Approach To Menstrual And Fertility Issues In Nigeria

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By Dr. ANUMA KALU ULU

I have over the years been bombarded with questions from a plethora of people in Nigeria seeking answers to common menstrual and other related issues, and this is an avenue to reach a wider audience.



Guys can dismiss this with a facile wave of their hands and concomitant misplaced indifference until they hear that this has a direct bearing to their having children and even to some extent determining the sex of their babies,  then they will pay rapt attention.

The first thing I will say here is that if you are a female and go into a medical personnel’s office for consultation of a mentrual irregularity and he tells you it is due to infection and proceeds to suggest antibiotics before or after a culture, please get up and leave that place and do not look back! Why, you may ask? This is because uterine infections do not contribute in  any way to menstrual complaints but will only present with pelvic pain, vaginal discharge and constitutional symptoms like fever and fatigue if very advanced and fulminant.

I am sounding this alarm because in 100% of the cases that have been discussed with me by patients from Nigeria,  they were usually told the menstrual problem was from infection, and then underwent some sham urine/vaginal culture showing staphylococcus (commonly and ominously just called Staph in Nigeria!) and were treated with a combination of antibiotics, with the problem invariably continuing because these patients were railroaded in the first place with wrong diagnosis and treatment.  Excuse my inability to suffer fools gladly but what on earth is Staph doing in the vagina where it can hardly survive?? Staph is skin colonizer, together with streptococcus (Strep) so when the skin around the vagina/labia is not cleaned well during swabbing or even accidentally touching the thigh (commonly called lap) of the patients picks up hordes of these Staph organisms which then grow erroneously in the culture result. An intact skin is a barrier to infection by these Staph and Strep organisms that inhabit the skin but they are the main causes of skin infections in breached skin, like impetigo, boils (abscesses), follicutis or hair root infections, etc.  This is why an accidental skin cut from a clean newly-opened razor can get infected about 3days later because these organisms that could not breach an intact skin, just poured into the broken skin, despite the razor itself not being contaminated. For infected skin,  these Staph organisms respond to regular antibiotics easily like ampiclox in Nigeria or cephalexin over here in the USA and one does not need any antibiotic combination (as the practice in Nigeria is to usually give about 3 different antibiotics combined, not forgetting your injection which is a must there and usually Rocephin).

I will not fail to mention a subset of resistant Staph called MRSA ( methicillin-resistant Staph aureus) which is infrequent but when noted will not respond to the regular antibiotics for Staph  infections but to antibiotics like Bactrim (Septrin in Nigeria), Doxycycline,  Clindamycin and in systemic infections, Vancomycin.  Rocephin does not have any activity against MRSA. If the patient is not septic, or the infection is not virulent or the patient is not acutely ill or vomiting and unable to tolerate anything by mouth, or in situations of gastrointestinal absorption problems,  there is really no need for antibiotic injections as being abused in Nigeria as oral antibiotics are just equally efficacious. 99% of the Staph in vaginal swabs and urine cultures in Nigeria do not need any treatment as they are just contaminations from the surrounding skin!! Let me not digress too much from the topic at hand, menses.

A normal menstrual cycle is usually 28days plus or minus 7days, meaning that anything from 21days to 35 days is normal. So those who complain that they get theirs twice a month could see how this is possible, especially if you fall into the 21-day cycle. Subtle variations are acceptable,  like 21days here this month, 25days there next month, etc but wide swings from 21days to 35 days will seem abnormal.

Even then, unless this happens at least 3 times consecutively, it should not be concerning.  This is because a woman’s menstrual cycle is subject to stress hormones so things like sadness as in death, joy as in travelling abroad, purchasing a car,  etc can trigger events that can lead to heavy flow, scanty flow or even cessation.  As such, any alteration unless life-threatening is not significant until it happens through 3 menstrual cycles in a row. The typical thing is for the Nigerian female to start worrying about the little aberration and even having sleepless  nights, a bad combination that will worsen the situation.

I am teaching you now not to fret over any of such changes, and by not fretting and thus not releasing  stress hormones,  your cycle may just restore to normalcy  in the next month.  Apart from regularity, most people in Nigeria worry about the colour, the quantity of blood flow especially how scanty and the number of days of flow,  especially when less than their usual number of days. It is like Nigerian women like to lose blood going by how much they fret over discrepancies and they think it is such a natural order of things that cannot be interfered with. It is almost heretical to alter the course of menses in Nigeria that most people cannot even take pain medications for painful menses because the natural order may be upended.  I can understand  this ignorance on the part of patients but when a multiplicity of them tell me that they were told by their doctors not to take pain medications for painful periods, then I am about ready to do away with science,  embrace religion the Nigerian way and proclaim that we need deliverance!! When i tell some Nigerian girls that most girls like them in the USA take medications that make them not to have their monthly period, their palpable disbelief is always summed up in the corollary question,  ‘where does the bad blood go?’

My answer is that there is no bad blood because unless the uterine lining is stimulated to prepare for a baby and then no baby eventually there is nothing to shed in menses. Here in the USA,  most girls are on the oral contraceptive pills to prevent unwanted pregnancy. They take 21 tabs once daily and for the next 7 days thereafter take a placebo that lets them have their menstrual flow. Some do not even want to have that, so they just jump to the other 21 tabs in the next pack and continue cyclically like  that. Others who do not have the discipline for daily medications resorted to the taking depoprovera injections every 3 months with same result. At present, the fad is to have an implant called nexplanon placed in the body after making a short cut into the skin, and for 8 years no pregnancy will occur and invariably no menses. With these innovations in the world, we in Nigeria are still worried that our period flow dropped from 4days to 3days, etc.

An established menstrual irregularity can be investigated with checking the blood count to ascertain the extent of blood loss,  checking coagulation profile to see proneness to bleeding, doing hormonal assays to ascertain menopausal status, doing ultrasound of the pelvis for structural abnormalities and then  surgical interventions like diagnostic and therapeutic D&C and finally laparoscopy.

READ ALSO: That Your Diagnosis Of Diabetes Mellitus In Nigeria Could Actually Be A Benign Prostate Hyperplasia (BPH)!

RELATIONSHIP WITH INFERTILITY:

A typical menstrual flow lasts 4 days and in these ones and in a typical 28-day cycle, the first 7days after the menses is called the safe safe period. This means that no matter what is done here, the  patient is unlikely to get pregnant. This can be adjusted accordingly,  like in a person with 5-day period flow, the safe period will be first 6days granted that is a 28-day cycle altogether. If more or less than 28days, a commensurate adjustment will be made accordingly. The next 7days after the initial 7days will be called unsafe period. This is where the ovulation period falls into and those looking to have a family are advised to try hard here. This is typically the 12th to 19th day of the cycle. Next 7days is the unsafe safe period. Unfertilized egg should be breaking down along with uterine lining all preparatory for the next menstrual flow at this point so it is safe, but like all human factors, some eggs may be tenacious so one could get pregnant still,  though extremely rare.

From the 28-day, the next menstrual flow starts all over, and though not optimum for coitus, this is also a safe period. Safety in this article refers to freedom from pregnancy.

FIBROIDS AND INFERTILITY:

Fibroids do not cause infertility directly because they do not interfere with fertilization but by their sheer weight and presence, cause mechanical obstruction to implantation of the fetus into the uterine wall or expansion of the already-implanted fetus as needed. When there is not enough space for both in the uterine cavity, it is the baby that will go. Fibroid is a growth in the myometrium (muscular layer of the uterus). If it stays in the muscle layer or bends with its stalk to the outer layer( the serosa) it will have nothing to do with fertility. If its stalk bends inwards into the uterine cavity, it can then cause miscarriages through mechanical competition with implanting fetus. That person would have been positive for pregnancy already.

DETERMINING SEX OF THE CHILD:

This is ultimately from God but there are things that can help us facilitate this process. In Nigeria, a lot of premium is placed on this because of the primacy of having male children. Although the trend is changing now due to cultural integration, there has not been a seismic shift so these pointers are still relevant. The most essential thing is for the woman to know when she ovulates. It is usually at the midpoint of her monthly cycle and could show symptoms as alternate-sided pelvic pains monthly, mid-menstrual vaginal bleeding, slight rise in basal body temperature or egg-yolk vaginal discharge. The egg only lasts 3 to 12hrs when released before dying whilst a sperm stays upwards of 2days in a woman when released, with the male-carrying sperm dying off first.  This same male sperm is faster and stronger and will get to the egg first and fertilize it. So, from all permutations,  if a woman pins down when she ovulates and then did not meet her man in the 2days prior but quickly meets him thereafter, the faster male sperm should reach the released egg first and the child should be male. If however all the male-bearing sperm had died before the egg is released, the female-bearing sperm will fertilize the egg to produce a female. It is absurd for a husband to blame a wife for giving him only female children since it is the man that actually determines the sex of the baby depending on which sperm he donated.

 

POST-MENOPAUSAL ISSUES:

For most people, menopause occurs from 45 to 55 years. So many changes occur here but i want to dwell only on two changes. The first is loss of bone density due to loss of calcium, resulting in more women breaking their bones and hips from this age going up. This is because estrogen maintains normal calcium homeostasis but dries up after menopause. This is why it is important for women nearing menopause to take their calcium and possibly vitamin D ( needed for calcium metabolism) from say age 40years, daily. The use of calcium to treat body pain as is done in Nigeria is actually criminal as lack of calcim does not give pain but can lead to softening of the bones and pronness to breaking, but not pain per se!!

Another change here is hot flashes.  Estrogen cools the body of women but after menopause  when it dries up, most women suffer bouts of feeling hot, sweating, restlessness and anxiety that can last for 1hour at a time and even several times a day, and generally feel hotter than others around them. It does not occur immediately menopause starts as it may take up to 3years for the estrogen to dry out but any postmenopausal woman with above symptoms has hot flashes. It is treated with hormone replacement therapy,  which replaces the menstrual hormones but in quantities too small to induce menses again but enough to provide relief from hot flashes. I have personally treated a lot of people in Nigeria with these symptoms which they erroneously ascribed to a ‘spiritual attack’ before my intervention.

This topic will take 2 articles to finish. Thank you

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