Understanding the common by learning from the rare (Period blog #4)

This is the fourth in a series of posts from our friend Professor Sonia Grover, looking at the types of blockages during a period and what these uncommon problems can teach us about endometriosis.

I have previously talked about some of the extraordinary things that happen at the time of periods, and how skipping periods is actually fine.

Skipping periods, not having them (when we know what is happening hormonally), is fine. I too can get worried when no periods are happening, as the body not making periods may be a way of the body saying, ‘I am not in good health’. So no periods because someone is losing weight, is underweight or overweight, or is burning more energy by doing lots of exercise and not taking in enough calories for this, or has a significant bowel or kidney problem, is clearly not good.

On the other hand, when someone is skipping periods due to using the pill continuously, or has no or minimal periods due to a hormonal intrauterine system, then that is fine because we know what is going on, and we know that there are balanced hormones. Just like how we know why a pregnant or breastfeeding woman is not having periods.

Learning from the unusual

In medicine, we often learn a lot by understanding or studying the rare or unusual. So let’s talk about some more uncommon, even rare things that have helped me understand periods, bleeding, pain and endometriosis.

Some teenage girls are born with a problem so that when their periods start, the blood can’t come out due to a blockage occurring at the hymen – somewhere between the uterus and the lower end of the vagina. This can be pretty painful as you could well imagine. The blockage may be anywhere between the level of the hymen, which is called an ‘imperforate hymen’ ( this is very easy to fix). Or more complicated, such as a blockage part way up the vagina – a transverse vaginal septum – or a missing or blocked cervix.  There can be other blockages affecting one side where there are two uteri present. Yes, it can all get a bit complicated! But mostly, these problems are relatively straightforward to fix.

The effect of a blockage

When a blockage is present, the periods will still start and are actually happening. But as the blood can’t get out, it has to backtrack and thus flows up through the tubes and into the young woman’s insides – into her peritoneal cavity. I have mentioned this before, this is called retrograde menstruation (backward flowing periods). As I mentioned in my last blog, this actually happens to some degree in just about every woman, but where there is a complete blockage, all the period blood has to go backwards and thus by the time we see these young women, they may have been doing this for one or two years. These young women almost invariably have pelvic pain and endometriosis, in fact, quite bad endometriosis.

So, our job, as gynaecologists, working with these young women, is to correct the blockage and to fix the pain. But, we rarely do anything about the endometriosis in these young women. Why? Well her body simply clears it all away once all the back bleeding – the retrograde menses – stops.

How do I know this? Sometimes we don’t operate immediately but instead stop the periods altogether for several months or even a year or so. Our aim is to stop the periods but also to stop the pain that the periods and the back bleeding are causing. By stopping the bleeding, we are usually able to fix most, if not all of the pain. We think it is important to stop the pain, as recurrent or ongoing pain probably contributes to the development of chronic pain. We then do the operation to fix the blockage when it suits the young woman, waiting for school holidays, or until exams are finished, or after the sports competition finals and so forth.

In some of the young women, we know that there is extensive endometriosis from an earlier exploratory operation or from detailed imaging. Yet when we come back to do the corrective surgery for the blockage, after several months of no bleeding at all (and with the pain having progressively improved), there is usually no endometriosis left to see. The body has simply made it all disappear. I suppose we all know the body can do some amazing ‘clean up jobs’ – think of grazes, bruises and even broken bones that within a few weeks or months simply resolve, often with no or minimal scarring.

So I don’t have a problem letting the young woman’s body do some of the clean up work, clearing the endometriosis. As long as I know that I have changed the balance of how much blood is going inwards and thus I know that I have fixed the predisposing cause. But more importantly, I have solved the pain from the blockage.

So these uncommon problems have taught us that endometriosis is quite likely to develop if you spill lots of menstrual blood inside and that in young women, this will disappear if we simply stop the spillage of retrograde blood. This raises some interesting questions regarding whether some endometriosis could actually be prevented!

Enough about bleeding, retrograde bleeding and pelvic pain. Next time I think we should talk about some other causes of pelvic pain – and there are quite a few to discuss!

– Sonia Grover

Professor Sonia Grover has extensive experience in paediatric and adolescent gynaecology having worked in this field for over 20 years. She has been instrumental in establishing this subspecialty in Australia as well as in Asia and internationally. Professor Grover’s clinical interests include all aspects of young women’s reproductive health – including menstrual problems (excessive bleeding and/or pain), amenorrhoea, ovarian problems, congenital anomalies affecting the reproductive tract and reproductive hormones and the cyclic exacerbation of ‘non-gynaecological symptoms’ including cyclic seizures, asthma, and chronic fatigue. Professor Grover’s ResearchGate profile here.

Sonia’s five-blog series:

#1: Period Pain
#2: Periods are extraordinary events, and it’s ok to skip them
#3: Heavy periods and retrograde bleeding
#4: Understanding the common by learning from the rare
#5: Ovulation Pain

Feature image adapted from Freepik.