Menses

It's been a man's world for a long time. In fact, for a long time most foibles were defined based on comparisons to women. Even to this day the surgical removal of a woman's uterus is called a hysterectomy because it was once thought that the womb was the seat of hysteria. Certainly PMS didn't help this notion, women sometimes being a little emotional during their period. What most men won't understand is that it's hard to feel great when you're miserable with the discomfort of cramps or inconvenienced with the soiling of menstrual blood. And what they can't understand is the power of hormonal changes. The fact that all of this makes possible reproduction goes unappreciated for the miracle that it is.

In some lower forms of life, the pineal gland, of which we ourselves have a remnant, acts as a third eye to pay attention to things like the full moon. The pineal gland in humans makes melatonin, all the rage with the new age marketing self-help gurus. Melatonin affects pigment in skin based on exposure to light of day and affects sleep based on exposure to the light and darkness of night. Nowadays it's sold as a sleep aid.

I'm no anthropologist and I do no research on such things, but I feel there's a connection with it all. As we evolved, our most important biological function, reproduction, became enmeshed environmentally with our very world--lunar months, menses, and probably pineal activity. We are the way we are because we are of this world--a planet with a diurnal sequence and with a moon which makes one revolution around us once a month.

It's probably no coincidence that a woman's period comes once a month. Many feel the phases of the moon probably have something to do with it. Once again women are maligned, "menses" meaning month as in lunar months, "luna" meaning moon, the cause of "lunacy." It all rolls together in one big chauvinistic semantics put-down. But when it comes right down to it, it's a woman's world after all, for all of the obvious reproductive and nurturing reasons. The period is only the outward sign that everything is working properly in anticipation for procreation.

Definitions

Gynecologists use certain words to describe abnormalities of the menstrual cycle:

Menorrhagia--heavy bleeding during a menstrual period; also, prolonged menstrual bleeding (>8 days).

Metrorrhagia--irregular timing of the menstrual periods (usually more frequent).

Menometrorrhagia--not only irregular, frequent periods, but ones that are particular heavy as well.

Oligomenorrhea--less than 8 periods a year or cycles coming less frequent than every 35 days, which can be a sign of PCOS

Dysmenorrhea--painful periods.

Eumenorrhea--a slang medical term for a cycle that has no abnormalities of flow, timing, or pain.

PMS: Radical Thinking and the End of Periods

Would there be any harm in eliminating periods in a woman who is not seeking pregnancy?

I have several patients who cheat with their birth control pills. They skip the "sugar pills" at the end of the pack and instead start the next pack right away. The last pills, you may recall, are not hormonal. They're designed as a memory device, so women will have a hormone withdrawal during that time and have their period. For many it's a way of checking things; it's a way of making sure everything's working right even though there's hormonal manipulation. But women who blast right into the next pack eliminate this withdrawal. They'll do this for quite a few cycles and go period-free until they experience what we call breakthrough bleeding--the body's way of giving up. The uterus is no longer able to hold its inner lining together and there is sloughing. So they're not off the hook completely. This tends to happen anywhere from three to nine months of this non-cyclic method. So we're talking about a period only one to three times a year instead of every single month.

Certainly this regimen is not FDA approved, nor have drug companies sought an indication for this. Therefore, I warn patients, it is what we call a non-labeled use of an FDA-approved drug. Most doctors feel non-labeled use is legitimate if the benefit outweighs the risk. We obstetricians have prescribe FDA-approved drugs for non-approved reasons for years with the much cheaper terbutaline to stop premature labor instead of the similar but much more expensive FDA-approved ritodrine.

I once wondered if it would be nice to allow my patients, if they wanted, to go period-free in just this way. After all, if they weren't seeking an actual pregnancy and they suffered from PMS, life would certainly be a little more comfortable without the "monthly visitor," "the curse," the "rent due," and all of those other ridiculous euphemisms.

Unnatural? Against nature? I guess so, but so is fighting that tendency to howl at the moon once a month (guys, I'm talking about you!). I thought about this a lot, but finally dismissed it. We're here on a world wherein a monthly period is steeped in environmental and astronomical tradition. We are the way we are because of the planet we live on and how we evolved. On top of all of that, if I were to do this, I feared a backlash from women who make such things causes. Because I was male, I was at particular risk of being lumped together with the misogynistic hysteria-labelers and lunacy-accusers of old. Although I was just trying to make things a little easier for people, I figured this is one cause I don't have to champion. I have enough to keep me busy. And then one day I read the latest copy of the prestigious Obstetrics and Gynecology journal. In a recent article, women who were not able to be treated satisfactorily for their PMS were offered a new approach.

Since we can't beat PMS--not yet, anyway--why not just make it happen less often?

The gist of the article goes on to say how women were allowed to have extended cycles by continuous "active" birth control pills without the placebos. (Some of my own patients, it seems, were way ahead of the academicians.) In the study, they were put into groups of differing extended cycles longer than the usual monthly cycles. Eventually most of the women were each able to find their unique extended cycles before breakthrough bleeding occurred. There was no talk of the moon or a woman's "badge of femininity." They simply set out to let the women with PMS, who they couldn't make feel better, feel awful much less often. I know from Internet correspondence through this website that there are many women (and men) who feel estrogen replacement after menopause is wrong, for it masks a certain right of passage for women. The philosophical implications of eliminating periods for any amount of time will be a highly charged issue as well. I wonder if the authors of the aforementioned article are putting their hands over their heads in wait for the onslaught of the self-appointed champions of women's rights of passage.

But is it any more unnatural to prevent ovulation with birth control pills than it is to prevent periods with birth control pills? Is it any more unnatural to create an early abortion using birth contol pills as a "morning after" pill?

It is only that for the most part ovulation goes without an outward sign that its elimination with the pill went into the annals of medical history without feminist protest. Under certain PMS circumstances, elimination of the premenstrual tension (and with it, the period) sounds good to me, and I feel it certainly does no harm. In fact, it's the way we used to treat endometriosis in the times before danacrine and the current Lupron.

Like the famous epidural/Lamaze conflict, everyone must make up their own minds on a point of philosophy and that dividing line between what we are and how we might lessen discomfort. A champion of the pristine state may have to deal with the women who truly suffer and who tell them what to do with the next full moon. In the meantime if a patient asks me to help her suffer less often, I won't argue with her. I'm supposed to be here to help.

Abnormal Menstrual Cycles

Everyone likes to be normal.

As inconvenient as it can sometimes be, the monthly menstrual period reassures a woman of reproductive age that she is normal. Indeed, many different things have to go right for this to happen. Hormones and other substances, as far away as the pituitary gland in the brain, react to numerous signals--signals both from higher up in a place called the hypothalamus and from lower down in the ovary. And everything has to be synchronized correctly to get the lining of the womb (uterus) to slough its lining if there's no pregnancy to implant. And so it goes that the cycle begins again every month until interrupted by pregnancy.

So when the periods come at the right time, every time, there is cause to feel good that all is well. And when periods, or any bleeding, fall out of the schedule, it's usually time for a check-up. Naturally there are many harmless reasons to have irregular bleeding. Getting on the right birth control pill make take a few tries, making a mess of the cycle until that happens. Breast-feeding places hormonal priorities on milk production, and the periods may come irregularly or go away altogether. Different medicines, especially ones that can affect the thyroid or drugs for anxiety and depression, or anti-seizure medications, can disrupt the timing of the hormones each month.

And then there are the women who just have longer cycles, resulting in periods thirty or thirty-five days apart. Some can have regular cycles every twenty-five days, which is what's normal for them. How different does a cycle have to be before a woman needs evaluation? That's hard to say, and it's usually a judgement call by her gynecologist. But as a woman approaches menopause, it becomes straight-forward. During this time, I usually follow an old GYN saying that says, "Less bleeding is O.K., more bleeding is not."

Following this simple rule, if a woman's periods are getting lighter, this is less bleeding, and so I just watch it. Periods also start spreading out about this time, and ultimately they stop. This is all "less," and usually isn't a concern. Of course I wouldn't like to see this sort of thing in a young woman, because it would have an impact on seeking pregnancy or suggest that something important is disturbing the synchronized events of the menstrual cycle, like medications, tumors, or abnormal hormonal functions. "More bleeding" is much more a worry in women approaching menopause and certainly after menopause. Periods that are getting progressively heavier over months and years qualify as "More." So do cycles getting closer together or even regularly timed periods that are just much heavier than before. Again, the causes may be harmless, but cancer of the uterus may start like this.

This possibility is such a concern that most GYN doctors feel compelled to get a sample of the lining of the womb to "take a look." The two most popular ways of doing this are Endometrial Biopsy ("EMB"), and Dilatation and Curettage ("D & C"). With an EMB, a thin, flexible, sterile straw is passed beyond the point from which a Pap smear is obtained. It is dragged back to gently skim away some of the fragile lining from the inside of the womb. This causes brief, albeit sometimes severe, cramping which goes away in a moment. The advantage of EMB over D & C is that it is very inexpensive, and it doesn't require an anesthetic or a surgical out-patient center. It's done right in the office, and the flexible plastic straw has made the procedure much more comfortable than when it used to be done with a rigid metal device in years past. The only problem with the EMB is that it is a sampling; it doesn't have the thoroughness of a D & C, which uses the same technique, but retrieves tissue over 360 degrees. Also, a D & C affords a gynecologist a chance to consider hysteroscopy, which is when a thin, lighted tube is passed into the womb vaginally to look inside. There are no incisions, and there might be found polyps or other growths that could explain the bleeding. In fact, such a problem could be removed right through the little scope, ending the problem. The down side to D & C, though, is that it needs anesthesia, implying the need for a surgery out-patient facility. A patient still goes home a couple of hours later, but it will blow the whole day as well as be costly.

Many are now advising that ultrasound may be a deciding factor in deciding whether endometrial sampling is necessary, and if so, whether it should be via EMB or D & C. The thickness of the lining of the uterus on ultrasound may add insight into any suspicions or lack thereof.

So a woman with suspicious bleeding is usually faced with a choice if in an age group at risk. She can have a simple, inexpensive procedure that is usually quite adequate, but not guaranteed--an EMB; or she can have an expensive outing to a surgicenter for a D & C (with possible hysteroscope) that will give her and her doctor the highest reliability of evaluation. Luckily, risk factors--and now, ultrasound--usually make it easy to choose which way to go. For example, if a woman's mother and grandmother both had uterine cancer, a D & C can give great peace of mind, since cancer of the womb can be hereditary. If a woman is younger or has no scary family history, an EMB will suffice, especially if the ultrasound looks innocent.  But it's a trade-off, both having their advantages and draw-backs. It is a decision made between a patient and her doctor. The only hard and fast rule is that any woman having ANY bleeding after menopause should have a D & C, because this situation has a substantial risk of cancerous or pre-cancerous causes. And caught early, a cure is likely.

Some physicians feel that every woman is entitled to a weird period every now and then, and it is reasonable to see if there's a pattern before doing an evaluation. Also, a simple GYN exam, especially in younger women, may give the reason for abnormal bleeding, such as an infection or irritation that can be treated with cream or a suppository. The first thing I do when a patient reports unusual bleeding is make sure I can't explain it with birth control pills or a simple vaginal infection. And then I consider her age. An adolescent can be merely watched for the same amount of irregular bleeding as a woman at menopause who may need a D & C. Someone riskier than the adolescent but less worrisome than the woman at menopause may need only the simple EMB. And it can all be tempered by ultrasound. It's all judgement, and I like to let the patient share the call based on the perspective I as a specialist can give her.

And then there's everyone else lucky enough to have regular, monotonous periods. They may complain, but they can go through life with peace of mind--a month at a time.

Abnormal Periods

Whether considered a blessing or a curse, most women have--and should have--a very regular pattern which their cycles follow; but often abnormalities occur.  Abnormal periods (menses) are probably one of the most frequent complaints I hear from my patients.  There can be many causes of an abnormal cycle, so careful evaluation of these complaints is in order.

First we must understand that the menstrual cycle is a delicate balance between hormones of the brain and ovaries, with resulting effects in the uterus (womb).  Although changes in this balance can cause abnormal bleeding, organic lesions, foreign objects, and medications can also cause problems.

A normal menstrual cycle is 28 days (+ or - 7 days) and lasts an average of 4-7 days. Abnormalities include menorrhagia (heavy bleeding), metrorrhagia (bleeding between cycles), oligomenorrhea (>35 days between cycles), and amenorrhea (>6 months between cycles). Since different abnormalities are more likely with each specific irregularity, a careful history is the first tool of diagnosis.  Women experiencing menstrual abnormalities are encouraged to keep a diary. Length of cycle, amount of bleeding (number of pads soiled), and interval between cycles are recorded, and the specific abnormality can then be defined and specific tests can then be done.

Physical examination for tumors or masses, an enlarged uterus, or an abnormal cervix should be performed by a physician.  A pap smear should also be done.  Various lab values can be checked depending on which group a patient falls into.  An  EMB (endometrial biopsy) can be obtained in the office by inserting a small, thin, plastic straw (curette) into the uterus which samples cells from the inside of the uterus that can then be screened for cancer and the degree of hormonal stimulation.  X-ray and ultrasound studies of the uterus may be ordered to look for tumors or  foreign objects which might distort the internal cavity of the uterus.  Hormone levels, pregnancy tests, and even chromosome analysis may be necessary for a complete diagnosis.

Non-gynecologic pathology can sometimes interfere with the menstrual cycle.  For instance, hypothyroidism (low thyroid), blood clotting abnormalities (hemophilia, leukemia), extreme weight loss or gain, and other conditions can cause problems with bleeding that are easily corrected once understood.  Some medications such as blood thinners or steroids (even some tranquilizers) can cause menstrual irregularity that resolves with medication readjustment. Working in the fitness industry, I also encounter many women with abnormalities in their cycle secondary to high exercise levels which can be fixed by adjusting their exertion times.  Other non-gynecologic causes such as birth control pills, IUD's, and trauma should be checked out as well.

Amenorrhea (literally translated, without periods) occurs most often in adolescents and menopausal patients, and of course with pregnancy.  If pregnancy if ruled out,  lab work can diagnose most abnormalities, and hormone regulation for a brief or extended period can usually bring things back to normal.  Young women with no secondary sexual development (breasts, pubic hair) by the age of 14 or no menses by the age of 16 should be evaluated for chromosomal or hormonal abnormalities, although skipping periods is common in this age group.  Women over 40 with amenorrhea, especially if associated with hot flashes or other menopausal symptoms, should be evaluated for menopause and hormone replacement considered.

Abnormal bleeding (either heavy bleeding or bleeding between periods) can have many causes.  Bleeding can occur from the vagina secondary to trauma, infection, or cancer and can be diagnosed with cultures, pap smear, or actual visualization of a lesion.  The cervix can bleed abnormally also secondary to fibroids, infection, polyps or cancer, as is the case with the uterus.

Ovarian and other estrogen producing tumors can also cause abnormal uterine bleeding.  I'm sure you noticed that cancer appeared several times in this list.  Although it must be ruled out, it is not the usual diagnosis with abnormal uterine bleeding.

Once all hormone abnormalities and lesions are ruled out, a large number of women are left with abnormal bleeding without a diagnosis.  This is referred to as Dysfunctional Uterine Bleeding (DUB) and is usually secondary to abnormal growth of the lining of the uterus (the endometrium), and is usually due to dysfunction of the hormone communication between the brain and the reproductive organs.  Almost all episodes of DUB occur at reproductive extremes (20% < age18 and 40% > age 40.)   Treatment depends on lab work and age group.  DUB in adolescents after exclusion of pregnancy will usually resolve with observation as  the patient matures and is often treated with birth control pills.  In the 20 - 30 age range actual pathology is more common and specific lab results will dictate treatment.  In postmenopausal women cancer must be ruled out, especially endometrial (uterine) cancer.  EMB and endocervical curettage with D and C are very important tools for diagnosis here.

Treatment of abnormal bleeding involves elimination of abnormalities.  In cases where no abnormality is found, bleeding can be controlled with either estrogen or progesterone therapy.  D and C may be helpful in some unresponsive or severe cases.  Cases unresponsive to therapy may require more extensive therapy still, such as removal of the lining of the uterus (endometrial ablation) or hysterectomy.  Treatment must be tailored, of course, to the individual patient's needs.

Menstrual problems are not simple diagnoses.  Likely causes vary with age groups and often extensive work-up reveals no abnormalities. Diagnosis--and treatment--is always possible but physician involvement is essential. One final point to make is that a repeat episode down the line is not always a recurrence and could represent a new, more serious problem and must be re-evaluated.

Dysfunctional Uterine Bleeding

Overview: This term is only applied to those situations wherein there is no ovulation, and because of that, no second half of the cycle when the tissue (endometrium) of the uterus normally matures. Instead, the first half of the cycle just fizzles along until the lining is sloughed in a continous and irregular, prolonged tissue exhaustion. This is a problem with ovulation, not with the uterus. If pregnancy is desired, an ovulation-inducer, like clomiphene, can be used; if pregnancy is not desired, its effects can be masked with birth control pills, which give the body not only estrogen, but also progesterone, which is diminished or absent with irregular or absent ovulation. But before resorting to treatment, the diagnosis can be established with an endometrial biopsy (EMB) with or without a serum progesterone level (which will be low).

Dysfunctional Uterine Bleeding: The phrase "hormone imbalance" has been used and abused so often that it's almost a cliché.  It's a trash can diagnosis used when a doctor can't figure what else to call it.  The truth is that such a term is an extreme oversimplification.  The physiology of a woman is a very complex interweaving of numerous processes.  The normal menstrual cycle involves the rise and fall of estrogen, the rise coming at the beginning of the cycle; and progesterone, the rise coming at mid-cycle, right after ovulation.  In fact, ovulation has to happen for progesterone to rise and join it's estrogen comrade in preparing the uterus (womb) for pregnancy.  They both crash each month when this doesn't happen--the prepared tissue bed falls apart and is discarded, and the woman sees this debris as her period.

The average age of menopause is around 51.  But the approach to menopause can take up to fifteen years.  Enter a new trash can diagnosis: "perimenopause."  Perimenopause is when the hormonal functioning declines but not enough to stop periods altogether.  But the period is just the outward sign to tip off a woman.  Even with periodic bleeding, there may be hot flashes, mood swings, and silent loss of minerals from her bones--osteoporosis.  There can be some signs of perimenopause beginning as early as age 35!

It's tempting to assume that all of the hormones are underachieving together.  But more than likely the estrogen or progesterone alone will falter, which will in turn affect the entire cycle.  Progesterone can be thought of as the "second-half" hormone.  This is because it begins to rise after ovulation, which occurs at mid-cycle.  It's job is to organize and mature all of that rich tissue in the uterus that has been primed so beautifully by the estrogen (for lack of a better term, the "first-half" hormone, although it does continue past the half-way mark).  This all assumes, of course, that one is ovulating regularly.

So what happens if you don't ovulate?

You're going to find it hard to make progesterone if you don't ovulate.  The stuff is made right in the spot from which ovulation takes place. No ovulation, then not enough progesterone and no second-half of the cycle.  This is more than an imbalance--this is a wrench in the works.

Part One of the cycle, the estrogen part, keeps on going, but its enthusiasm fizzles out after a time.  Soon, all of the estrogen-stimulated tissue in the uterus "overgrows."  Without the organizing and tidying-up help of progesterone, it can even overgrow into pre-cancerous tissue, called "hyperplasia."  But more than likely there will be irregular shedding of this disorganized tissue.  Since it has not been consolidated by progesterone, it won't come out in a scheduled appearance like with the monthly period; instead, it will go on and on until a woman seeks help from a gynecologist.

Irregular bleeding because of lack of ovulation, and therefore because of lack of progesterone, is called "dysfunctional" bleeding.  This is a better term than hormone imbalance, because it correctly refers to the foul-up of the functioning cycle.  It can be diagnosed by taking a blood sample to check for the presence of progesterone--if it comes back good, then there was an ovulation and it's not dysfunctional bleeding.  If it comes back absent or too low, then the bleeding is dysfunctional.  Also, an endometrial biopsy can actually date the part of the lining of the uterus as to what part of the cycle it's in.

There are many who feel ovulation depends on a good enough rise of estrogen in the beginning of the cycle.  If the estrogen rise is sluggish or faulty, the follicle cannot be prepared for ovulation very well.  Of course this affects the production of, once again, progesterone.  Therefore it's possible for dysfunctional bleeding, although due to insufficient progesterone, to have really been caused by a faulty first half of the cycle instead.

This is what happens when physiology is determined by processes that run in circles (cycles).

What the woman sees as a hormone imbalance is not only irregular bleeding, but also the emotional swings and other symptoms of "perimenopause."  But perimenopause is an inaccurate label, because it implies being over the age of 35.  Young girls who haven't grown into their cycles often have dysfunctional bleeding for a while.  Breast-feeding woman don't make progesterone either, unless they ovulate (which means that breast-feeding woman really can become pregnant).  Strenuous athletics hamper good ovulation.  It may take long distance runners longer to get pregnant than women who partake in only moderate exercise.

Treatment relies on correctly identifying the problem.  Is it dysfunctional?  Is there truly the lack of ovulation?  Or are there other causes, like fibroids, polyps, cervicitis (inflammation of the mouth of the womb), or other problems unrelated to gynecology, like thyroid disorders, medication side effects, or substance abuse?  And then, once the diagnosis is confirmed, does the physician treat the second half of the cycle by putting in progesterone (pills, shots, or suppositories), or the first half of the cycle by stimulating the effects of estrogen (with ovulation inducers).

Certainly the desire for pregnancy is a big determinant on which way to go, because if a woman doesn't want to get pregnant, then she is better served just masking the whole irregular process by taking birth control pills or menopausal estrogen replacement.  And for those resistant to these methods, there's the unfortunate final solution, hysterectomy, or the new 8-minute out- patient solution, uterine balloon therapy.

Although a lot of gynecology involves surgery, it is mainly a thinking doctor's specialty, because the processes are so intricate and interrelated.  But with a little patience, even the most confusing of "hormone imbalances" can be "balanced" once again.

Painful Period Creates Dilemma for Gynecologist (Painful Periods in Younger Women)

Some women have an easy time, reporting periods that are always on time, never heavy, never uncomfortable.

"And then there are the rest of us," a patient tells me, describing her discomfort.

Periods that are painful can be quite harmless, but many young women are concerned about the possibility of a condition called endometriosis, normal menstrual tissue placed in abnormal locations, like the abdomen. A patient with her child-bearing ahead of her should respect this possibility, because endometriosis can render her infertile. And this is where the dilemma comes in:

Endometriosis is a surgical diagnosis.

By that I mean that the disease process has to be actually seen, and this can only be done through a laparoscope (thin lighted scope through the navel) or by surgery involving an incision. A biopsy can confirm the diagnosis, but usually the disease is evident by visual inspection alone. What a gynecologist cannot do is make the diagnosis by a simple physical exam or by taking a history.

The dilemma is then presented to the patient:

If endometriosis is suspected, does she accept a surgical procedure, albeit a minor one, to rule it in or out, or does she take her chances that she just has painful periods that are normal for her? If she accepts the procedure, and the suspected diagnosis doesn't pan out, she's had an unnecessary procedure. If she blows off the surgery, she could endanger her fertility. It's a bad choice without a perfect answer.

Till after the surgery. And if the diagnosis is made, the surgery was worthwhile. And if there are no lesions, the surgery was for nothing? No, not quite. At least a patient can experience whatever discomfort she has with peace of mind, knowing it's alright to mask the pain with medicine specific for it. A laparoscope can also be used to obliterate the endometriosis, using electrocautery or a laser. Often, the out-patient procedure eliminates the disease. And a prescription can further treat it for added security or if not all of the endometriosis is eliminated through the scope.

But the biggest problem is making the decision to have the surgery. Just how much pain is acceptable? Again, a question with no perfect answer. Each patient must be individualized. A careful pain history--including timing in relation to the menstrual cycle--family history, and time of onset can be useful in selecting those patients particularly at risk. An added method, one I like to use, is to give an increasing pain history a time limit. If the pain does not respond to the civilizing influence of birth control pills (a nice side effect of the pill) or analgesics, and if a certain agreed-upon time limit is breached, it's usually time to present the patient with the famous dilemma of whether to have a laparoscope procedure or not. A decision should be made together with the patient--with her parents, if very young; or with her husband, especially if there is already a concern for failure to become pregnant.

Thanks to the excellent safety record of laparoscopy, even this last resort need not be a regret. In fact, most patients who have the disease ruled out never grumble that there wasn't endometriosis there to make the procedure worthwhile.

Painful Periods Beyond Childbearing Need Evaluation Also

In the article above, I wrote about painful periods and their impact on women of adolescence and childbearing years. But fear of endometriosis and infertility don't necessarily concern a lot of women who only care about their suffering. Many causes of painful periods, or dysmenorrhea, can run the gamut from harmless hormonal considerations all the way to serious distortions of the anatomy.

First, there is the woman who has dysmenorrhea without any demonstrable cause. All work-ups may have excluded physical causes, and worse, this torment can contribute to the chemically mediated suffering of PMS, or Pre-menstrual Tension Syndrome. Alternately, there are painful periods due to abnormalities of the uterus.

Uterine fibroids, benign overgrowths and swirls of the muscle of the womb, interfere with the normal contraction of the uterine cavity which controls the amount of bleeding each cycle. With more bleeding comes more clots, more distention of the inside of the womb, and more cramping. Adenomyosis, another benign condition consisting of glands like the lining of the womb penetrating deeper into the muscle layers than normal, yields a boggy, soft, tender consistency. Often the uterus is enlarged, the extra weight twanging the ligaments that normally hold the uterus in place, radiating pain to areas of the ligaments' insertions, i.e., the lower back, inguinal regions, vaginal sidewalls, and even the inner thighs. Remarkably, cancer is usually not associated with painful periods, most causes being of the unknown, fibroid, and adenomyosis varieties.

What to do about painful periods? Since we're not dealing with cancer, we have the luxury of avoiding surgery until the last resort. Birth control pills are a wise first choice, especially if a woman desires contraception in addition to relief. As mentioned last week, the pill has a nice side effect of lessening the severity of painful periods. Unless there are fibroids--beware! The pill may make fibroids get even bigger, compounding the problem. With adenomyosis, the pill has a mixed track record in improving the pain. Progesterone therapy may be helpful, but I have found that success is infrequent with this hormonal method. Fibroids will respond to a new class of medicines, GnRH agonists, but these drugs shrink fibroids by creating an undesirable menopausal-like state. And then there is surgery.

Hysteroscopy, a simple out-patient procedure, can be used to look into the womb from a vaginal approach to see if there are any polyps or missed fibroids hanging in the uterine cavity. If so, removal may be accomplished through the hysteroscope. A patient can be back to work the next day. But this low-yield diagnostic tool should only be offered if no other obvious anatomical reason presents.

Thermal Endometrial Ablation, using the ThermaChoice uterine balloon therapy, will end periods are at least make them normal in 85% of cases. A simple eight-minute out-patient procedure, it is indicated in those cases of painful periods that aren't cause by adenomyosis, fibroids, or other anatomical abnormalities.

Hysterectomy is the final solution to painful periods. Certainly the "H-word" should never even be mentioned if there's the slightest uncertainty about wanting more children. But for the rest of women who have had it with their suffering and who have failed to get relief with other measures, this surgery can change their lives. It's a surgery I never talk anyone into. The question I ask a patient is, "Is the pain so bad that you would be willing to have an operation to end it?"

If she says no, I continue her with conservative methods, adding non-steroidal anti- inflammatory analgesics (like Anaprox, Motrin, Toradol) as needed. If she says yes, then there is every medical and ethical indication for surgery. If the pain is interfering with her lifestyle, causing her to miss work, making sex impossible, she usually knows what her answer is. But it must be her answer, because pain is a subjective thing. There is no way my exam can tell she's not suffering enough with her periods. It is a judgmental thing between my patient and me. If she's been a good sport at more conservative approaches, and if we're down to our last resort, then we should not be afraid of our the last resort. Because at some point a patient with this suffering must begin her life again with all it has to offer. And with the new approaches to surgery--epidural and powerful anti-inflammatories--hysterectomy is not the feared procedure it once was. But that is a different article.