PPAF While Nursing - Return to Fertility

I've just gotten my fifth PPAF at 14 months PP and finally its a little more normal, indicating that my body was able to put up a reasonable lining. My cycles have evened out to be about 5 weeks long, though the time between when I and when arrives is pretty consistently 2 weeks now.

We are wanting to start to TTC for #2 soon so it was rather worrying to me that my lining was so thin. Nothing's really changed in terms of how much I am feeding him I don't think. Perhaps my body is just getting back fully into the swing of things.

Menstrual Irregularities

Here's a page which illustrates/explains different types of menstrual irregularities:

http://www.femalehealthmadesimple.com/FileTwelveFinal.html

"Any woman of childbearing age who has missed more than two consecutive periods -- but was not pregnant -- needs to investigate it and possibly have her period induced. Preventing the development of hyperplasia is the reason."
From: Endometrial Hyperplasia, WebMD

"Excessive estrogen stimulation can lead to significant increases in uterine lining thickness. The tissue becomes hyperplastic or atypically hyperplastic . It may become cancerous."

(and)

"Inadequate ovulation may cause excessive, irregular, or frequent menses recurring less than every 3 weeks. Inadequate ovulation leads to an excess of estrogen, which stimulates growth of the menstrual lining, and a decreased level of progesterone - which normally would be present in levels that would adequately thin the menstrual lining and prevent excess or irregular bleeding."
From: Dr Decker, Heavy Menstrual Cycles Management Options

"We like to see a lining of at least 8mm in thickness when measured by ultrasound at the time of maximal thickness during the cycle (see above ultrasound images of an 11.5 mm lining). There is some ongoing debate as to "how thin is too thin", as well as to "how thick is too thick". In general, 8-13 mm is good, less than 6 is potentially a problem, and greater than 15 or so could possibly reduce chances for a successful pregnancy."
From: Uterine problems causing infertility or miscarriage

Why we have bleeding problems... Links/References

At the beginning of the year I posted some links about dysfunctional uterine bleeding (DUB) and one list member (on the fibroid group) asked if I would look into why women tend to have flooding first thing in the morning. Most of you probably know this phenomena whether or not you have DUB -- its when you are sound asleep and suddenly awaken because a big gush of blood is coming out all at once and you run to the bathroom if you can though sometimes you wake up too late and the sheets, your underwear and your nightclothes all need washing.

I wish I had a hematologist to confer with but doctors tend to keep to themselves or just don't overlap with my software oriented social network. I've got a few references here some mechanical and some physiological to causes for bleeding. Since excess estrogen/low progesterone is one theory of part of the cause of fibroids it is interesting to see that the same conditions also set the stage for bleeding problems. Also, I couldn't find references to early morning menstrual bleeding but there was a reference to there being early morning changes in the blood which might be related, at least in action.

"Most very heavy menstrual bleeding does not mean that a woman is shedding substantially more endometrium. The endometrial slough is determined by the size of the uterus and the hormonally induced endometrial thickness. The uterus has large blood vessels that come through the myometrium to feed and supply the endometrium. Really heavy bleeding occurs when the uterine muscle cannot do its job of contracting around these vessels. This is important because after the endometrium is passed out, the basilis layer may be very thin, which could expose the raw muscle surface. This means that the large
vessels can pump blood directly into the uterine cavity if the muscle cannot contract well."
http://www.centerforendo.com/news/adenomyosis/adenomyosis.htm

"what frequently happens when excessive amounts of estrogen are secreted. Parts of the endometrium outgrow their blood supply and are discarded but not simultaneously. While the one part recovers another part is discarded and the bleeding continue for prolonged periods. In the illustrations the bleeding might decrease while the one area heals before the the other area starts bleeding."

"Fibroids usually cause excessive cyclic bleeding. The amount of blood loss is increased and /or the duration of the bleeding is increased. The mechanism is probably due to enlargement of the womb, thus increasing the surface area of the endometrium."
http://www.femalehealthmadesimple.com/FileTwelveFinal.html

"The plasminogen (fibrinolytic) system (Figure 1 ) comprises an inactive proenzyme, plasminogen, that can be converted to the active enzyme, plasmin, that degrades fibrin and that activates matrix metalloproteinases (MMPs), which in turn degrade extracellular matrix(ECM)"
"There is a clear correlation between the circadian variation in the time of onset of myocardial infarction, with the highest incidence at about 8 a.m., and the circadian rhythm of plasma PAI-1 activity, which is also highest early in the morning."
http://www.asheducationbook.org/cgi/content/full/2001/1/1

"PGE2 --> vasodilation; PGF2a --> vasoconstriction; progesterone is necessary to increase ararchidonic acid, the precursor to PGF2a. With decreased progesterone there is a decreased PGF2a/PGE2 ratio. Since vasoconstriction is promoted by PGF2a, which is less abundant due to the decrease in progesterone, vasodilation results thereby promoting AUB [Abnormal Uterine Bleeding]"
http://www.unmc.edu/Olson/PowerPoint/36 (no longer available)

Definitions of (girlie) bleeding

In the time I've hung out online with women trying to get pregnant I've had the chance to learn more of the nuances of spotting. I've heard women say that if there is any blood contained in your cervical fluid they they considered it spotting. At the end of your period though it it more residual flow, I have that too. This type of spotting tend to be brownish.

[added in this article link 2/4/06]
Menstrual Mysteries -- more info about determining problems with your menses based on quantity.

Spotting is bleeding outside of your period. I've had spotting this month and it just continued as red coloration to my cervical fluid, this is dysfunctional uterine bleeding related to my miscarriage.

Spotting also is the first sign of an impending period for many women. I'm pretty sure that this is light pinkish, with maybe a little brown as the blood oxidizes.

Heavy menstrual flow is when you need to use more than one pad an hour, though I consider this really heavy, medically referred to as Menorrhagia. Because your body is bleeding so much the chemicals that are supposed to keep the flow fluid can't work as well and you do get some coagulation -- the clots, or liver-like lumps. I find that when I have clotting I tend to get really nauseous kinda intense cramping feelings -- I think this might be the clot passing through the cervix -- when I miscarried there was a similarity to the sensation though the miscarriage was more painful in my opinion.

My previous period was unusual, again it seemed to be related to my body trying to get rid of retained tissue from my miscarriage. I had bleeding for 3-4 days that was bright red and had no clots. On toilet tissue it looked like I was dabbing at a wound, it was plain blood and without the mucus component of a normal menstrual flow. I consider this abnormal for me, though women with fibroids contacting the endometrium might experience this as a frequent event.

"Women lose between 20 and 80 cc's (1-2 ounces) of blood during a normal period." (hah! right)
http://www.fwhc.org/health/moon.htm

This page includes diagrams and links to more information about normal/abnormal menstrual bleeding and includes a reference to fibroids (scroll down the page)
MENSTRUAL ABNORMALITIES

I found a lot of mention of the fact that doctors often underestimate women's blood flows and that there is a pictorial chart (see link below) that women used in one study that was a clearer indictator of blood loss. I'm sure many of us have experienced this underestimate by docs -- perhaps if those of us with heavy periods would catch the blood that pours out of us when we go to the toilet and bring it to the doctor's office they might be able to see what we go through.

The Medical Algorithms Project has a copy of the The Pictorial Blood Loss Assessment Chart (PBAC), an excel spreadsheet that helps calculate blood loss
http://www.medal.org/

My bad bleeding

Starting approximately two weeks ago I started feeling wired like I had too much drip coffee, and kind of anxious feeling as well. I don't drink caffeine regularly and rarely have coffee at all so this was weird. I also didn't have a lot of stress at work or at home so it was even weirder. Then last week I started having insomnia, I was getting up in the middle of the night for hours an ultimately only having 5-6 hours of sleep. It kept getting worse and that anxious feeling kept building. I also had a loss of appetite. It was like something was seriously off in my system.

Then I started feeling vague pregnancy symptoms last week as well, like a vague recap of my first week pregnant including some itchiness, breast fullness, light nausea and my thyroid felt funny again as well. I had two faint positive pregnancy tests on Friday and Saturday but they didn't get darker. On top of everything I was experiencing I felt utterly confused. On Monday I had a beta HCG draw and it was 13, down from 46 a month ago (or perhaps I had a chemical pregnancy?) The nurse called and said that it was probably residual beta from my miscarriage in July.

I continue to feel awful and anxious and tired and then Monday night my period arrives, the second one since my miscarriage. It is very red and very viscous, there is no slimy mucus to it, and not really clotting either. It just is very runny bright red blood. I easily bled 2 cups worth at least, it is hard to estimate since I would have gushes when I went to the toilet. I had a headache, my body felt full of cold water, my thyroid felt strained. I also had odd cramping. I stayed home from work yesterday and took ibuprofen and vitamin C which did seem to help control it somewhat. I also went for an acupuncture treatment and that helped with some of the symptoms, I didn't feel so watery inside any longer. I woke up this morning and had hardly bled at all overnight, practically just spotting. I feel dry and clotting in my abdomen.

I called my RE this morning because I want to get to the bottom of this. It isn't just my fibroid, it isn't just the miscarriage and I'm not taking meds or herbs so something is just out of whack with me.

Since someone posted about von Willebrand's Disease (VWD) in the past year I've thought that I had a predisposition towards it. I brought up my long periods and nosebleed problems as a child, plus my anemia but no doctor has responded to the symptoms (tell me the patient doesn't need to suggest the disorder and I won't believe you). My father is very prone to bruising and I am a bit as well. We'll see. I did see this page on the All About Bleeding/VWD site that talks about how some hormones can influence bleeding problems. As I recover hormonally still it is very possible and also women in my family have noted thyroid problems post pregnancy. I did ask for a check of my thyroid hormones weeks ago as well as on Monday but they didn't write the script for that. I'm going to ask the doctor about getting it checked.

http://www.allaboutbleeding.com/vwd_and_you/view.asp?id=4634

Oh, and you know how I love my links, I found this one that I thought was a good reference about NSAIDs and menstrual bleeding:

Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding (Cochrane Review)
Lethaby A, Augood C, Duckitt K
http://www.update-software.com/abstracts/AB000400.htm