Period Problems: what is causing them?

Period Problems: what is causing them?

By I.Soussis, MD, Fertility Specialist 

A woman experiences her period for the whole of her reproductive life. Sometimes, she considers as normal symptoms that should not exist.

Ηow do you know if your period is causing problems that it shouldn’t?

In most cases you should not worry if you:

  • get cramps

  • have low back pain

  • feel fatigue or discomfort

You should talk to your doctor if:

  • the pain is so bad you miss days of work or school every month

  • have such heavy bleeding that is causing anemia

These are things that may need investigation.

Most women’s menstrual cycles range between 21 to 35 days, or up to 45 days for teens. A recent study of 600.000 cycles from Britain, showed that only 13% of women have what we consider a “normal” cycle of 28 days. Bleeding usually lasts between three to seven days. What’s normal for one woman may not be for another.

The most common menstrual irregularities are:

  • not having a period at all

  • irregular periods

  • prolonged of shord periods

  • severely painful cramps

These problems can have many different causes, including:

  • scarring, caused by endometriosis or previous operations

  • hormonal imbalances (polycystic ovarian syndrome)

  • certain diseases or conditions (eg coagulation disorders)

  • medications (eg regular use of aspirin)

Uterine fibroids and endometriosis are two common causes.


Fibroids are benign tumors, made of muscle or connective tissue cells that grow inside or outside of the wall of the womb. Although the majority of women have at least one fibroid during their lives, most of them don’t have symptoms.

Very heavy bleeding during a woman’s period is the most common symptom of fibroids. Ultrasound is very good at diagnosing them.


Endometriosis is caused by the lining of the uterus (endometrium) when it grows outside it, on other organs. The cardinal symptoms of endometriosis are period pain, pain during sex and infertility. Endometriosis probably accounts for at least a third of infertility in women.

Endometriosis diagnosis is very difficult. Currently, there is no blood test or imaging technique that can diagnose endometriosis. The only way to diagnose endometriosis is laparoscopy. This can lead to a delay in diagnosis, in part because no one wants to be quick to do surgery.

Both fibroids and endometriosis have familiar tendencies. Women may not know that severe pain or heavy bleeding aren’t normal. Sometimes the mother would advise the daughter to “put up with it, it’s normal for a woman”.

However, there are treatments that can improve your health and quality of life.

It is the duty of the doctor to advise appropriately and to offer the right treatment.

Endometriosis can also affect adolescents

Endometriosis can also affect adolescents

By I.Soussis MD

Although endometriosis is commonly characterized as a disease affecting adult women of reproductive age, a review article compiled by an international panel of experts and published in Best Practice & Research Clinical Obstetrics and Gynaecology highlighted that it can also affect adolescents and younger women.

In addition, the authors reported that many women may experience their first symptoms in their teen years, but that they may not be recognized as indicative of endometriosis until later in their lives.

Risk factors for endometriosis in adolescents and young women include:

  • congenital abnormalities of the Müllerian duct  (due to increased incidents of retrograde menstruation),
  • first-degree relative with endometriosis, which accounts for approximately 50% of the risk for developing the disease,
  • early onset of menses,
  • prolonged menstruation (> 5 days),
  • short menstrual cycle interval (< 28 days), and
  • early-onset dysmenorrhea.

Studies have also reported associations between endometriosis and exposure to passive smoke during childhood and elevated levels of 2,4-dihydroxybenzophenone (found in sunscreens).

Other risk factors include premature birth, low body mass index, high caffeine or alcohol intake, and acne.

Consumption of soy formula as an infant has been observed to double the risk of endometriosis compared to that in women who were not exposed to dietary soy isoflavones as infants, reported the authors.

Potential protective factors identified:

  • use of oral contraceptives (OCs)
  • regular exercise
  • onset of menses after age 14
  • increased intake of omega-3 fatty acids

Black and Hispanic race compared to white or Asian race may also offer some degree of protection.

Symptoms and signs in adolescents:

Endometriosis lesions often have a different appearance in adolescents than in adults when visualized on laparoscopy: ovarian endometriomas and deep endometrial lesions are more the norm compared to powder-burn lesions seen in adult women.

Ovarian endometriomas are typically filled with “syrup-like chocolate material” and are surrounded by duplicated ovarian parenchyma. They have fibrotic walls and adhesions on the surface, according to the authors and are lined by endometrial epithelium, stroma, and glands. They are typically visualized in the rectovaginal septum, rectum, rectosigmoid colon, bladder, ureter, uterine ligaments, and vagina.

As in adults, the lesions should be staged from minimal disease (Stage 1) to severe disease (Stage 4), based on their size, location, and the types seen, and the extent of adhesions.

Distinguishing primary dysmenorrhea from endometriosis:

Many teens present with dysmenorrhea, which in light of the new information about the development of endometriosis in adolescents and young women should be evaluated to rule out endometriosis.

In adolescents with endometriosis, dysmenorrhea tends to be the first symptom of the disease and increases in severity over time. The pain is both cyclic and acyclic and interferes with school attendance, social activities, and exercise. Teens who are sexually active often report dyspareunia and gastrointestinal distress.

The clinical diagnosis can be verified with pelvic ultrasound and magnetic resonance imaging (MRI), but laparoscopy is the only way to obtain a definitive diagnosis.

The disease is unlikely to resolve spontaneously and is typically treated with nonsteroidal anti-inflammatory drugs, oral contraceptives, and progestin-only contraceptives. Laparoscopy and surgery may be an option for adolescents who fail to respond to medical therapy.

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Endometriosis and migraines

Endometriosis and migraines

By I.Soussis. MD,MSc, FRCOG

A new study of 391 adolescent girls in the Boston area revealed that those with a surgically diagnosed

endometriosis were more likely to suffer from migraines. The study was published in Fertility and Sterility.

Endometriosis is a chronic condition in which the endometrium grows outside the uterus, typically in the abdominal cavity or on internal organs. Patients often experience significant pain and discomfort during their period or intercourse. Endometriosis may also lead to infertility or hysterectomy.

Current diagnostic methods that rely on laparoscopy, which often patients try to avoid, are delaying the diagnosis typically five to 10 years from the onset of symptoms.

Τhe presence of migraine may be a useful clue to better early detection.

Researchers compared the self-reported frequency and pain of migraine among two populations: adolescent girls with surgically-diagnosed endometriosis and girls of a similar demographic with no such diagnosis.

After adjusting for differences in population, researchers found that those with endometriosis were 5 times more likely to suffer from migraine than the comparable group.

Researchers have also seen a close linear relationship between the severity of migraine pain and the odds of endometriosis. The more painful the migraine was, the more likely it was that a subject had endometriosis. In a scale of zero to ten, for each one point increase in pain the odds of endometriosis increased by 22%.

A serious limitation of this study is that girls who have confirmed endometriosis were more likely to have taken hormonal medications, which could increase the risk of migraines.

The results of this study seem to corroborate a rapidly growing body of evidence from other researchers who have drawn the same conclusion in adult women and it presents a useful signal to help us diagnose women more accurately and at a younger age.


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