Scanty menstruation

The reasons

Manifestations of poor monthly

Diseases that accompany hypomenorrhea

Diagnostics

Treatment of scanty menses

Complications and prognosis

Scanty menstruation, or hypomenorrhea, is a reduced amount of bleeding during menstruation (50 ml or less). Hypomenorrhea refers to menstrual disorders and can be a symptom of many diseases.

Normally, menstrual blood loss is 50-150 ml, the duration is from 3 to 5 days, the menstrual cycle lasts 21-35 days, and there is no strong pain.

Scanty monthly periods are often combined with oligomenorrhea (shortening of menstruation – less than 3 days), opsymenorrhea (rare menstruation, once every 2-3 months) and spaneomenorrhea (2-3 times a year).

Types of hypomenorrhea

There are primary and secondary hypomenorrhea. They say about primary hypomenorrhea when the monthly periods of a young girl are very scarce from the very first arrival and remain so even a year later. 

A decrease in menstrual blood loss in mature women after a period of normal periods is evidence of secondary hypomenorrhea .

The reasons

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The regulation of the menstrual cycle involved multifunctional system: the cortex of the brain – the hypothalamus – pituitary – ovary – uterus. Any failure at any level will lead to a breakdown of the menstrual cycle, including scanty periods. Hypomenorrhea can be caused by both physiological and pathological causes.

Physiological causes of poor menses:

  • the formation of menstruation in adolescents during the year;
  • premenopausal period;
  • lactation.

All of these factors are associated with the physiological imbalance of sex hormones in the body, that is, in adolescence, optimal production of estrogen and progesterone has not yet been established, and in the premenopausal ovarian function is naturally depleted. During the period when the menstruation after birth has recovered, but the woman is still breastfeeding, hypomenorrhea can be observed in her due to the increased content of prolactin in the blood (the hormone prolactin is elevated during lactation).

Pathological causes of poor monthly:

1) affecting the uterus and the functional (menstruating) layer of the endometrium: 

  • abortion and curettage of the uterus;
  • inflammatory diseases of the uterus and appendages;
  • tuberculosis of the genital organs;
  • surgery on the uterus (removal of myoma nodes, partial removal of the uterus, cesarean section);
  • sexually transmitted diseases;

2) violating the production of sex hormones in the ovaries:

  • injuries and operations on the pelvic organs (for example, removal of a part of the ovary with a cyst);
  • endocrine diseases, including PCOS and obesity;
  • autoimmune diseases;
  • genital infantilism and malformations;
  • occupational hazards (radiation, chemicals);

3) leading to an imbalance of sex hormones secreted in the pituitary-hypothalamic system (brain):

  • intoxication and poisoning;
  • severe and significant weight loss ( anorexia , diets, excessive exercise);
  • lack of vitamins, anemia;
  • mental injury, constant stress, depression;
  • brain tumors and injuries;
  • autoimmune diseases;
  • effect of hormonal contraception;
  • major bleeding during traumatic labor;
  • malfunction of other endocrine organs.

Manifestations of poor monthly

The main symptom of hypomenorrhea are small, spotting or droplet bleeding dark brown.

Scanty periods can also be accompanied by shortening the duration, that is, their duration can be no more than 2 days. Together, this is called hypomenstrual syndrome.  

In some cases, scanty monthly flow on the background of pain. Women complain of pain in the lower abdomen, lower back, “shooting” in the rectal region, the sacrum. This is especially characteristic of adhesions in the uterus and the fusion of the cervical canal.

Subfebrile (prolonged slightly elevated body temperature to 37-37.5 degrees) may indicate the relationship of the scarcity of menstruation with the current infectious process in a woman.

If the cause of poor or rare menstruation is associated with impaired hormone secretion by the ovaries or pituitary gland, hypothalamus, thyroid gland, then the woman may observe signs of premature aging of the skin, dryness and itching in the vagina, decreased sexual desire, irritability, tearfulness, and tendency to depression.

Signs of malfunction of the thyroid gland and hypothalamus (in the brain) can be a woman’s weight gain simultaneously with the appearance of scanty periods, the appearance of milky nipples, dull complexion, puffiness, drowsiness, apathy.

Diseases that accompany hypomenorrhea

Sinechia (adhesions, adhesions) in the uterine cavity

This condition is referred to in the “Gynecology syndrome Asherman “. The formation of intrauterine adhesions leads to numerous abortions and curettage of the uterus, in which the walls of the uterus were injured. Sometimes it can be just a single abortion or a one-time curettage (for example, about residual placental tissue after childbirth), but under conditions of infection. Trauma and inflammation leads to the formation of adhesions in the uterus and cervix.  

Women complain that prior to abortion or curettage they had a regular menstrual cycle, now menstruation is scanty, usually sharply painful. In some cases, menstruation may cease altogether, and the adhesive process will progress in the uterine cavity and in the cervical canal .

In this case, sex hormones are produced by intact ovaries, and when examining the level of sex hormones in the blood, their compliance with the norm will be determined.

Ultrasonography in the uterus describes adhesions and adhesions between the walls, the uterine cavity is narrow, the mucous layer of the endometrium is insufficient in height. Under the conditions of the adhesive and inflammatory process, the endometrium is unable to menstruate and accept a fertilized egg. Therefore, in addition to hypomenorrhea , infertility or habitual miscarriage is diagnosed in a woman .

Adhesions (atresia) of the cervical canal of the cervix

This condition is observed after operations on the cervix, in which the wall of the cervical canal is injured. For example, after removal of the vaginal part of the cervix at the initial stage of cancer (amputation of the cervix according to Sturmdorf ), after diatermoexcision of the cervix due to dysplasia.

After trauma and inflammation, an adhesive process also develops in the wall of the cervix , the outflow of menstrual blood becomes difficult.

Women complain of painful cramping and pulling pains in the lower abdomen, discharge scanty, sometimes with stagnant odor. Menstruation can go in this case for a long time – “smear” for up to 2-3 weeks, until the uterus is emptied through a narrow opening. If the adhesive process led to the complete overgrowth of the uterus, then a hematometer arises – a sharply painful condition in which a large number of menstrual clots accumulate in the uterus. When the hematometer can be temperature rises up to 38 degrees.

PCOS: polycystic ovary syndrome

Oligomenorrhea and opsomenorrhea are very characteristic of patients with PCOS . Sometimes women complain of rare (up to 1 time in 2-6 months) menstruation.  

When scleropolytosis, the membrane of the ovary and the follicles (sclera) thickens. At the same time, many follicles with egg cells mature in the ovaries at the same time. Due to the dense membrane, a rupture of the follicle, which must release an egg cell (ovulation does not occur) cannot occur. The ovaries increase in size, the capsule is dense, white, on the ultrasound they describe a multitude of small cysts of follicles enlarged in the ovary (polycystic). Many maturing and over-ripe follicles secrete sex hormones chaotically. Against the background of an excess of androgens, an imbalance of sex hormones in a woman’s body is disturbed and carbohydrate metabolism increases insulin resistance. Many women grow stout, in blood tests they find a periodic increase in the level of glucose, a state of ” pre-diabetes ” type 2. Often there are fluctuations in blood pressure (increase).

During external examination, sometimes there are signs of an excess of androgens: acne soup on the skin, increased growth of hard hair on the face and body, greasiness of the glands, deposition of fat on the abdomen and shoulder girdle (male type). Such symptoms are not observed in all patients, but only in those whose testosterone levels are elevated significantly.  

Due to the lack of ovulation and the normal development of the endometrium, these women experience difficulties with the onset of pregnancy. If pregnancy occurs, then hyperandrogenism (an excess of male hormones) can cause a loss in the early period.

Hyperandrogenism can also be associated with the pathology of the adrenal cortex. Find out the cause of hyperandrogenism (ovarian or adrenal) can be by analyzing the hormonal background of the blood.

Hyperprolactinemia

An increase in the blood hormone prolactin causes an imbalance between the amount of estrogen and androgens, inhibition of the production of sex hormones, impaired insulin sensitivity, and lipid metabolism.  

In addition to the scarcity or cessation of menstruation, a woman notices a general apathetic weakness, drowsiness, fatigue, puffiness of the face, milky discharge from the chest, hair loss, dull skin and face color, weight gain. Blood tests show an increase in prolactin levels. Often, hyperprolactinemia is associated with impaired thyroid function. Such patients also have problems with conceiving and carrying a child.

Inflammatory diseases of the pelvic organs: chronic endometritis, adnexitis, genital tuberculosis and other infections of the genital tract

Inflammatory processes of the reproductive system can occur with severe symptoms, and can go with virtually no manifestations. For example, in genital herpes, a woman can remember only about an episode of herpes sores in the vulva, and in fact, adhesions in the fallopian tubes and chronic endometritis in the functional layer of the endometrium can asymptomatically develop.

In any case, after an infectious process has been transferred, normal organ tissue may become inactive. In the ovaries after inflammation, tissue with follicles that secrete hormones and eggs, is replaced by connective tissue. The endometrial mucous layer in the uterus becomes “bald”, scanty, so it cannot be rejected normally and painlessly during menstruation and replaced with a fresh layer. Such patients in the future have problems not only with irregular menstruation, but also with the onset of pregnancy and gestation.

Tuberculosis of the genital organs

Urinary tract tuberculosis is very difficult to suspect and establish. Characteristic signs of tuberculous infection:

  • constant low-grade – up to 38 ° C – temperature,
  • mental disorders (irritability, nervousness, tearfulness),
  • reduced appetite
  • chronic adnexitis or endometritis that is not treatable. 

Chronic endometritis 

Constant or recurrent pain in the lower abdomen, fever during the period of exacerbation, menstrual flow with an unpleasant odor.

Chronic adnexitis 

Periodic aching pain in the inguinal areas, fever during exacerbation, tightness and adhesions in the area of ​​appendages, which are determined during a pelvic exam, infertility.

Sexually transmitted diseases

STDs include:

  • chlamydia,
  • ureaplasmosis,
  • cytomegalovirus infection, etc. 

Most often they are asymptomatic or with minor complaints (discharge from the genital tract with an unpleasant smell, itching and burning in the perineum, pain during intercourse, signs of chronic endometritis and / or adnexitis).

In inflammatory diseases of the pelvic organs, it is usually always possible to identify a connection with a provocative factor: with the change of sexual partner, with the occurrence of active inflammation after an abortion or other manipulation of the uterus, with hypothermia.

Ovarian exhaustion syndrome and resistant ovary syndrome

In this case, the uterus and endometrium remain healthy, but for a normal menstrual reaction there are not enough sex hormones. Disruption of the production of sex hormones occurs at the level of the ovaries. In the body of a woman with these diseases comes premature menopause at a young age (35-40 and less than 35 years).

In ovarian depletion syndrome (SRI), the hormone-producing tissue in them is replaced by connective tissue. This is sometimes due to hereditary factors, sometimes after inflammation in the ovaries, after a toxic effect on the body. A woman who had previously menstruated and possibly even had time to give birth, notes that her periods are becoming poorer and poorer, and then gradually stop altogether. When viewed by a gynecologist uterus and ovaries are reduced in size. In the ovaries, ultrasound does not visualize the follicles at all. An analysis of the antimullerian hormone in the patient’s blood may indicate that there is no reserve of follicles and eggs in the ovaries. 

The content of sex hormones in the blood at the level of menopause, a woman notices aging of the skin, “hot flashes”, fluctuations in blood pressure, anxiety, irritability, sweating, discomfort in the vagina – symptoms typical of menopause.

With resistant ovarian syndrome (FRY) , a young woman also gradually becomes scarce and stops menstruating due to the lack of enough sex hormones in the blood. In this disease, the ovarian tissue retains the required number of follicles and eggs, is not replaced by connective. 

Here the cause of the disease is a failure of the regulation of the brain. The ovary becomes insensitive to stimulation by hormones above (from the pituitary-hypothalamus). The body signals an estrogen deficiency in the blood, but the ovaries remain insensitive to FSH (follicle-stimulating hormone) and LH ( luteinizing hormone).

The clinic also has scanty periods with their gradual absence and the inability to conceive. The difference between SRIA and SIA: when the ovaries are resistant, follicles remain in them, the symptoms of menopause are less clinically expressed.

Psycho-emotional stress, excessive exercise in sports or school (“high school syndrome”), drastic weight loss, difficult working conditions can disrupt the release of ovarian-controlling hormones from the pituitary and hypothalamus. Here, menstruation becomes scarce or disappears altogether with a healthy uterus and ovaries. Control of the production of sex hormones is also impaired with tumors, injuries of the pituitary gland and hypothalamus, with infections of the brain and after hemorrhages in the brain.

Diagnostics

In order to find out the cause of scanty menstruation, the patient goes to an appointment with a gynecologist. What can see and suggest a gynecologist at the first admission:

  • When viewed on a chair, the reduced size of the uterus and ovaries, dry and reddened mucosa with contact bleeding may indicate a lack of sex hormones in the body.
  • The woman herself during questioning can say that she has decreased sexual desire, describe the signs of premature menopause and complain about skin aging.
  • Enlarged dense ovaries may be a sign of PCOS.
  • Increased growth of hard hair on the face , white line of the abdomen, inguinal folds, legs and skin condition suggests an excess of male sex hormones in the blood. 
  • On examination of the mammary glands, one can observe galactorrhea (the secretion of milk secretion from the nipples) with hyperprolactinemia. 
  • At the reception, the patient passes a smear on the degree of purity from the vagina, which can be observed “senile” type of smear (as in menopause), signs of chronic inflammation.
  • During the conversation, a woman can tell about a previous weight gain, about a postponed abortion with an infectious complication, surgery, traumatic labor, chronic infections, postponed meningitis, that she recently had an autoimmune disease – a lot of information about the provoking factor.

Important! At the reception, it is desirable to come with the “menstrual calendar”, that is, to pre-mark in red in the calendar calendar monthly for the last time (so as not to remember painfully at the reception!).

After the conversation and examination of the patient, the doctor may already approximately assume that the cause of scanty periods in the uterus or in the ovaries, or the dysfunction of other organs must be ruled out.

What examinations can be prescribed by a gynecologist:

  • Ultrasound of the pelvic organs: you can see a picture of ovarian scleropolytosis or, conversely, diminished ovaries with no follicles, a decrease in uterus size, identify a hematometer with obstruction of the cervical canal, a picture of adhesions ( synechiae ) in the uterine cavity, “bald” insufficient for the second phase of the cycle endometrium in the uterus.
  • Blood tests for determining hormonal status: estrogens , progesterone , testosterone , prolactin , adrenal hormones and thyroid hormones , FSH and LH , and others.        
  • Tests for the presence of ovulation in the cycle. This may be the old method of measuring basal temperature: daily in the morning body temperature is measured in the rectum, the indicators are recorded in the graph; in case of ovulation, the basal temperature rises, which is reflected in the graph. The method takes time and self-control, but there is no cash cost. When tracking the presence of ovulation in the ovary using ultrasound tests conducted several times in a row (we observe the growing and bursting follicle) and urine tests for ovulation, the woman will not experience the difficulties of daily measurement of the basal temperature in the rectum, but will be spent financially on tests and ultrasound.
  • Antimuller hormone – talks about the stock of follicles and eggs in the ovaries and about the patient’s perspective on childbearing and the resumption of menstruation. With a premature menopause, it is almost zero. 
  • The blood sugar and a test of tolerance to glucose with glucose 100g (in violation of sensitivity to insulin).   
  • A visit to a TB doctor (if indicated, if there is a suspicion of genital tuberculosis).
  • Smear analyzes and PCR diagnostics for sexually transmitted diseases.
  • Smear from the cervix on oncocytology .
  • X-ray of the Turkish saddle and examination of an oculist (to exclude a pituitary tumor);
  • Consultation with an endocrinologist, an ultrasound scan of the thyroid gland and an ultrasound scan of the adrenal glands to exclude hormone-producing tumors in these organs.
  • Samples with the introduction of estrogen, progesterone, FSH and LH from the outside (the doctor prescribes a certain drug to the patient according to the scheme and observes whether the menstrual-like reaction appears in response to its introduction or withdrawal). With their help, the doctor determines what hormone is not enough and whether the uterus is healthy (can it even menstruate).
  • Hysteroscopy and endometrial biopsy. These are already invasive methods of examination (mini-operation). During hysteroscopy, the uterine cavity and cervix are examined from the inside by a video camera. One can see and dissect intrauterine adhesions, diagnose obstruction of the fallopian tubes in the initial sections, make an endometrial scraping for analysis (according to the scraping result, morphologists can describe hormone deficiency, chronic endometritis), etc. 
  • Laparoscopy with examination and ovarian biopsy is sometimes prescribed to women who are screened for scant or absent menstruation and infertility before IVF. During laparoscopy for infertility, signs of tuberculous and other infectious lesions of the pelvis can be detected. 

Treatment of scanty menses

Treatment of hypomenorrhea depends on the cause that caused it.

If gynecological diseases were the causal factors in the occurrence of scanty menstrual periods, the therapy is performed by a gynecologist. In the case of tuberculosis infection, treatment is carried out by a TB doctor. In case of endocrine pathologies, the endocrinologist deals with the treatment , in case of mental disorders, it is recommended to jointly supervise the patient with a gynecologist and a psychologist, according to indications – a psychiatrist.

Hypomenorrhea treatment continues for more than one month.

Dissection of intrauterine synechiae, fusion of the cervical canal and emptying hematometers are performed by hysteroscopy or hysteroresectoscopy under general anesthesia. After the surgical stage of dissection of adhesions, a stage of hormonal therapy should be followed. A combination of estrogen and gestagen (not COC) is usually prescribed. Against the background of hormone replacement therapy, the growth of a normal endometrium is necessary.

In PCOS, the treatment regimen contains weight loss, administration of drugs that improve insulin sensitivity, correction of hyperandrogenism , operational benefit (making incisions on the ovaries, making it possible for the ovaries to exit and ovulate). Surgical treatment is carried out with infertility and the desire of the patient to conceive.

In case of hyperprolactinemia , its correction is carried out (the drug “ bromkriptin ”, “ dostinex ”). With a lack of thyroid hormones, they are introduced into the body with a replacement purpose.

Replacement therapy with sex hormones is also carried out in case of the syndrome of depleted ovaries and resistant ovaries. Without the introduction of hormonal drugs from the outside, premature menopause will develop in the woman’s body.

In chronic adnexitis and endometritis, antibiotics and anti-inflammatory drugs, resorptional therapy and physiotherapy are prescribed. In chronic endometritis, endometrial insufficiency is usually always present. In order to further the woman to menstruate and bear the child, after anti-inflammatory therapy, rehabilitation is prescribed. Its goal is to improve the blood flow in the pelvis, to restore the functional layer of the uterus, to prevent sclerotic changes in the ovaries after inflammation. The woman was recommended laser blood purification, ozone therapy, endometrial growth stimulation through the use of hormonal drugs and stem cell preparations.

With an excess or lack of weight, it is corrected, vitamins are assigned according to the phases of the menstrual cycle.

Complications and prognosis

Undiagnosed and untreated diseases, in which scanty periods appear, can lead to the following complications:

  • decrease in sexual desire, frigidity;
  • secondary amenorrhea (complete or almost complete absence of menstruation); 
  • early menopause with early consequences – osteoporosis and pathological fractures, cardiovascular and other metabolic disorders, urogenital disorders);
  • infertility;
  • habitual miscarriage;
  • in chronic pelvic inflammatory diseases, the risk of ectopic pregnancy and chronic pelvic pain syndrome increases ; 
  • development of type 2 diabetes, uncontrolled obesity, “metabolic syndrome”, in which the functions of the endocrine system of the body as a whole are violated.

The forecast for the restoration of menstruation to regular and moderate in most cases favorable if the treatment is carried out in a timely manner and in full.

After correction of deviations in the imbalance of hormones (sex, prolactin, thyroid gland), both the normal cycle and the reproductive function can be restored. After operative and complex treatment of PCOS, women conceive independently and with the help of IVF.

Even in the complete absence of sex hormone release in the syndrome of exhausted and resistant ovaries, they can be replaced from the outside with the help of drugs. Menstruation will come on time, cyclically. Symptoms of estrogen deficiency are arrested. Hormone replacement therapy is carried out for a long time, from the time of diagnosis to the age of the usual postmenopausal. But the forecast to conceive independently in this case will be unfavorable.

After the examination, it is determined whether there is a reserve of eggs in the ovaries. It depends on whether it is possible to conduct IVF with a woman’s egg. In most cases, childbearing with SIA and ARF is possible only with IVF with the donor egg.

After dissection of intrauterine adhesions, long-term treatment is required, the prognosis for gestation of pregnancy is rarely favorable (if the process is not running).

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