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Menstrual disorders

Amenorrhea, Dysmenorrhea, Menorrhagia, Metrorrhagia

What is menstrual disorders?

Menstrual disorders are problems related to a woman's menstrual cycle. They are among the most common conditions in women. Many menstrual disorders are not a cause for concern, but others require a physician consultation.

Menstruation is the discharge of blood and tissue that occurs each month as part of a woman's menstrual cycle. The cycle can vary from 21 to 42 days in length, although the average length is 28 days. This cycle is controlled by hormones produced in certain parts of the brain and the ovaries to prepare the reproductive organs for pregnancy. The lining of the uterus (endometrium) thickens in response to the hormones. If pregnancy does not occur, the lining begins to break down and discharges from the body through the vagina as the menstrual period.

Menstruation begins on average when a girl is about 12 or 13 years old (puberty) and continues monthly until menopause occurs many years later. These are considered a woman's reproductive years and indicate the woman is physically able to become pregnant. Menstrual periods usually occur once a month and last for several days during each month. A missed menstrual period is frequently the first sign that pregnancy has occurred. The uterine lining is not shed, but rather will grow during pregnancy and provide an area for growth of the placenta (a temporary organ that provides nourishment for the developing fetus).

As a woman ages and hormone levels slowly begin to decrease, the menstrual cycle eventually ends (menopause). Menopause typically occurs during a woman's early 50s but it may occur earlier or later in life.

Menstrual disorders occur when certain factors interrupt the hormones that control menstruation. Common disorders include:

  • Missed periods
  • Periods that are unusually heavy or light
  • Periods that are unusually long
  • Unusually infrequent periods
  • Unusually painful periods
These disorders can be temporary or permanent. In addition, many women experience some variation in menstrual cycle symptoms from one month to the next, especially during the first years after the beginning of menstruation (menarche). Some disorders may interfere with a woman's ability to participate in everyday activities, attend work or school and sleep. Certain menstrual disorders may also interfere with a woman's ability to become pregnant.

Types and differences of menstrual disorders

Women can experience a variety of menstrual disorders, including:

Amenorrhea. An absence of menstrual periods. This condition may be further classified as:
  • Primary amenorrhea. The lack of a first menstrual period by the age of 16 years. This condition is also known as “delayed menarche.”
  • Secondary amenorrhea. The absence of menstrual periods in a woman who has previously menstruated regularly. The periods must be absent for at least three months to be considered amenorrhea.
Dysmenorrhea. Severely painful menstrual periods. This condition may be further classified as:
  • Primary dysmenorrhea. Painful menstrual periods that are not caused by an underlying disease or condition.
  • Secondary dysmenorrhea. Painful menstrual periods caused by an underlying disease or condition. In some patients, the pain may extend beyond the menstrual period and become chronic (e.g., endometriosis).
Hypomenorrhea. Unusually light menstrual periods.
Menorrhagia. Unusually heavy or long menstrual periods. Women with menorrhagia may soak through one or more sanitary pads or tampons an hour for several consecutive hours, or have periods that last longer than seven days (or longer than a usual menstrual period). Menorrhagia may be a cause for concern because heavy bleeding can lead to an iron deficiency, and ultimately result in anemia.
Metrorrhagia. Menstrual bleeding that occurs at frequent, irregular intervals.
Menometrorrhagia. Prolonged menstrual periods that occur at irregular intervals. This condition is a combination of menorrhagia and metrorrhagia.
Oligomenorrhea. Unusually infrequent menstrual periods. Woman with oligomenorrhea have fewer than six to eight periods per year.
Polymenorrhea. Unusually frequent menstrual periods compared to the normal variation of menstrual cycles.
Postmenopausal bleeding. Vaginal bleeding that occurs more than 12 months after the last menstrual cycle.
Premenstrual syndrome (PMS). Physical, emotional and behavioral symptoms that commonly occur in the two weeks prior to menstruation. Some women experience symptoms so severe that they interfere with daily activities. These women may have a severe condition known as premenstrual dysphoric disorder (PMDD), which is diagnosed according to specific criteria established by medical authorities.

How is it diagnosed?

A wide variety of underlying conditions can contribute to menstrual disorders. To pinpoint the cause, physicians rely on the patient's medical history, physical examination and lab and imaging tests. Determining the exact cause of the menstrual disorder is important because it helps the physician plan appropriate treatment.

Physicians begin by obtaining the patient's medical history as well as menstrual history. The details of a woman's medical history may help the physician determine the cause of the patient's menstrual problems. As a result, women are encouraged to be as open and honest as possible when answering the physician's questions.

The patient may be asked about her sexual development during puberty, as well as current symptoms, medications, sexual activity and contraceptive use. The physician will also determine if the patient has a history of gynecologic disorders, gynecologic surgery, sexually transmitted diseases (STDs) or blood clotting disorders. The patient's personal history and family history of medical conditions will be noted as well. Patients should also be prepared to answer questions regarding the growth, puberty and menstrual patterns of their female family members.

During the initial office visit, the patient should provide her physician with detailed information regarding any significant physical and emotional changes. This includes changes in weight, eating habits, exercise routine and stress level.

The physician will ask questions about the patient's menstrual flow and menstrual cycle length. As a result, patients may benefit from recording a “menstrual diary.” This diary should include details such as the dates, type of flow and length of menstrual periods. Patients who do not have this information at the initial office visit may be asked to create and maintain one after the visit. Physicians may also ask patients to monitor their temperature each day to determine when the patient is ovulating (releasing an egg from the ovaries).

The second step in diagnosing a menstrual disorder is the physical examination. A careful evaluation of the patient will include a pelvic examination, which can reveal structural abnormalities that may be contributing to the menstrual problem.

A number of tests may be ordered following the physical exam. The tests are used to detect abnormalities and narrow the field of possible causes by eliminating certain conditions. The exact tests used vary based on the patient's medical history, symptoms and physical findings. The tests may be performed during the initial visit or during a follow-up visit. Tests commonly used to diagnose underlying causes of menstrual disorders include:

  • Urine tests. Uses a sample of urine to detect a variety of illnesses. A urine test may be performed to determine if a patient is pregnant, has a urinary tract infection, sexually transmitted diseases, or is in the process of menopause.
  • Blood tests. Tests used to detect abnormally high or low levels of substances in the blood. Blood tests may be used to measure the patient's blood count and hormone levels.
  • Pap smear. Involves the collection of a sample of cells from the cervix and upper vagina. The cells are then examined for abnormalities under a microscope. This test may be used to detect infection, inflammation, cervical cancer or abnormal changes.
  • Pelvic ultrasound. High-frequency sound waves are used to produce images of internal organs. This test can reveal abnormalities in the uterus, ovaries, cervix or vagina including thickening of the endometrium.
  • Magnetic resonance imaging (MRI). Uses a powerful magnetic field to create images of structures and organs within the body, allowing a computer to produce clear cross-sectional or three-dimensional images. It may be ordered to determine if hypothalamic or pituitary gland abnormalities exist, as well as the presence of certain types of growths in the reproductive organs.
  • Computed axial tomography (CAT scan). Allows for multiple x-rays to be taken from different angles around the patient. The “slices” or cross-sectional images of the patient's body are analyzed by a computer. CAT scans can reveal growths or other abnormalities in areas such as the uterus or fallopian tubes.
  • Endometrial biopsy. Involves the collection of a tissue sample from the endometrium (lining of the uterus). The sample is then examined for cancer or other abnormalities under a microscope.
  • Hysteroscopy. A thin, lighted, flexible tube (hysteroscope) is inserted through the vagina. It allows the physician to visually examine the cervix and uterus.
  • Sonohysterogram. Involves the injection of fluid through the vagina and cervix and into the uterus. An ultrasound is then used to evaluate the lining of the uterus and is particularly useful in determining the thickness of the endometrium.
  • Dilation and curettage (D&C). A procedure in which the opening of the cervix is dilated or stretched and tissue from the uterus is collected. The tissue is then examined for abnormalities, signs of cancers or to ensure the complete evacuation of placental tissue after a miscarriage. It can also be performed as a diagnostic procedure for certain kinds of abnormal uterine bleeding.
  • Hysterosalpingography. Involves the injection of dye through the cervix and into the uterus and fallopian tubes. X-rays are then taken to help the physician evaluate the uterus and fallopian tubes.

How is it treated?

After the underlying cause of a menstrual disorder is uncovered, the physician can determine the best form of treatment. With the proper treatment, physicians may be able to establish or restore normal menstrual periods and possibly fertility.

Treatment decisions are based on a number of factors, including:

  • Cause and extent of the disorder
  • Predicted progression of the disorder
  • Effect of the disorder on the patient's daily life
  • The patient's age and overall health
  • The patient's medical history
  • The patient's tolerance for certain medications, procedures and therapies
  • The patient's personal preferences
  • Fertility
Common treatments include:
Oral contraceptives. Birth control pills may be used to treat menstrual disorders. There is a wide variety of types and forms available, and these medications are commonly used to treat polycystic ovarian syndrome and endometriosis, and to regulate irregular menstrual cycles.
Hormone replacement therapy. Hormonal medications containing estrogen, and in some cases progesterone, may be recommended for the symptoms of menopause.
Lifestyle changes. A physician may recommend changes in diet and exercise regimen.
Analgesics (e.g., ibuprofen). Painkillers may be used to relieve pelvic pain and discomfort associated with menstrual disorders. Additionally, ibuprofen has been shown to decrease menstrual bleeding in some studies.
In some cases medication can trigger a menstrual disorder. Physicians may recommend that patients with medication-induced menstrual disorders switch to another medication.

Lifestyle changes and medications are usually the first line of treatment for menstrual disorders. However, these methods are not always successful and surgery may be recommended.
Surgeries that may be used to treat certain menstrual disorders include:
  • Dilation and curettage (D&C). During D&C, the uterus is widened (dilated). The physician then removes the tissue by suction or sharp curettage (scraping). In some cases, a long metal instrument with a loop on the end (curette) will be used to scrape the walls of the uterus after suctioning, a process known as curettage. This procedure may be used to remove abnormal growths (e.g., polyps, fibroids) or cancer.
  • Endometrial ablation (EMA). During EMA, the physician uses a hysteroscope (a thin, lighted, flexible tube) to view the uterine lining. Then one of several different methods (e.g., laser, electrocautery instrument, thermal balloon) is used to remove or destroy the uterine lining. Pregnancy is not possible after EMA.
  • Endometrial resection (EMR). A surgical procedure involving the removal of the endometrial lining (the lining of the uterus) with an electrosurgical wire loop. In addition to removing the uterine lining, a quarter-inch of the uterus' underlying muscle is removed. Resection can be used in women who have heavy bleeding but do not have any other underlying uterine problems. Pregnancy is not possible after an EMR.
  • Hysterectomy. In some severe circumstances the surgical removal of a woman's uterus may be necessary.
In some cases, the diagnosis of an underlying condition such as cancer or early menopause can result in extreme distress. As a result, psychological counseling is sometimes a component of treatment.

Medications

  • Amenorrhea and Menorrhagia. Aygestin (Norethindrone), Provera (Medroxyprogesterone)
  • Menorrhagia. Apri (Desogestrel-ethinyl estradiol)
  • Dysmenorrhea. Celebrex (Celecoxib), Motrin (Ibuprofen), Aleve (Naproxen), Ovral (Norgestrel), Alesse (Levonorgestrel), Voltaren (Diclofenac), Indocin (Indomethacin)

Prevention methods for menstrual disorders

Many of the underlying causes of menstrual disorders cannot be prevented. However, women can reduce the risk of some causes by maintaining a healthy lifestyle, including eating a balanced diet and getting regular exercise.

Beneficial steps include:

  • Making appropriate changes in diet and exercise activity to achieve a healthy weight. Polycystic ovarian syndrome, for example, can often be managed by maintaining a healthy weight. Women may wish to consult a registered dietician for assistance with dietary changes. Women with eating disorders, such as anorexia nervosa, may need to gain weight in order to restore normal menstruation.
  • Avoiding recreational drug use, excessive alcohol consumption and cigarette smoking.
  • Striving for a healthy balance in work, recreation and rest.
  • Assessing areas of stress or conflict in life. If necessary, contacting a mental health professional (e.g., psychologist, psychiatrist) for help dealing with stress.
In addition, women should take the proper steps to protect themselves from sexually transmitted diseases. This includes using condoms consistently during sexual contact, especially with high-risk partners. These include sexual partners who have multiple sexual partners, people whose sexual background is unknown and intravenous drug users.

What might complicate it?

Complications of amenorrhea relate to the underlying condition including endocrine disorder, hormonal imbalance, congenital abnormalities of the reproductive tract, emotional disorders, and ovarian tumor or cyst. Complications of dysmenorrhea also depend on underlying condition. Menorrhagia can be complicated by miscarriage, complications of pregnancy, iron deficiency anemia, and infertility with menopause if hysterectomy is necessary. Complications of metrorrhagia include early miscarriage of unsuspected pregnancy, disorder of the uterus, ovaries, or pelvic cavity (such as endometriosis), lesions in the cervix or lining of the uterus (endometrium), or a cancer (malignancy) in the genital tract.

Predicted outcome

In amenorrhea, if underlying cause is not a health threat, some women choose not to receive treatment. Predicted outcome may be related to any underlying conditions.

Primary dysmenorrhea often diminishes after the age of 25 or after childbirth. The predicted outcome for secondary dysmenorrhea is dependent on the underlying condition. For menorrhagia and metrorrhagia, prognosis depends on the underlying cause.

Alternatives

Possible diagnoses that mimic amenorrhea include pregnancy or disorders associated with the central nervous system, thyroid, pituitary, ovary, or uterus.

Endometriosis, adenomyosis, fibroids, polyps, pelvic inflammatory disease, ovarian cysts, intrauterine device, psychogenic, cervical stenosis, endometrial carcinoma, tuberculosis, complications of pregnancy, irritable bowel, anatomic anomaly, ectopic pregnancy, or intrauterine adhesions are possible diagnoses that present similarly to dysmenorrhea.

Pregnancy-related conditions, malignancies, infections, medication produced, clotting disorders, or systemic diseases may produce the same symptoms as menorrhagia or metrorrhagia.

Appropriate specialists

Gynecologist and endocrinologist.

Last updated 5 July 2021