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Menstruation is a complex process controlled by a number of female sex hormones. The hypothalamus, pituitary gland and the ovaries secrete these critical hormones in minute amounts. Even a slight imbalance of these hormones is felt far and wide.

Regular or irregular, very light, scanty menstrual bleeding is known as hypomenorrhea.

The amount of bleeding is the point of focus.

Oligomenorrhea on the other hand is infrequent menstruation.

Normal menstruation occurs every 28 days. In oligomenorrhhea menstruation is more than 35 days apart. It is vital to remember that having infrequent periods or scanty bleeding does not automatically mean that there is a problem with fertility.

Most of the time, infertility rates of women who menstruate normally are the same as those who have hypomenorrhea and oligomenorrhea.

Use of hormonal contraceptive methods is one of the most common causes of having scanty periods. Hormonal oral contraceptive pills, intrauterine contraceptive devices that release hormones (Mirena), hormonal implants (implanon, Jadelle) and hormonal injections (depo-provera) are a few common examples. Low estrogen levels inhibit endometrial proliferation and as a result there will be less endometrium to shed during periods.

Low thyroid hormone levels can cause scanty menstrual bleeding. Patients with hypothyroidism may also have lethargy, a puffy face, a slow heart rate and carpal tunnel syndrome.

High androgen levels (testosterone), in addition to having male-like hair distribution and a deepening of the voice can cause scanty periods.

A high level of breast milk hormone (prolactin) that may be secreted by a pituitary tumor causes bi-temporal hemianopia if the tumor is large enough.

Blood tests for TSH, T3, T4, FNAC of thyroid, autoantibodies, testosterone, prolactin, skull X-ray, MRI can be used to detect these abnormalities.

The premenopausal period is marked by scanty menstrual bleeding. The gap between periods gets bigger and bigger with time. The hypothalamic and pituitary hormone levels (FSH) go up as the ovaries lose their ability to secrete estrogen and progesterone.

When the surface area of the endometrium is small there may be scanty menstruation without any hormonal cause. This is the case in constitutional hypomenorrhea. There are often family members with similar complaints. Fertility is not disturbed in any way. But in some rare cases the embryological development of the uterus is faulty and there is an abnormally small uterus (uterine hypoplasia). An ultrasound scan will clearly diagnose this condition.

Asherman syndrome is a condition where the two opposing surfaces of the uterine cavity fuse together as a result of healing after over enthusiastic curettage or after endometritis. A dilatation and curettage is a common gynecological procedure done to explore the uterine cavity to detect and pathology such as endometrial cancer.

Any cervical pathology that obstructs the outflow pathway of the uterus will manifest itself as hypomenorrhea. A large cervical fibroid is a common example.

The cerebral cortex is a key controller of menstruation and any severe emotional upheaval is known to cause menstrual irregularities.

Anorexia nervosa is a severe psychological condition where there are abnormal low levels of body fat. Adipocytes convert androsteindione to estrogen. When this step does not occur or occurs at sub-normal levels menstruation will suffer similarly.

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