be problems with a woman’s reproductive system. Abnormal Uterine Bleeding is also caused by many other factors such as Polycystic Ovary Syndrome, which are multiple cysts in the ovaries, usually with a peripheral distribution in the ovarian cortex. Women who are on dialysis may also have heavy or prolonged periods. So do some women who use an intrauterine device (especially the copper device) for birth control.